Including the latest on acne, psoriasis, atopic dermatitis, hair and nails, hidradenitis suppurativa, rheumatologic diseases, and more.
GENERAL DERMATOLOGY
Using data derived from a global health records database, the investigators compared the relative risk of developing hematologic malignancy among 327,502 patients with UNCLASSIFIED GENERALIZED PRURITUS compared to a similarly sized matched cohort of patients without itching. There was an increased risk of select hematologic malignancy in those with pruritus, but only during the initial 12 months following onset. This increased risk did not persist at 5 or 10 years following onset of pruritus.
TO READ MORE: Deng J, et al. Risk of Hematologic Cancer in Patients With Undifferentiated Pruritus. JAMA Dermatol. 2022 Jul 1;158(7):791-795. doi: 10.1001/jamadermatol.2022.1562. PMID: 35612839; PMCID: PMC9134041.
PEDIATRIC DERMATOLOGY
A retrospective, cross-sectional, single-institution study of 297 adolescent patients given the diagnosis of HIDRADENITIS SUPPURATIVA disclosed that 43% of these did not fully meet diagnostic criteria. Most notably, many failed to experience >2 active disease recurrences within a 6-month time period. Despite this, there was other abundant chart evidence to support the diagnosis of hidradenitis. Median age at onset was 14.
TO READ MORE: Kittler NW, et al. Evaluation of Hidradenitis Suppurativa Diagnostic Criteria in Pediatric Patients. JAMA Dermatol. 2022 Oct 26:e224564. doi: 10.1001/jamadermatol.2022.4564. Epub ahead of print. PMID: 36287577; PMCID: PMC9607937.
A prospective, investigator-blinded, randomized controlled clinical study explored the benefit of early twice daily use of emollients, for two months, in newborns with a high risk of ATOPIC DERMATITIS (AD). The cumulative incidence of AD at one year was 32.8% in the intervention group vs. 46.4% in the control group (no intensive emollient use). This was statistically significant.
TO READ MORE: Chaoimh CN, et al. Early initiation of short-term emollient use for the prevention of atopic dermatitis in high-risk infants-The STOP-AD randomised controlled trial. Allergy. 2022 Aug 23. doi: 10.1111/all.15491. Epub ahead of print. PMID: 35997592.
ACNE
The integrin blocker vedolizumab, which is used for refractory inflammatory bowel disease, has now been associated with SEVERE ACNE VULGARIS. Oral isotretinoin was required for treatment.
TO READ MORE: Blankenship K, Burns L, Scharf M. Vedolizumab-Induced Acne Fulminans: An Uncommon and Severe Adverse Effect. Cutis. 2022 Sep;110(3):E19-E20. doi: 10.12788/cutis.0632. PMID: 36446123.
A small (N=5) study demonstrated that moderate to SEVERE CYSTIC ACNE may respond well to a series of three treatments with an ablative fractional carbon dioxide laser. As might be expected, erythema and minor crusting were apparent 3 to 5 days following each treatment.
SOURCE: Gomes LLA, et al. Ablative fractional laser treatment of active acne: A pilot study. American Society for Dermatologic Surgery Annual Meeting; Oct. 6-10, 2022; Denver.
PSORIASIS
Pooled data from 8 phase 2 and phase 3 randomized, controlled studies utilizing BIMEKIZUMAB for the management of moderate to severe plaque psoriasis were analyzed for safety. The three most commonly reported adverse events were nasopharyngitis (19.1 per 100 patient-years), oral candidiasis (12.6 per 100 patient-years) and upper respiratory tract infection (8.9 per 100 patient-years). Based upon this analysis involving 1789 patients, bimekizumab appears to be safe.
TO READ MORE: Gordon KB, et al. Bimekizumab Safety in Patients With Moderate to Severe Plaque Psoriasis: Pooled Results From Phase 2 and Phase 3 Randomized Clinical Trials. JAMA Dermatol. 2022 Jul 1;158(7):735-744. doi: 10.1001/jamadermatol.2022.1185. PMID: 35544084; PMCID: PMC9096693.
