Exploring the relation between brain response to speech at 6-months and language outcomes at 24-months in infants at high and low risk for autism spectrum disorder: A preliminary functional near-infrared spectroscopy study.

Infants at high familial risk for autism spectrum disorder (ASD) are at increased risk for language impairments. Studies have demonstrated that atypical brain response to speech is related to language impairments in this population, but few have examined this relation longitudinally. We used functional near-infrared spectroscopy (fNIRS) to investigate the neural correlates of speech processing in 6-month-old infants at high (HRA) and low risk (LRA) for autism. We also assessed the relation between brain response to speech at 6-months and verbal developmental quotient (VDQ) scores at 24-months. LRA infants exhibited greater brain response to speech in bilateral anterior regions of interest (ROIs) compared to posterior ROIs, while HRA infants exhibited similar brain response across all ROIs. Compared to LRA infants, HRA+ infants who were later diagnosed with ASD had reduced brain response in bilateral anterior ROIs, while HRA- infants who were not later diagnosed with ASD had increased brain response in right posterior ROI. Greater brain response in left anterior ROI predicted VDQ scores for LRA infants only. Findings highlight the importance of studying HRA+ and HRA- infants separately, and implicate a different, more distributed neural system for speech processing in HRA infants that is not related to language functioning.

Facial allergic granulomatous reaction and systemic hypersensitivity associated with microneedle therapy for skin rejuvenation.

IMPORTANCE: Microneedle therapy includes skin puncture with multiple micro-sized needles to promote skin rejuvenation or increase transdermal delivery of topical medications. In cosmetic practices, various cosmeceuticals are applied before microneedling to enhance the therapeutic effects. This results in intradermal tattooing of the topical product. Despite rapid increase in the use of microneedles in dermatology, there are few data about their safety. OBSERVATIONS: We describe 3 women, aged 40s to 60s, who developed open [corrected] facial granulomas following microneedle therapy for skin rejuvenation. Two patients had undergone microinjection of the same branded topical moisturizer (Vita C Serum; Sanítas Skincare) during microneedle therapy. Biopsy in all cases showed foreign body-type granulomas. Results of tissue cultures were negative. Chest radiography and serum angiotensin-converting enzyme findings were normal. The first 2 patients had a positive patch test reaction to Vita C Serum. Initial treatment with topical and oral corticosteroids was ineffective. Therapy with doxycycline hydrochloride and minocycline hydrochloride led to partial improvement in one case and resolution in another. CONCLUSIONS AND RELEVANCE: Application of topical products prior to microneedling can introduce immunogenic particles into the dermis and potentiate local or systemic hypersensitivity reactions. Because the microneedle therapy system is accessible for home use, health care providers need to be aware of its potential consequences.

Psychopharmacological therapies in dermatology.

When patients with psychodermatologic disorders present in clinic, the dermatologist can refer them to psychiatrists or other mental health care professionals. However, it is often the case that these patients will refuse a psychiatric referral because they either do not believe they have a disorder of psychiatric nature or they feel there is societal stigma associated with psychiatric illness. Therefore, it is essential for dermatologists to understand the common classifications for psychodermatological cases and to know how to optimally treat these patients with pharmacotherapy. The intent of this article is to help guide physicians in understanding the classifications of psychodermatological cases and in managing these conditions with pharmacotherapies. In this article, two classifications for psychodermatological cases are presented, followed by a discussion of medical therapies used to treat the main categories of psychopathologies that are more frequently encountered in dermatology. These include depression, anxiety, delusions, and obsessive-compulsive disorder.

Delusional infestations: clinical presentation, diagnosis and treatment.

Patients with delusional infestations (DI), previously named delusions of parasitosis, have a fixed, false belief that they are infested with living or non-living pathogens. Patients have abnormal cutaneous symptoms such as itching, biting, or crawling sensations. They often demonstrate self-destructive behavior in an effort to rid the pathogens from under their skin, leading to excoriations, ulcerations, and serious secondary infections. This review article aims to provide an overview of DI including its clinical presentation, diagnosis, and treatment. Strategies on how to establish a strong therapeutic alliance with DI patients are discussed. In addition, antipsychotic medications used in the treatment of DI are described.

