In Vivo Reflectance Confocal Microscopy Evaluation of Microneedle Patch Penetration Depth.

BACKGROUND: Firstly, confirm penetration of the skin's most exclusive layer, the stratum corneum (SC), by commercially available microneedle patches using reflectance confocal microscopy (RCM). Secondly, determine the deepest layer of the skin penetrated by the microneedle patches. MATERIALS AND METHODS: In this proof-of-concept study, 3 commercially available dissolving microneedle patches with different active ingredients were included in this study. RCM images of the cheek were taken prior to patch application at 4 different layers of the skin: stratum corneum, stratum spinosum-granulosum, dermal-epidermal junction, and papillary dermis. Patches were then applied to the cheeks of participants according to manufacturer guidelines. Immediately after removal, the same area and layers were imaged using RCM and assessed for features of penetration. RESULTS: Micropores were visualized in RCM images of skin layers post-application of all patches when compared with imaging before application. Characteristics of penetration included uniformly sized, shaped, and spaced well-defined circular areas, which are the created micropores. All 3 patches penetrated the SC to the level of the papillary dermis. CONCLUSION: This study confirms that the dissolving microneedle patches penetrate the most exclusive layer of the skin, the SC, down to the level of the papillary dermis as visualized through RCM. Confirming penetration with RCM shows the potential of these patches to be used for medication transmission. While future studies are needed to assess the efficacy of microneedle patches applied for their advertised skin conditions, confirming the penetration of the microneedle technology through RCM is a significant first step in this process. J Drugs Dermatol. 2023;22(11):1107-1110     doi:10.36849/JDD.6994.

Predicting COVID-19 prognosis in hospitalized patients based on early status.

IMPORTANCE: COVID-19 remains the fourth leading cause of death in the United States. Predicting COVID-19 patient prognosis is essential to help efficiently allocate resources, including ventilators and intensive care unit beds, particularly when hospital systems are strained. Our PLABAC and PRABLE models are unique because they accurately assess a COVID-19 patient's risk of death from only age and five commonly ordered laboratory tests. This simple design is important because it allows these models to be used by clinicians to rapidly assess a patient's risk of decompensation and serve as a real-time aid when discussing difficult, life-altering decisions for patients. Our models have also shown generalizability to external populations across the United States. In short, these models are practical, efficient tools to assess and communicate COVID-19 prognosis.

A Randomized Control Trial Comparing the Efficacy of Platelet-Rich Plasma and 5% Topical Minoxidil for the Treatment of Androgenetic Alopecia.

Androgenetic alopecia (AGA) is the most common cause of hair loss in men and has limited treatment options. Minoxidil is a common therapeutic option for AGA patients because of its availability. Platelet-rich plasma (PRP) therapy is a newer option in AGA management with promising results that may be suitable for some patients. Despite a great prevalence of AGA outside the United States and Europe, there remains limited studies on the efficacy of PRP for AGA treatment. Our study's objective was to compare the efficacy of PRP and minoxidil therapy for the treatment of AGA in a Pakistani population. 72 patients were included in this randomized control trial and were either treated with PRP or topical minoxidil. After 12 weeks of treatment, the hair pull test was performed and extracted hair was counted. We report a 91.7% negative hair pull rate in the PRP treatment group which was significantly greater than the 69.4% negative hair pull rate in the minoxidil-treated group. Our study suggests that PRP therapy demonstrates a higher efficacy compared to minoxidil for treating AGA, especially in our patient demographic. These results have the opportunity to improve patient compliance and overall satisfaction while offering an improved option in patients unsatisfied with topical minoxidil.  Citation: Shah R, Asim M, Ouellette S, et al. A randomized control trial comparing the efficacy of platelet-rich plasma and 5% topical minoxidil for the treatment of androgenetic alopecia. J Drugs Dermatol. 2023;22(9):905-909. doi:10.36849/JDD.7031.

Subacute cutaneous lupus erythematosus with a psoriasiform presentation: A diagnostic clinical conundrum.

Key Clinical Message: For practitioners experiencing worsening psoriasis, subacute cutaneous lupus erythematosus (SCLE) with a psoriasiform presentation should be ruled out. Initial treatment for a presumptive diagnosis of psoriasis using hydroxychloroquine or ultraviolet phototherapy may cause SCLE to worsen. Abstract: Psoriasiform subacute cutaneous lupus erythematosus is an unusual presentation scarcely reported in literature. We report a case of a 54-year-old man who presented with an itchy, papulosquamous rash of the upper extremities and face for 7 months. The initial physical examination revealed the classical morphology of psoriasis. One and a half years after the diagnosis of clinical worsening, the patient noticed a new papular eruption on the right posterior upper arm. A skin biopsy was performed, confirming a diagnosis of subacute cutaneous lupus erythematosus. This case report highlights the importance of considering rare presentations of cutaneous lupus erythematosus and therapeutic challenges in management.

