A Systematic Review on Treatment Outcomes of Striae.

BACKGROUND: Striae are fine lines on the body that occur following rapid skin stretching (i.e., following pregnancy, puberty, weight change). The aim of this systematic review was to assess the current literature on treatment outcomes associated with striae. OBJECTIVE: (1) To assess the efficacy and safety of different treatment options reported for striae and (2) to determine the most efficient treatment options for each subtype of striae. METHODS: A systematic search was performed on MEDLINE, Embase, and PubMed with no publication date or language restrictions. All articles with original data and treatment outcomes were included. RESULTS: One hundred fifty-one studies on the treatment of striae met inclusion criteria (83% female, mean age at diagnosis = 30.2), and 4,806 treatment outcomes of striae were described. Energy-based devices were the most reported modality (56%; n = 2,699/4,806), followed by topicals (19%; n = 919/4,806) and combinations (12%; n = 567/4,806). The highest rates of complete response were injection-based devices for striae distensae (7%; n = 12/172), CO 2 lasers for striae alba (4%; n = 12/341), and platelet-rich plasma injections for striae rubra (31%; n = 4/13). CONCLUSION: Treatment options for striae are varied, likely indicating a lack of effective treatments due to the diversity in striae subtypes. Improved outcomes in striae management may be achieved with additional research on factors that predict treatment response.

Infectious Mononucleosis: An Updated Review.

BACKGROUND: Infectious mononucleosis is common among adolescents and young adults. Although the majority of cases resolve spontaneously, life-threatening manifestations, and complications have been recognised. OBJECTIVE: The purpose of this article is to familiarize clinicians with the clinical manifestations, evaluation, diagnosis, and management of infectious mononucleosis. METHODS: A search was conducted in October 2022 in PubMed Clinical Queries using the key terms "infectious mononucleosis" OR "Epstein-Barr virus" OR "EBV". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the aforementioned search was used in the compilation of the present article. RESULTS: Infectious mononucleosis, caused by Epstein-Barr virus, most commonly affects adolescents and adults aged 15 to 24 years. Epstein-Barr virus is transmitted primarily in saliva. Infectious mononucleosis is characterized by a triad of fever, tonsillar pharyngitis, and lymphadenopathy. Fatigue may be profound but tends to resolve within three months. Periorbital and/or palpebral edema, typically bilateral, occurs in one-third of patients. Splenomegaly and hepatomegaly occur in approximately 50% and 10% of cases, respectively. A skin rash, which is usually widely scattered, erythematous, and maculopapular, occurs in approximately 10 to 45% of cases. Peripheral blood leukocytosis is observed in most patients; lymphocytes make up at least 50% of the white blood cell differential count. Atypical lymphocytes constitute more than 10% of the total lymphocyte count. The classic test for infectious mononucleosis is the demonstration of heterophile antibodies. The monospot test is the most widely used method to detect the serum heterophile antibodies of infectious mononucleosis. When confirmation of the diagnosis of infectious mononucleosis is required in patients with mononucleosis-like illness and a negative mono-spot test, serologic testing for antibodies to viral capsid antigens is recommended. Infectious mononucleosis is a risk factor for chronic fatigue syndrome. Spontaneous splenic rupture occurs in 0.1 to 0.5% of patients with infectious mononucleosis and is potentially life-threatening. Treatment is mainly supportive. Reduction of activity and bed rest as tolerated are recommended. Patients should be advised to avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly is still present. Most patients have an uneventful recovery. CONCLUSION: Infectious mononucleosis is generally a benign and self-limited disease. Prompt diagnosis is essential to avoid unnecessary investigations and treatments and to minimize complications. Splenic rupture is the most feared complication. As avoiding exposure to EBV is almost impossible, the most effective way to prevent EBV infection and infectious mononucleosis is the development of an effective, safe, and affordable EBV vaccine that can confer life-long immunity.

Xeroderma pigmentosum: an updated review.