Patients with PSORIATIC ARTHRITIS (PsA) are more likely to demonstrate significant cardiometabolic comorbidities than both the general population and psoriatics who do not have joint involvement. Specifically, patients with PsA have an increased risk of hospitalization due to ischemic heart disease, as well as increased risks of obesity, diabetes mellitus, hypertension, and hypertriglyceridemia. Treatment with biologic drugs may help, but only modestly. For example, TNF-α, IL-17-, and IL-23-inhibitors reduced coronary noncalcified plaque burden during treatment by about 6%.
TO READ MORE: Gupta S, et al. Comorbidities in psoriatic arthritis: a systematic review and meta-analysis. Rheumatol Int. 2021 Feb;41(2):275-284. doi: 10.1007/s00296-020-04775-2. Epub 2021 Jan 9. PMID: 33423070; PMCID: PMC7835184.
Data were analyzed from a two-year period, derived from large perspective, multicenter registry of psoriatic patients under the care of a dermatologist. During the investigational time period, 1489 patients who developed PSORIATIC ARTHRITIS (PsA) were studied. Higher body mass index (BMI) was associated with increased risk of PsA. Only working part time (compared to full time), the presence of fatigue and skin pain, and a higher Psoriasis Epidemiology Screening Tool (PEST) score were also associated with the development of PsA.
TO READ MORE: Ogdie A, et al. Prospective cohort study of psoriatic arthritis risk in patients with psoriasis in a real-world psoriasis registry. J Am Acad Dermatol. 2022 Dec;87(6):1303-1311. doi: 10.1016/j.jaad.2022.07.060. Epub 2022 Aug 17. PMID: 35987397.
ATOPIC DERMATITIS
RUXOLITINIB CREAM, a newly approved agent for mild to moderate atopic dermatitis, is associated with rapid itch reduction. This improvement is sustained for several months. These findings are found in pooled data from the phase 3 trials.
TO READ MORE: Blauvelt A, et al. Rapid pruritus reduction with ruxolitinib cream treatment in patients with atopic dermatitis. J Eur Acad Dermatol Venereol. 2023 Jan;37(1):137-146. doi: 10.1111/jdv.18571. Epub 2022 Sep 21. PMID: 36066323.
A 3.52-fold risk of VENOUS THROMBOEMBOLIC EVENTS (VTEs) has been reported in association with use of tofacitinib to treat rheumatoid arthritis in patients over 50. However, this systematic review and meta-analysis of two cohort studies and 15 randomized clinical trials, comprising 466,993 individuals, failed to verify this association in atopic dermatitis patients treated with JAK inhibitors. Among the 5722 atopic dermatitis patients receiving JAK inhibitors, the incidence of VTE was quite low and not significantly different from atopic dermatitis patients receiving either placebo or dupilumab.
TO READ MORE: Chen TL, et al. Association of Risk of Incident Venous Thromboembolism With Atopic Dermatitis and Treatment With Janus Kinase Inhibitors: A Systematic Review and Meta-analysis. JAMA Dermatol. 2022 Nov 1;158(11):1254-1261. doi: 10.1001/jamadermatol.2022.3516. PMID: 36001310; PMCID: PMC9403856.
COSMETIC DERMATOLOGY
Although reportedly rare, PLATELET RICH PLASMA INJECTIONS into the glabella, forehead and lateral canthus can be associated with vision loss. This can even lead to complete blindness.
SOURCE: Wu S, et al. Vision loss after platelet-rich plasma injection: A systematic review. American Society for Dermatologic Surgery Annual Meeting; Oct. 6-10, 2022; Denver.