Metastatic renal cell carcinoma presenting as multiple cutaneous lesions visualized through reflectance confocal microscopy.

We present the first case of metastatic renal cell carcinoma visualized via reflectance confocal microscopy (RCM). This case describes the RCM features of such a tumor, in an effort to improve noninvasive characterization of cutaneous metastases.

Topical Application of 0.5% Timolol Maleate Hydrogel for the Treatment of Superficial Infantile Hemangiomas.

BACKGROUND: Oral propranolol is considered the first line therapy in the treatment of infantile hemangiomas (IHs). However, there are considerable side effects due to its ability to penetrate the blood brain barrier. Alternatively, topical timolol, a non-selective beta blocker, has resulted in fewer side effects and is 4–10 times more potent in comparison to oral propranolol. This study evaluates the efficacy of 0.5% timolol maleate hydrogel for the treatment of IH. METHODS: This study was conducted via a quasi-experimental design from October 30, 2020 – April 29, 2021, at the Department of Dermatology Benazir Bhutto Hospital, Rawalpindi. 145 infants between 1–12 months in age diagnosed with superficial cutaneous hemangiomas were included in the study with a male to female ratio of 2.4:1. A thin layer of timolol maleate 0.5% hydrogel was applied to the entire surface of the patient’s IH three times daily. Digital photographs and measurements of the hemangiomas were taken at one-month intervals for a maximum of 6 months. RESULTS: The age range in this study was from 1–12 months with a mean age of 6.10 ± 2.52 months. The majority of the patients 89 (61.4%) were between 1–6 months of age. Of the 145 patients, 89 (61.4%) showed an excellent response, 44 (30.3%) showed a good response, and 12 (8.3%) showed no response to the topical 0.5% timolol maleate hydrogel treatment. CONCLUSION: The use of topical 0.5% timolol maleate hydrogel is a promising therapeutic option for the treatment of superficial IHs. Anwar F, Mahmood E, Sharif S, et al. Topical application of 0.5% timolol maleate hydrogel for the treatment of superficial infantile hemangiomas. J Drugs Dermatol. 2023;22(6):594-598. doi:10.36849/JDD.7054.

Role of VivaScope 2500 ex vivo confocal microscopy in skin pathology: Advantages, limitations, and future prospects.

BACKGROUND: Vivascope 2500 ex vivo confocal microscopy (EVCM) is an emerging optical imaging device that allows nuclear level resolution of freshly excised tissues. EVCM provides, rapid real-time pathological examination in many subspecialties of pathology including skin, prostate, breast, liver, etc. In contrast to traditional time-consuming frozen sectioning and histological analysis. AIMS: To evaluate the current state of EVCM utilization. MATERIALS AND METHODS: This study highlights the advantages, limitations, and prospects of EVCM in skin pathology. RESULTS: Our findings demonstrate that EVCM is a promising adjunctive tool to assess margins in Mohs surgery and to provide rapid, accurate diagnosis of cutaneous tumors, infectious and inflammatory diseases. CONCLUSION: EVCM is a revolutionary device that can be used as an adjunct to paraffin-fixed, hematoxylin and eosin-stained slides and frozen sectioning. Additional refinements are required before EVCM can be used as an alternative to frozen sectioning or traditional tissue processing.

Dermal Hypersensitivity Reaction to Semaglutide: Two Case Reports.

Glucagon-like peptide-1 (GLP-1) receptor agonists are a class of antidiabetic agents that work by inducing insulin secretion and inhibiting release of glucagon in a glucose-dependent manner. They are especially promising given their long duration of action, decreased risk of hypoglycemia, and added benefit of weight loss. Semaglutide is a GLP-1 receptor agonist that has been approved for type II diabetes and chronic weight management in obese adults. Cases of hypersensitivity reactions have been previously reported in patients taking GLP-1 receptor agonists dulaglutide and liraglutide. However, to our knowledge, there have been no reports of hypersensitivity reactions to semaglutide. Here, we present two cases of dermal hypersensitivity reactions in patients taking semaglutide for type II diabetes. In the first case, a 75-year-old woman who had been taking semaglutide for 10 months presented with an eruption on her legs, back, and chest for 3 months duration. Histology showed a subepidermal blister with eosinophils, suggestive of a drug hypersensitivity reaction. In the second case, a 74-year-old white man who had been taking semaglutide for 1 month presented with an eruption on the bilateral flanks and lower abdomen for 3 weeks duration. Histology revealed perivascular inflammatory cell infiltrate with eosinophils, also suggestive of a drug hypersensitivity reaction. Both patients began experiencing resolution of their symptoms within 1 month of discontinuing semaglutide. J Drugs Dermatol. 2023;22(4): doi:10.36849/JDD.6550 Citation: Ouellette S, Frias G, Shah R, et al. Dermal hypersensitivity reaction to semaglutide: Two case reports. J Drugs Dermatol. 2023;22(4):413-415. doi:10.36849/JDD.6550.