Background: Early recognition of xeroderma pigmentosum is important to minimize the complications arising from the harmful effects of exposure to ultraviolet radiation. This narrative review aims to familiarize physicians with the clinical features, diagnosis and management of xeroderma pigmentosum. Methods: A search was conducted in December 2021 in PubMed Clinical Queries using the key term "xeroderma pigmentosum". The search strategy included all clinical trials, observational studies and reviews published within the past 10 years. The information retrieved from the search was used in the compilation of this article. Results: Xeroderma pigmentosum is a condition of abnormal DNA repair of ultraviolet radiation-induced and oxidative DNA damage, which leads to increased skin cancer susceptibility. Approximately 50% of patients with xeroderma pigmentosum have increased photosensitivity and certain types of xeroderma pigmentosum are more prone to ocular disease and progressive neurodegeneration depending on the causative mutation. The diagnosis should be suspected in patients with increased photosensitivity and characteristic cutaneous, ophthalmological and neurological findings. A definite diagnosis can be made by the identification of biallelic mutation in one of the causative genes. Strict and consistent sun avoidance and protection and early detection and treatment of premalignant and malignant skin lesions are the mainstays of management. Treatment options for actinic keratosis include cryotherapy, topical imiquimod, topical 5-fluorouracil, chemical peeling, excision, CO2 laser resurfacing, fractional/pulsed laser therapy, and photodynamic therapy. Cutaneous malignancy can be treated by photodynamic therapy, curettage and electrodesiccation, or surgical excision. Oral isotretinoin, oral niacinamide, topical imiquimod and topical fluorouracil can be used for the prevention of skin malignancy. Treatment options for poikiloderma include chemical peeling, dermabrasion and laser resurfacing. Methylcellulose eyedrops and soft ultraviolet-protective contact lenses may be used to keep the cornea moist and protect against the harmful effects of keratitis sicca. Investigational therapies include the use of T4 endonuclease-V liposome lotion and oral nicotinamide to reduce the rate of actinic keratoses and non-melanoma skin cancers and gene therapy for radical cure of this condition. Conclusion: Although currently there is no cure for xeroderma pigmentosum, increased awareness and early diagnosis of the condition, followed by rigorous sun avoidance and protection and optimal management, can dramatically improve the quality of life and life expectancy.

Acanthosis Nigricans: An Updated Review.

BACKGROUND: Early recognition of acanthosis nigricans is important because acanthosis nigricans can be a cutaneous manifestation of a variety of systemic disorders and, rarely, as a sign of internal malignancy. OBJECTIVE: The purpose of this article is to familiarize pediatricians with the clinical manifestations, evaluation, diagnosis, and management of acanthosis nigricans. METHODS: A search was conducted in November 2021in PubMed Clinical Queries using the key term "acanthosis nigricans". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article. RESULTS: Acanthosis nigricans is characterized by symmetric, hyperpigmented, and velvety plaques with ill-defined borders, typically involving intertriginous areas. Obesity is the most common cause of acanthosis nigricans which is increasingly observed in obese children and adolescents and can serve as a cutaneous marker of insulin resistance. Early recognition of acanthosis nigricans is important because acanthosis nigricans can also be a cutaneous manifestation of a variety of systemic disorders and, rarely, as a sign of internal malignancy. This may consist of weight reduction, discontinuation of causative drugs, treatment of underlying endocrinopathy, or treatment of an underlying malignancy. For patients with isolated acanthosis nigricans and for those whose underlying cause is not amenable to treatment, treatment of the lesion may be considered for cosmetic reasons. Topical retinoids, vitamin D analogs, chemical peels, and other keratolytics are often used for the treatment of localized lesions. Seldom, systemic therapy such as oral retinoids may be considered for extensive or generalized acanthosis nigricans and acanthosis nigricans unresponsive to topical therapy. Other uncommon treatment modalities include dermabrasion, laser therapy, and surgical removal. CONCLUSION: Although acanthosis nigricans is treatable, a complete cure is difficult to achieve. The underlying cause should be treated, if possible, to resolve and prevent the recurrence of acanthosis nigricans. The diagnosis is mainly clinical, based on the characteristic appearance (symmetrically distributed, hyperpigmented, velvety, papillomatous, hyperkeratotic plaques with ill-defined borders) and the typical sites (intertriginous areas, flexural area, and skin folds) of the lesions. The diagnosis might be difficult for lesions that have atypical morphology or are in an unusual location. Clinicians should be familiar with the clinical signs, evaluation, diagnosis, and therapy of acanthosis nigricans because of the link between it and underlying diseases.

Henoch-Schönlein Purpura in Children: An Updated Review.