CONTACT DERMATITIS
Tulipalin A, found in tulips and the Peruvian lily, is an important sensitizer, often responsible for CONTACT DERMATITIS IN FLORAL EMPLOYEES. This leads to erythematous scaling on periungual skin and on the first and second fingertips of the dominant hand. Secondary spread to the face, neck, arms, and even genitalia may also occur. When avoidance is not possible, wearing nitrile gloves is advisable. Tulip hypersensitivity is also rarely associated with a type 1 reaction consisting of urticaria, rhinitis, and dyspnea.
TO READ MORE: Lee KP, et al. Botanical Briefs: Tulipalin A. Cutis. 2022 Sep;110(3):145-149. doi: 10.12788/cutis.0613. PMID: 36446113.
A systematic review of consort allergic contact dermatitis included 183 articles and 26 patients. Consort contact dermatitis is the result of exposure to an allergen from another person. Sites of predilection include face (48.6%), hand, arm, neck and genitalia. The most common consorts were partners/spouses (50.0%, about 30% were related to sexual activity). Direct contact with the consort was responsible in just over 80% of cases. Medications (35.6%), plants/botanicals (11.7%), and fragrances (8.7%) were most often implicated.
TO READ MORE: Lee J, et al. Consort Allergic Contact Dermatitis: A Systematic Review. Dermatitis. 2022;33:181-186.
Among a cohort of 323 patients with confirmed allergic contact dermatitis, more than half of the cases were due to FRAGRANCES AND BOTANICAL EXTRACT ALLERGENS. The single most common sensitizers were derivatives of linalool and limonene. Other allergens of note included tree-moss, oak-moss, isoeugenol, and cinnamon derivatives. Over one-third of these would have been missed by using the standard test kits.
TO READ MORE: Krijl RC, et al. What is the added value of patch testing with 30 fragrance allergens in addition to the European Baseline series? Contact Dermatitis. 2022 May;86(5):390-397. doi: 10.1111/cod.14065. Epub 2022 Feb 21. PMID: 35122278; PMCID: PMC9302649.
Analyzing data from long time periods elucidated frequency of select allergens in North America. Many well-known PRESERVATIVES showed consistently decreasing rates of patch test positivity (including Quaternium 15, bronopol, imidazolidinyl urea, DMDM hydantoin, and diazolidinyl urea). Paraben mix now has the lowest positivity rate (0.6%) of any major preservative. The preservative of most persistent significance is methylisothiazolinone.
TO READ MORE: Elmobdy K, et al. Long-Term North American Trend in Patch Test Reactions: A 32-Year Statistical Overview (1984-2016). Dermatitis. 2022 Sep 21. doi: 10.1097/DER.0000000000000943. Epub ahead of print. PMID: 36125806.
INFECTIOUS DISEASES
Differentiation of bacterial cellulitis from conditions which might mimic it (contact and stasis dermatitis, deep venous thrombosis) may be difficult. A prospective, five-year analysis of patients presenting to an urban emergency department identified select findings which favor the diagnosis of cellulitis. These included: unilateral involvement, history of antecedent onychomycosis or trauma, and peripheral leukocytosis. The factors proved much more predictive than age.
TO READ MORE: Chand S, et al. Risk Factors Predicting Cellulitis Diagnosis in a Prospective Cohort Undergoing Dermatology Consultation in the Emergency Department. Cutis. 2022 Sep;110(3):122-125. doi: 10.12788/cutis.0602. PMID: 36446117.
The bulk of literature suggests that receipt of a human papilloma virus (HPV) vaccine helps resolve RECALCITRANT WARTS. In this small retrospective European study (N=18), one or more HPV vaccination sessions only led to an 11% complete resolution rate of palmoplantar warts. The mean time to response was 3.5 months. However, this study was seriously flawed in that 14 of the 18 subjects were immunocompromised (e.g., HIV+ with decreased CD4 cell count, organ transplant, common variable immune deficiency).
TO READ MORE: Merio L, et al. Human papilloma virus vaccine for palmoplantar warts: A retrospective study of 18 patients. J Eur Acad Dermatol Venereol. 2022 Aug 16. doi: 10.1111/jdv.18523. Epub ahead of print. PMID: 35972053.