Tinea versicolour in underrepresented groups: An All of Us database analysis.

Tinea versicolour, used interchangeably with pityriasis versicolour (PV), is a superficial fungal infection of the stratum corneum caused by Malassezia furfur, a fungus of the normal flora of the skin. PV occurs when conditions favour proliferation of the organism's mycelial form, such as in environments with high temperatures/humidity, in immunodeficient/immunocompromised states, and during pregnancy. PV presents as numerous well- demarcated macules with a powdery scale. Prior epidemiologic studies have indicated that underrepresented groups defined by race experience a higher burden of PV as compared to White patients. However, the burden of PV in other underrepresented groups has not previously been examined, as underrepresented groups are frequently excluded from studies evaluating the impact of dermatologic disease. The new National Institute of Health All of Us Research Program (AoU) aims to build one of the world's largest and most diverse databases to promote elucidation of health disparities, particularly in communities that have been historically excluded from biomedical research.

One-class machine learning classification of skin tissue based on manually scanned optical coherence tomography imaging.

We investigated a method for automatic skin tissue characterization based on optical coherence tomography (OCT) imaging. We developed a manually scanned single fiber OCT instrument to perform in vivo skin imaging and tumor boundary assessment. The goal is to achieve more accurate tissue excision in Mohs micrographic surgery (MMS) and reduce the time required for MMS. The focus of this study was to develop a novel machine learning classification method to automatically identify abnormal skin tissues through one-class classification. We trained a deep convolutional neural network (CNN) with a U-Net architecture for automatic skin segmentation, used the pre-trained U-Net as a feature extractor, and trained one-class support vector machine (SVM) classifiers to detect abnormal tissues. The novelty of this study is the use of a neural network as a feature extractor and the use of a one-class SVM for abnormal tissue detection. Our approach eliminated the need to engineer the features for classification and eliminated the need to train the classifier with data obtained from abnormal tissues. To validate the effectiveness of the one-class classification method, we assessed the performance of our algorithm using computer synthesized data, and experimental data. We also performed a pilot study on a patient with skin cancer.

Onychomycosis in underrepresented groups: an all of us database analysis.

Few research studies evaluating the impact of dermatologic diseases in the United States (US) have adequately included underrepresented groups. All of Us (AoU) is an ongoing precision medicine-based research initiative by the National Institutes of Health (NIH) that facilitates research in populations traditionally underrepresented in biomedical research by prioritizing them for data collection. Our objective was to evaluate the burden of onychomycosis in underrepresented groups defined by the framework provided by AoU. The AoU Registered Tier dataset version 5 was used which includes data collected between May 30, 2017 and April 1, 2021. We conducted a cross-sectional analysis linking survey and electronic health record (EHR) data to estimate the prevalence of onychomycosis in underrepresented groups defined by race, ethnicity, age (≥ 75 years), disability, sexual orientation/gender identity (LGBTQIA +), income (annual household income ≤ $35 000) and education (less than a high school degree). The latest All of Us data release includes 329,038 participants. Of these, 251,597 (76%) had EHR data and 13,874 had onychomycosis (overall prevalence, 5.5%; 95% CI, 5.4-5.6). Multivariate analyses adjusted by tinea pedis, diabetes mellitus, immune compromise, nail psoriasis, and insurance status, in addition to the aforementioned variables, revealed that, compared with White participants, Black and Hispanic participants had a higher adjusted odds of onychomycosis (OR, 1.29; 95% CI, 1.23-1.36 and OR, 1.24; 95% CI, 1.17-1.31, respectively). Higher adjusted odds of onychomycosis were also observed in underrepresented groups. Our findings suggest a disproportionately high burden of onychomycosis in underrepresented groups, although further studies are needed to replicate our findings and address this disparity.

Tinea pedis in underrepresented groups: All of Us database analysis.

