Discrepancies by dermatology resident gender in diagnostic confidence and management of female and male genital lichen sclerosus.

Physician gender may impact their exposure to genital dermatoses during residency. The purpose of this study was to survey current dermatology residents regarding their comfort in diagnosing and managing lichen sclerosus. As residents progress through training, confidence improves in diagnosing and managing both male and female lichen sclerosus. However, residents overall feel less comfortable with male genital lichen sclerosus, with female residents displaying the greatest confidence discrepancy. This study highlights gender discrepancies with dermatology resident confidence and practice habits and may serve to further guide curricula to address these disparities.

Etiologies and management of cutaneous flushing: Nonmalignant causes.

The flushing phenomenon may represent a physiologic or a pathologic reaction. Although flushing is usually benign, it is prudent that the physician remains aware of potentially life-threatening conditions associated with cutaneous flushing. A thorough investigation should be performed if the flushing is atypical or not clearly associated with a benign underlying process. The diagnosis often relies on a pertinent history, review of systems, physical examination, and various laboratory and imaging modalities, all of which are discussed in the 2 articles in this continuing medical education series. This article reviews flushing associated with fever, hyperthermia, emotions, menopause, medications, alcohol, food, hypersensitivity reactions, rosacea, hyperthyroidism, dumping syndrome, superior vena cava syndrome, and neurologic etiologies.

Etiologies and management of cutaneous flushing: Malignant causes.

The second article in this 2-part continuing medical education series reviews the following malignant causes of flushing: mastocytosis, medullary thyroid carcinoma, pheochromocytoma, carcinoid tumors, gastroenteropancreatic neuroendocrine tumors, bronchogenic carcinoma, vasointestinal polypeptide secreting tumors, and renal cell carcinoma. The information provided will allow physicians to better distinguish patients who have worrisome presentations that require a more thorough investigation. Appropriate diagnostic workup and treatment options for these malignancies are reviewed.

Varicella zoster virus encephalitis in a patient with disseminated herpes zoster: report and review of the literature.

Herpes zoster infection occurs owing to reactivation of varicella zoster virus and classically manifests as a vesicular eruption involving a single dermatome. Disseminated herpes zoster - defined as having greater than twenty vesicles outside the primary or adjacent dermatome - is uncommon and typically occurs in immunocompromised individuals. Central nervous system complications during or following a zoster outbreak are exceedingly rare. Encephalitis is reported to affect only 0.1-0.2% of patients and occurs more often in disseminated cases and in outbreaks involving those dermatomes in close proximity to the central nervous system. We present an elderly woman with disseminated herpes zoster and altered mental status who was subsequently diagnosed with varicella zoster virus encephalitis and describe the characteristics of patients with disseminated zoster who developed varicella zoster virus encephalitis.

Apremilast in Recalcitrant Cutaneous Dermatomyositis: A Nonrandomized Controlled Trial.

Importance: Cutaneous disease in dermatomyositis has no standardized treatment approach and so presents a challenging task for patients and clinicians. Objective: To study the efficacy and safety of apremilast as an add-on therapy in patients with recalcitrant cutaneous dermatomyositis. Design, Setting, and Participants: This phase 2a, open-label, single-arm nonrandomized controlled trial was conducted at a single center from June 2018 to June 2021. Participants were 8 patients with recalcitrant cutaneous dermatomyositis, defined by a cutaneous disease activity severity index (CDASI) score greater than 5 despite treatment with steroids, steroid-sparing agents, or both. Data were analyzed from June 2018 to June 2021. Interventions: Apremilast 30 mg orally twice daily was added to ongoing treatment regimens. Main Outcomes and Measures: The primary outcome was the overall response rate (ORR) at 3 months. Key secondary outcomes were the safety and toxicity of apremilast and the durability of response at 6 months. The CDASI, muscle score, dermatology life quality index (DLQI), and depression assessments were performed at baseline and regularly until month 7. Skin biopsies were performed at baseline and 3 months after apremilast (defined as 3 months into active apremilast therapy) and tested for gene expression profiling and immunohistochemical stains. Adverse events were assessed using the Common Terminology Criteria for Adverse Events version 5.0. Results: Among 8 patients with recalcitrant cutaneous dermatomyositis (all women; mean [SD] age, 54 [15.9] years), a response was found at 3 months after apremilast among 7 patients (ORR, 87.5%). The mean (SD) decrease in CDASI was 12.9 (6.3) points at 3 months (P < .001). Apremilast was well tolerated, with no grade 3 or higher adverse events. Sequencing of RNA was performed on skin biopsies taken from 7 patients at baseline and at 3 months after therapy. Appropriate negative (ie, no primary antibody) and positive (ie, tonsil and spleen) controls were stained in parallel with each set of slides studied. Of 39 076 expressed genes, there were 195 whose expression changed 2-fold or more at P < .01 (123 downregulated and 72 upregulated genes). Gene set enrichment analysis identified 13 pathways in which apremilast was associated with downregulated expression, notably signal transducers and activators of transcription 1 (STAT1), STAT3, interleukin 4 (IL-4), IL-6, IL-12, IL-23, interferon γ (IFNγ), and tumor necrosis factor α (TNFα) pathways. In immunohistochemical staining, there was a mean (SD) decrease in phosphorylation levels STAT1 (22.3% [28.3%] positive cells) and STAT3 (13.4% [11.6%] positive cells) at the protein level, a downstream signaling pathway for the downregulated cytokines. Conclusions and Relevance: These findings suggest that apremilast was a safe and efficacious add-on treatment in recalcitrant dermatomyositis, with an overall response rate of 87.5% and associations with downregulation of multiple inflammatory pathways. Trial Registration: ClinicalTrials.gov Identifier: NCT03529955.

Biologic therapy in psoriasis: navigating the options.

Psoriasis is a T cell-mediated inflammatory disease associated with comorbidities impacting the overall health and quality of life of those affected. This article offers a brief overview of treatment classes available and an approach to choosing biologic treatments based on individual patient characteristics, including disease severity, comorbidities, and ultimate treatment goals.