FACIAL DEMODICOSIS may accompany immunocompromised or iatrogenic immunosuppression. A case series of 28 is reported. Erythema, telangiectasia, and pustules were the most frequent clinical findings. A lesion-content smear subject to light microscopy and dermoscopy may be useful to establish the correct diagnosis. Oral and topical metronidazole, oral and topical ivermectin, and topical benzoyl peroxide were the most frequently utilized therapies.
TO READ MORE: Amitay-Laish I, et al. Facial demodicosis in the immunosuppressed state: a retrospective case series from a tertiary referral center. Int J Dermatol. 2022 Oct;61(10):1245-1252. doi: 10.1111/ijd.16162. Epub 2022 Apr 10. PMID: 35398883.
SPOROTRICHOSIS can cause lesions in cats. This fungal disease can then be transmitted to humans, particularly by cat scratches. This phenomenon is most common in Brazil but has also been repeatedly reported from the United States, Malaysia, and India. Lesions assume the typical sporotrichoid pattern, and itraconazole (200mg QD-BID) is the treatment of choice.
TO READ MORE: Gallo S, et al. First three cases of cat-associated zoonotic cutaneous sporotrichosis in Colombia. Int J Dermatol. 2022 Oct;61(10):1276-1279. doi: 10.1111/ijd.16377. Epub 2022 Aug 12. PMID: 35959537.
Intralesional dilute methotrexate has not performed well as a treatment for WARTS. In a small (N=20) open label study of plantar warts, biweekly injections of full concentration methotrexate (25mg/ml) performed much better. Fifteen of twenty warts cleared completely, although it often required 5 to 6 injection sessions. Thirty percent to 40% of subjects reported pain and/or bruising.
TO READ MORE: Zoheir MGT, et al. Intralesional full-concentration (25 mg/mL) methotrexate in the treatment of plantar warts: A pilot study. Dermatol Ther. 2022 Nov;35(11):e15815. doi: 10.1111/dth.15815. Epub 2022 Sep 21. PMID: 36101002.
A large (N=149, 126 completed) Indian study of treatment-naïve TINEA CORPORIS AND TINEA CRURIS found that itraconazole therapy may be effective. Complete cure rates were 82% in the 100 mg daily group, 93.2% in the 200 mg daily group, and 100% in the 400 mg daily group, with an overall cure rate of 92.1%. Although varying widely, the mean duration of therapy to achieve cure was 6.6 weeks. There was a substantial relapse rate, however. The highest relapse rate was 59.4% in the 100 mg daily group.
TO READ MORE: Khurana A, et al. Effect of Different Itraconazole Dosing Regimens on Cure Rates, Treatment Duration, Safety, and Relapse Rates in Adult Patients With Tinea Corporis/Cruris: A Randomized Clinical Trial. JAMA Dermatol. 2022 Sep 14;158(11):1269–78. doi: 10.1001/jamadermatol.2022.3745. Epub ahead of print. PMID: 36103158; PMCID: PMC9475442.
HAIR AND NAILS
A complex meta-analysis of published studies attempted to define factors which determine the success or failure of PLATELET-RICH PLASMA (PRP) injections for androgenetic alopecia. In summary, the authors found that as the number of sessions increases and the interval between session decreases, efficacy of PRP increases. Moreover, chemically activated PRP and double centrifugation increase PRP efficacy. Younger and female patients respond best, all other factors being equal.
TO READ MORE: Gupta AK, et al. Platelet-Rich Plasma Monotherapies for Androgenetic Alopecia: A Network Meta-Analysis and Meta-Regression Study. J Drugs Dermatol. 2022 Sep 1;21(9):943-952. doi: 10.36849/JDD.6948. PMID: 36074501.