Access to health care in patients with psoriasis and psoriatic arthritis: data from National Psoriasis Foundation survey panels.

IMPORTANCE: This article represents a real-world perspective on access to health care including the number and types of physicians seen by patients with psoriasis. It is important for practicing dermatologists to recognize patients who may be less likely to seek care for this multifaceted systemic disease as well as to be aware of reasons for not seeing physicians. OBJECTIVES: To examine the relationship between psoriasis patient characteristics and access to health care and to determine out-of-pocket costs for psoriasis care. DESIGN: Cross-sectional survey. SETTING: Patients with psoriasis and psoriatic arthritis in the general community in the United States. PARTICIPANTS: A random sample of patients with psoriasis and psoriatic arthritis from more than 75,000 National Psoriasis Foundation members. MAIN OUTCOMES AND MEASURES: Number and type of physicians seen in the past 2 years and out-of-pocket health care expenses were measured. RESULTS: Among 5604 patients with psoriasis and psoriatic arthritis, 92.4% had seen at least 1 physician in 2 years. Compared with males, female patients with psoriasis were 1.47 times more likely to seek care (adjusted odds ratio, 1.47; 95% CI, 1.18-1.83). Patients with private insurance and Medicare were more likely to seek care compared with uninsured patients (adjusted odds ratio, 3.02; 95% CI, 2.23-4.08 and 2.85; 1.91-4.24, respectively). Among patients with psoriasis seeking care, 78.3% were seeing specialists; 22% obtained care from primary care physicians. Primary reasons for not seeking treatments included giving up on disease treatment (27.6%) and prohibitive cost (21%). Compared with patients with mild disease, patients with severe psoriasis were more likely to seek a specialist for care (adjusted odds ratio, 1.64; 95% CI, 1.37-1.98). Patients spent an average of $2528 out-of-pocket per year for psoriasis care. CONCLUSIONS AND RELEVANCE: About one-quarter of patients seek psoriasis care from primary care physicians, and insurance status affects care-seeking patterns. Giving up on treatment and prohibitive costs remain primary reasons for not seeking care.

Geriatric dermatology review: Major changes in skin function in older patients and their contribution to common clinical challenges.

There is a paucity of data to guide evidence-based treatment decisions in managing older dermatologic patients, in part because of the frequent exclusion of older adults from clinical trials. Hence, we provide a comprehensive review of important conditions in geriatric dermatology, or "dermatogeriatrics." It is our hope the field of "dermatogeriatrics" will become more evidence-based and recognized as a field in its own right so that we can better meet the needs of our growing numbers of older patients, now and in the future.

Geriatric dermatology: Part I. Geriatric pharmacology for the dermatologist.

Issues related to prescribing dermatologic drugs in the elderly are less recognized than age-related skin findings. This is related in part to the lack of a standardized residency training curriculum in geriatric dermatology. As the number of elderly patients rises in the United States, drug-related iatrogenic complications will become increasingly important. This review discusses age-related changes in pharmacokinetics and pharmacodynamics of common dermatologic drugs. These changes include volume of distribution, renal function, liver toxicity from interactions of commonly prescribed drugs, and medications that can decompensate cognition in the older patient population. We outline seven prescribing principles related to older dermatology patients, including useful strategies to reduce polypharmacy and improve drug adherence, using an evidence-based approach whenever possible.

Geriatric dermatology: Part II. Risk factors and cutaneous signs of elder mistreatment for the dermatologist.

Cutaneous signs may be the most visible hint of elder mistreatment. Dermatologists are in a unique position to recognize and report physical abuse and neglect in the older patient population. In this review, we describe the scope and impact, risk factors, cutaneous signs, and appropriate responses to suspected elder mistreatment. There is a critical need for additional evidence to inform clinical practice in the field of elder abuse and neglect. Recognition and reporting of suspected elder mistreatment by the dermatologist can be life-saving for the older patient.