BACKGROUND: Tinea pedis is the most common form of dermatophytosis resulting in interdigital infections. All of Us (AoU) is a National Institute of Health initiative with an emphasis on patient populations traditionally underrepresented in biomedical research. OBJECTIVES: Our objective was to evaluate the burden of tinea pedis in underrepresented groups in the United States, utilising the novel AoU research program. METHODS: We analysed AoU Registered Tier dataset version 5, which includes data collected between 30 May, 2017, and 1 April, 2021. We conducted a cross-sectional analysis linking survey and electronic health record (EHR) data to estimate the prevalence of tinea pedis in underrepresented groups. RESULTS: All of Us data release includes 329,038 participants. Of these, 251,597 (76.5%) had electronic health record data and 6932 had tinea pedis (overall prevalence, 2.76%; 95% CI, 2.69-2.82). Multivariate analyses revealed that compared with White participants, Black and Hispanic participants had a higher adjusted odds of tinea pedis (OR, 1.29; 95% CI, 1.20-1.38 and OR, 1.38; 95% CI, 1.28-1.48, respectively). Higher adjusted odds of tinea pedis were observed in underrepresented groups defined by: age > =75 years (OR, 1.45; 95% CI, 1.33-1.57), LGBTQ status (OR, 1.17; 95% CI, 1.09-1.27), less than a high school education (OR, 1.22; 95% CI, 1.11-1.34), income <$35,000 (OR, 1.09; 95% CI, 1.02-1.16) and physical disability (OR, 1.56; 95% CI, 1.08-1.24). CONCLUSIONS: Our findings are consistent with overall age, and gender-specific prevalence estimates from prior epidemiologic studies, validating the scientific consistency of the new AoU database. Additionally, there may be an increased burden of tinea pedis among Black and Hispanic individuals.

Fatal low-dose methotrexate toxicity: A case report and literature review.

Methotrexate (MTX) is a chemotherapeutic agent that acts primarily by inhibiting the folic acid cycle. In addition to its application for treating malignancies, MTX is also used to treat chronic inflammatory diseases including psoriasis. Adverse effects have been reported even at low doses (up to 25 mg/week), and there is risk of toxicity in the form of myelosuppression, hepatotoxicity, or pulmonary fibrosis. Here, we report a case of a 67-year-old male with a past medical history of end stage renal disease on peritoneal dialysis and moderate-to-severe psoriasis with psoriatic arthritis presented with abdominal pain, diarrhea, rash, mucositis, and mucocutaneous ulcers and erosions. The patient was taking methotrexate 10 mg weekly without folic acid supplementation and was found to be pancytopenic. Despite treatment, the patient developed multiorgan failure and passed away after 16 days of hospitalization. Myelosuppression is considered the most serious side effect with the highest risk of mortality. Risk factors for toxicity include renal insufficiency, advanced age, lack of folate supplementation, drug interactions, and medication errors. Importantly, serum levels of MTX do not correlate with toxicity; therefore, folinic acid rescue therapy should be started as soon as MTX toxicity is suspected. MTX toxicity is rare with low dose, proper dose scheduling, and adherence to the recommended guidelines. It is imperative that physicians considering therapy with low dose MTX for dermatologic indications take into consideration a patient's risk factors for toxicity and monitor appropriately.

Demystifying the mechanism of action of professional facial peeling: In-vivo visualization and quantification of changes in inflammation, melanin and collagen using Vivascope® and ConfoScan®.

Professional peeling using chemicals (chemical peeling) is a popular non-surgical procedure commonly used for the treatment for photoaging, pigmentary disorders, scarring, fine lines, and wrinkles. The objective of our case study was to elucidate the mechanism of action of professional peels/peeling. For proof-of-concept, we used a commercial blended peel containing trichloroacetic acid and lactic acid. The facial peeling was performed by a physician on four subjects. These subjects were followed over time in the clinic to take clinical pictures and monitor surface and anatomical changes in inflammation, melanin, and collagen at regular intervals post-peel (5 min, 48 h, and day 9). Dermoscope and Vivascope® were used to image surface and subsurface anatomical changes, respectively, and ConfoScan® was used to quantify aforementioned anatomical changes. Based on Vivascope and ConfoScan analysis, we could see clear visual clinical evidence of controlled injury-healing mechanism of peel's action: immediate but transient onset of inflammation within 5 min (indicate injury response by skin), followed by melanin redistribution evident at 48 h (indicate activation of skin's defense system), and remodeled fibrous collagen network without any inflammatory cells on day 9 (healing response). To our knowledge, this is the first ever clinical study to deconvolute the mysterious mechanism of action of peels, in-vivo.