Results from a burden of disease survey indicated that patients with ALOPECIA AREATA will accept localized stinging and burning as a result of therapeutic interventions, but not significant general health risks. The most acceptable treatment determined in this study was topical therapy (74%); conversely, only 45% of those surveyed found injections into affected area to be acceptable.
TO READ MORE: O’Connor LF, et al. Characterizing the willingness to undergo treatment in patients with alopecia areata. Arch Dermatol Res. 2022 Oct;314(8):749-757. doi: 10.1007/s00403-021-02286-z. Epub 2021 Oct 5. PMID: 34609599.
CUTANEOUS ONCOLOGY, SURGERY AND LASERS
As of September 2022, the FDA has become aware of just under 20 published cases of SQUAMOUS CELL CARCINOMA and just under 30 published cases of both T- and B-cell lymphoma associated with both saline and silicone breast implants. Ten medical device reports (MDRs) of squamous cell carcinoma and 12 MDRs of lymphoma related to breast implants have also been received. Tumors arose within the fibrous capsule surrounding the implant, manifesting as a hard, sometimes painful deep nodule.
TO READ MORE: FDA Safety Alert. Breast Implants: Reports of Squamous Cell Carcinoma and Various Lymphomas in Capsule Around Implants: FDA Safety Communication. September 8, 2022. Accessed December 27, 2022.
Hedgehog pathway inhibitors are approved for management of locally advanced and metastatic BASAL CELL CARCINOMA. The authors point out that, in certain circumstance, these agents may be suitable for non-advanced tumors. In this case report, the patient had so many lesions that surgical intervention and even radiotherapy would have been difficult. The vast majority of these non-advanced basal cell tumors resolved with traditional vismodegib therapy.
TO READ MORE: Frantz, R. et al. Vismodegib as a Treatment for Multiple Non-locally Advanced Basal Cell Carcinomas. SKIN The Journal of Cutaneous Medicine, 6(5), 421–423. https://doi.org/10.25251/skin.6.5.13
A small (N=25) single-center, retrospective study was done of patients undergoing DERMATOLOGIC SURGERY WHILE ACTIVELY RECEIVING IMMUNE CHECKPOINT INHIBITORS (nivolumab, pembrolizumab, or a combination of ipilimumab and nivolumab). The analysis disclosed a very low rate of adverse events, with easily treated surgical site infection noted in only two patients. Bottom line: receipt of immune checkpoint inhibitors should not be considered a contraindication to necessary skin surgery.
PRESENTED AT: Puza C, et al. Immune checkpoint inhibitors and dermatologic procedures: A retrospective review of safety and complications. Presented at: 2022 American Society of Dermatologic Surgery Annual Meeting, Denver Colorado, October 7-10, 2022.
HIDRADENITIS SUPPURATIVA
A commentary makes the case for simple SURGICAL DEROOFING as a management tool for hidradenitis when conservative medical therapy fails. The authors point out that this relatively easy to perform, in-office procedure has a low complication rate (12.5%) and low recurrence rate (14.5%).
TO READ MORE (including step-by-step directions): Allison D, Sterner J, Parker J, Martin K. Surgical Deroofing for Hidradenitis Suppurativa. Cutis. 2022 Sep;110(3):147-149. doi: 10.12788/cutis.0597. PMID: 36446109.
Editor’s note: The authors claim that this is a “novel” procedure. I was doing this in the 1970s.
Using 2008-2018 data derived from the National Ambulatory Medical Care Survey, investigators demonstrated conclusively that HIDRADENITIS IS SEASONAL. Among the 2.33 million outpatient visits documented, 21% occurred during Winter-Spring, 28% during the Fall, and 51% during Spring-Summer.
TO READ MORE: Shih T, et al. Seasonal Trends of Ambulatory Visit Burden in Hidradenitis Suppurativa Patients. SKIN The Journal of Cutaneous Medicine. 2022; 6(5), 387–391. doi.org/10.25251/skin.6.5.5.