Epigenetically mediated pathogenic effects of phenanthrene on regulatory T cells.

Phenanthrene (Phe), a polycyclic aromatic hydrocarbon (PAH), is a major constituent of urban air pollution. There have been conflicting results regarding the role of other AhR ligands 2,3,7,8- tetrachlorodibenzo-p-dioxin (TCDD) and 6-formylindolo [3,2-b]carbazole (FICZ) in modifying regulatory T cell populations (Treg) or T helper (Th)17 differentiation, and the effects of Phe have been understudied. We hypothesized that different chemical entities of PAH induce Treg to become either Th2 or Th17 effector T cells through epigenetic modification of FOXP3. To determine specific effects on T cell populations by phenanthrene, primary human Treg were treated with Phe, TCDD, or FICZ and assessed for function, gene expression, and phenotype. Methylation of CpG sites within the FOXP3 locus reduced FOXP3 expression, leading to impaired Treg function and conversion of Treg into a CD4(+)CD25(lo) Th2 phenotype in Phe-treated cells. Conversely, TCDD treatment led to epigenetic modification of IL-17A and conversion of Treg to Th17 T cells. These findings present a mechanism by which exposure to AhR-ligands mediates human T cell responses and begins to elucidate the relationship between environmental exposures, immune modulation, and initiation of human disease.

Primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations.

Primary psychiatric conditions encountered in dermatology include dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations. For these disorders, the primary pathologic condition involves the psyche; therefore, any cutaneous findings are self-induced. Herein, we review common primary psychiatric conditions in dermatology - dermatitis artefacta, neurotic excoriations and TTM - and examine their epidemiology, clinical presentation, differential diagnosis and treatment strategies. For all primary psychiatric disorders, the most effective underlying strategy is to first establish a strong therapeutic rapport with the patient. Various pharmacologic and non-pharmacologic therapies can then be attempted afterwards to successfully manage these patients.

Delusions of parasitosis.

Patients with delusions of parasitosis (DOP) are more commonly recognized in dermatology practices today. However, dermatologists may feel uncomfortable treating these patients because of the psychiatric nature of their disorder. As a result of the fact that DOP patients strongly prefer to seek treatment from dermatologists rather than mental health professionals, it is important for dermatologists to be well equipped with a basic understanding of the disorder and with tools to assist this patient population. In this review, we discuss the epidemiology, presentation, differential diagnosis and treatment strategy for patients with DOP.

Caution advised in interpretation of US FDA risk classification for dermatological medications during pregnancy.

Prescription and non-prescription medications are frequently used by women of childbearing age. As many as 40 to 80 percent of women receive at least one prescription drug during pregnancy. It is essential to understand the potential teratogenicity of medications and offer pregnant women appropriate counseling. Available classification references include the Swedish Catalogue of Approved Drugs, the US Food and Drug Administration, the Australian system, and the Evidence-Based Medicine system.

Trends in older adult psoriasis outpatient health care practices in the United States.

BACKGROUND: Psoriasis is among the top dermatologic diagnoses for older adult patients, and the number of older adult psoriasis patients is expected to rise. PURPOSE: To characterize trends in older adult psoriasis health care practices of US ambulatory physician offices from 1993 to 2009. METHODS: We used data from the National Ambulatory Medical Care Survey to assess demographics, specialties seen, and treatment in visits by older adult patients, 55 years of age and older. RESULTS: There were approximately 14.1 million outpatient visits for psoriasis among the older adult population during the study period. Older adult psoriasis patients were 52.4% female and 47.6% male. The most frequent older adult age group seen for psoriasis was the 55 to 64 year age group. Dermatologists saw 69.3% of patients, internists saw 14.5%, and general and family practitioners saw 11.6%. Topical corticosteroids were the most frequently prescribed medications. Dermatologists preferred clobetasol whereas non-dermatologists more commonly prescribed betamethasone. For both the 18 to 54 year age group and the 55 and older group, the leading 7 out of 10 medications prescribed were topical corticosteroids and calcipotriene. However, etanercept, coal tar, and fluocinolone were among the leading medications in the younger group but not in the 55 and older group. CONCLUSIONS: Treatment approach for older adult psoriasis patients showed some differences among medical specialties and among the younger and older age groups. Further research specific to older adult psoriasis patients is needed to determine optimal treatment strategies for this patient population.