BACKGROUND: Henoch-Schönlein purpura (HSP) is an IgA-mediated systemic smallvessel vasculitis with a predilection for the skin, gastrointestinal tract, joints, and kidneys. It is the most common form of systemic vasculitis in children. OBJECTIVE: The study aimed to familiarize physicians with the etiopathogenesis, clinical manifestations, evaluation, and management of children with Henoch-Schönlein purpura. METHODS: A PubMed search was conducted in January 2020 in Clinical Queries using the key terms "Henoch-Schönlein purpura" OR "IgA vasculitis" OR "anaphylactoid purpura". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. This paper is based on, but not limited to, the search results. RESULTS: Globally, the incidence of HSP is 10 to 20 cases per 100, 000 children per year. Approximately 90% of cases occur in children between 2 and 10 years of age, with a peak incidence at 4 to 7 years. The diagnosis should be based on the finding of palpable purpura in the presence of at least one of the following criteria, namely, diffuse abdominal pain, arthritis or arthralgia, renal involvement (hematuria and/or proteinuria), and a biopsy showing predominant IgA deposition. Most cases are self-limited. The average duration of the disease is 4 weeks. Long-term complications are rare and include persistent hypertension and end-stage kidney disease. Therapy consists of general and supportive measures as well as treatment of the sequelae of the vasculitis. Current evidence does not support the universal treatment of HSP patients with corticosteroids. Oral corticosteroids may be considered for HSP patients with severe gastrointestinal pain and gastrointestinal hemorrhage. CONCLUSION: Most cases of HSP have an excellent outcome, with renal involvement being the most important prognostic factor in determining morbidity and mortality. Unfortunately, early steroid treatment does not reduce the incidence and severity of nephropathy in children with HSP. In HSP children who have severe nephritis or renal involvement with proteinuria of greater than 3 months, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker should be considered in addition to corticosteroids to prevent and/or limit secondary glomerular injury.

Satisfaction and Awareness of Systemic Psoriasis Treatments: A National Survey Comparing Biologic and Nonbiologic Users.

BACKGROUND:: There is ongoing development of new therapies for psoriasis, including biologic and systemic agents such as interleukin-17, interleukin-23, and phosphodiesterase-4 inhibitors. The development of these agents has changed the landscape of psoriasis treatment options. OBJECTIVE:: The objective of this study was to characterize the impact of newer biologic and systemic agents approved by June 2016 on patient outcomes. We sought to evaluate and compare biologic users and nonbiologic systemic users with respect to their treatment awareness and satisfaction. METHODS:: We conducted a national Canadian survey from July to September 2016 on adult patients with moderate-to-severe psoriasis using biologic agents or nonbiologic systemic agents as their current primary treatment modality. Patients were asked to evaluate their overall satisfaction with their treatment agent and their awareness of other treatment options. Responses from biologic and nonbiologic systemic users were compared. RESULTS:: Overall, 343 participants were included (biologic users: n = 218; nonbiologic users: n = 125). Treatment satisfaction: Biologic users had a higher overall satisfaction score than nonbiologic users ( P < .001). Among nonbiologic agents, apremilast (62%) was associated with the highest satisfaction proportion. Among biologic agents, ustekinumab (77%) and adalimumab (72%) were associated with the highest proportions of satisfaction. With respect to treatment awareness, 30% of nonbiologic patients did not have enough information to form an opinion about biologics. CONCLUSIONS:: This study demonstrates the greater treatment satisfaction of biologic users compared with nonbiologic users for moderate-to-severe psoriasis. Given that nearly one-third of nonbiologic users did not have enough information to form an opinion about biologic agents, physicians may consider counselling these patients on the use of biologic agents for psoriasis management.

Penile warts: an update on their evaluation and management.