In a comprehensive, literature-based review, the authors assert that the odds ratio of developing METABOLIC SYNDROME in patients with hidradenitis is 2.66. It is uncertain if the inflammation related to obesity and the metabolic syndrome induce hidradenitis or, conversely, if inflammation associated with hidradenitis induces the metabolic syndrome. In any event, the levels of various adipokines (leptin, adiponectin, omentin, visfatin and resistin) are correlated with both hidradenitis and metabolic derangements, and there appears to be a shared “adipokine profile.” Lifestyle modifications, such as paleo, keto, gluten-free and Mediterranean diets, may benefit both hidradenitis and associated metabolic syndrome.
TO READ MORE: Mintoff D, et al. Metabolic syndrome and hidradenitis suppurativa: epidemiological, molecular, and therapeutic aspects. Int J Dermatol. 2022 Oct;61(10):1175-1186. doi: 10.1111/ijd.15910. Epub 2021 Sep 16. PMID: 34530487.
RHEUMATOLOGIC DISEASES
Although somewhat variable in degree of benefit, topical and oral tofacitinib improved four patients with otherwise REFRACTORY DERMATOMYOSITIS. Treatment duration varied from 1 to 3.5 years. Tofacitinib may be considered as an adjunct when other therapies fail to clear dermatomyositis.
TO READ MORE: Plante J, et al. A Retrospective Review of Tofacitinib in the Treatment of Refractory Dermatomyositis. J Drugs Dermatol. 2022 Oct 1;21(10):1133-1134. PMID: 36219043.
COVID19
As of October 2022, the CDC no longer recommends UNIVERSAL MASKING in health care settings, unless the facility is in an area of high COVID-19 transmission. This relaxed guidance reflects high levels of vaccine and infection induced immunity, as well as the availability of several effective, approved treatments.
TO READ MORE: CDC. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. Updated September 23, 2022. Accessed December 27, 2022.
A retrospective analysis was conducted of 5941 CUTANEOUS REACTIONS TO COVID-19 VACCINATION that were reported in the literature. As might be expected, local injection site reactions were most frequent. Otherwise, a heterogeneous variety of skin eruptions have been noted. Cutaneous reactions to COVID-19 vaccinations were found to be infrequent and not life-threatening. One interesting finding was that mRNA vaccines may predispose to a delayed inflammatory reaction to previously injected hyaluronic acid filler, even though the filler procedure was done up to a year previously.
TO READ MORE: Avallone G, et al. SARS-CoV-2 vaccine-related cutaneous manifestations: a systematic review. Int J Dermatol. 2022 Oct;61(10):1187-1204. doi: 10.1111/ijd.16063. Epub 2022 Feb 9. PMID: 35141881; PMCID: PMC9111829.
Analysis from Cosmos, a HIPAA compliant database of 163 million patients, revealed that individuals with confirmed COVID-19 who received PAXLOVID are about two times less likely to be hospitalized and about four times less likely to die, compared to those who are eligible for Paxlovid but did not receive the drug. Older (over age 50), fully vaccinated patients have the best clinical outcomes with Paxlovid.
TO READ MORE: Epic Research. Paxlovid significantly reduces COVID-19 hospitalizations and deaths (press release). September 22, 2022. Accessible at: Paxlovid Significantly Reduces COVID-19 Hospitalizations and Deaths (prnewswire.com).
Editor’s note: Despite the recognized risk of relapse, it appears that use of Paxlovid for the current predominant COVID-19 strains is quite advantageous.
Long COVID can occur in children and adolescents. The most common symptom is loss of taste or smell and the most common sign is myocarditis. Children with the highest risk of long COVID were under 5 years of age and those with comorbid chronic conditions. “Brain fog,” common in adults, was not seen in children.
TO READ MORE: Slomski A. Long COVID in Children. JAMA. 2022 Oct 4;328(13):1288. doi: 10.1001/jama.2022.15439. PMID: 36194229.