Treatment of psoriasis and long-term maintenance using 308 nm excimer laser, clobetasol spray, and calcitriol ointment: a case series.

Psoriasis is a chronic inflammatory skin disease that is characterized by thickened red plaques covered with silvery scales. Excimer laser therapy is a cutting-edge advancement in UVB phototherapy. In contrast to traditional phototherapy, the 308 nm excimer laser only targets psoriasis plaques, while it spares uninvolved skin. It allows for treatment with a supra-erythmogenic dose of UVB irradiation. Targeted UVB therapy is a possible treatment especially for many who have failed topical treatments, systemic therapy, and traditional phototherapy. For safe and effective psoriasis treatment, a combination of therapies may be used, including a combination of laser treatment with topical medications. We present two cases demonstrating effective treatment with excimer laser in conjunction with clobetasol spray and calcitriol ointment for 12 weeks. Long-term near-clearance of psoriasis was sustained after 6 months and one-year follow up periods without further therapy.

The safety of systemic treatments that can be used for geriatric psoriasis patients: a review.

Background. Patients with moderate-to-severe psoriasis are often treated with systemic immunosuppressant agents that decrease immune system function. For the elderly, these medications are often problematic due to their already immunosuppressed state and comorbidities. However, there are few studies examining the effects of these medications on the elderly age group. Therefore, there is often discomfort among dermatologists treating elderly patients with psoriasis in utilizing systemic agents, frequently resulting in inadequate treatment. Objective. We review the safety profiles of systemic treatments often used to treat psoriasis and their possible adverse risks to the geriatric population. Methods. We conducted a search of PubMed's Medline database of articles published from 2000 to 2011, which resulted in 14 articles. Conclusion. Treating geriatric patients with moderate-to-severe psoriasis remains a challenge due to immunosenescence and comorbidities. More studies focusing on psoriasis treatment safety in the geriatric population are needed.

Excimer laser therapy for hairline psoriasis: a useful addition to the scalp psoriasis treatment algorithm.

Psoriasis is a chronic, inflammatory skin condition with negative impacts both physical and psychological. Scalp psoriasis, especially around the hairline, can cause significant impairment in quality of life due to its visibility. Options for treatment of facial psoriasis, including hairline involvement, are the use of low potency topical steroids, calcineurin inhibitors, and vitamin D analogues. Though the use of excimer laser for scalp psoriasis has been reported, there are no cases or studies specifically examining excimer laser phototherapy for the treatment of hairline psoriasis. We present a case of rapid improvement of hairline psoriasis using a regimen of 308 nm excimer laser with clobetasol spray and recommend an algorithm for the optimal treatment of scalp psoriasis utilizing currently available antipsoriatic therapies.

Quality-of-life instruments: evaluation of the impact of psoriasis on patients.

The negative impact of psoriasis on a patient's quality of life (QoL) is well documented in the literature. Patients often suffer poor self-esteem, difficulties in social interactions, and significant psychological distress. It is, therefore, critically important that a clinician evaluate the extent to which the disease impacts a patient's QoL. This chapter reviews several validated and reliable generic, dermatology-specific, and disease-specific QoL instruments useful in measuring the impact of psoriasis on patient's QoL. These QoL instruments can be especially helpful in identifying those patients who would most benefit from systemic or biologic therapy.

Porokeratotic eccrine ostial and dermal duct nevus treated with a combination erbium/CO2 laser: a case and brief review.

Porokeratotic eccrine ostial and dermal duct nevus (PEODDN) is an uncommon disease that presents early in childhood and is characterized by keratotic papules, often in a linear configuration. We describe a 12-year-old girl with characteristic lesions of PEODDN and describe her response to treatment with a combination CO2/Erbium laser. We also briefly review the literature on PEODDN.