BACKGROUND: Penile warts are the most common sexually transmitted disease in males. Clinicians should be familiar with the proper evaluation and management of this common condition. OBJECTIVE: To provide an update on the current understanding, evaluation, and management of penile warts. METHODS: A PubMed search was completed in Clinical Queries using the key terms 'penile warts' and 'genital warts'. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. RESULTS: Penile warts are caused by human papillomavirus (HPV), notably HPV-6 and HPV-11. Penile warts typically present as asymptomatic papules or plaques. Lesions may be filiform, exophytic, papillomatous, verrucous, hyperkeratotic, cerebriform, fungating, or cauliflower-like. Approximately one-third of penile warts regress without treatment and the average duration prior to resolution is approximately 9 months. Active treatment is preferable to watchful observation to speed up clearance of the lesions and to assuage fears of transmission and autoinoculation. Patient-administered therapies include podofilox (0.5%) solution or gel, imiquimod 3.75 or 5% cream, and sinecatechins (polypheron E) 15% ointment. Clinician-administered therapies include podophyllin, cryotherapy, bichloroacetic or trichloroacetic acid, oral cimetidine, surgical excision, electrocautery, and carbon dioxide laser therapy. Patients who do not respond to first-line treatments may respond to other therapies or a combination of treatment modalities. Second-line therapies include topical/intralesional/intravenous cidofovir, topical 5-fluorouracil, and topical ingenol mebutate. CONCLUSION: No single treatment has been shown to be consistently superior to other treatment modalities. The choice of the treatment method should depend on the physician's comfort level with the various treatment options, the patient's preference and tolerability of treatment, and the number and severity of lesions. The comparative efficacy, ease of administration, adverse effects, cost, and availability of the treatment modality should also be taken into consideration.

Nevus Lipomatosus Superficialis on the Left Proximal Arm.

We report a 58-year-old woman with a solitary type of nevus lipomatosus superficialis on the left proximal arm. To our knowledge, the occurrence of a solitary type of nevus lipomatosus superficialis on the arm has very rarely been reported. A perusal of the literature revealed but one case, to which we are going to add another one. Recognition of this clinical manifestation is important so that a proper diagnosis can be made.

Canadian Clinical Practice Guidelines for Rosacea.

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.

A consensus on acne management focused on specific patient features.

BACKGROUND: Most treatment guidelines for acne are based on clinical severity. Our objective was to expand that approach to one that also comprised individualized patient features: a case-based approach. METHODS: An expert panel of Canadian dermatologists was established to develop demographic and clinical features considered to be particularly important in acne treatment selection. A nominal group consensus process was used for inclusion of features and corresponding appropriate treatments. RESULTS: Consensus was achieved on the following statements: follicular epithelial dysfunction contributes to acne pathogenesis; inflammation from underlying disease(s) or prior treatment may impact further patient management; management focusing on specific patient features and on addressing psychosocial factors, including impact on quality of life, may improve treatment adherence and outcomes; and case-based scenarios are a practical approach to illustrate the effect of these factors. To address the latter, eight case profiles were developed. CONCLUSIONS: Management of acne should be based on multifactorial considerations beyond clinically determined acne severity and should include patient-reported impact, gender, skin sensitivity (including preexisting dermatoses), and phototype.

Pathway to dry skin prevention and treatment.

BACKGROUND: This article presents an evidence-supported clinical pathway for dry skin prevention and treatment. OBJECTIVE: The development of the pathway involved the following: a literature review was conducted and demonstrated that literature on dry skin is scarce. To compensate for the gap in the available literature, a modified Delphi method was used to collect information on prevention and treatment practice through a panel, which included 10 selected dermatologists who currently provide medical care for dermatology patients in Ontario. An advisor experienced in this therapeutic area guided the process, including a central meeting. Panel members completed a questionnaire regarding their individual practice in caring for these patients and responded to questions on assessment of dry skin etiology, frequency of skin care visits for consultation and follow-up, assessment, and referral to other specialties. The panel members reviewed a summary of all responses and reached a consensus. The result was presented as a clinical pathway. CONCLUSION: The panel concluded that our current awareness of dry skin and therefore prevention and effective treatment is limited; that identifying dry skin and its clinical issues requires tools such as clinical pathways, which may improve patient outcomes; and that additional research on dry skin etiology, prevention, and treatment is necessary.

Cutaneous manifestations of modern technology use.

BACKGROUND: Modern-age technology is increasingly implicated in traditional dermatologic conditions. OBJECTIVE: This review provides a concise overview of the cutaneous manifestations from modern technology use. METHODS: We describe a case of laptop computer-induced erythema ab igne and provide a review of the literature pertaining to the etiology, clinical features, diagnosis, and management of reported cases of dermatoses resulting from the use of modern technology. RESULTS: Sources of modern technology implicated in the reported cases include video games, laptop computers, personal computers and accessories, and smart and cellular phones. These presentations have primarily been localized to the extremities, particularly the hands and face. Diagnoses were associated with trauma or repetitive strain, irritant contact dermatitis, or allergic contact sensitivities. Removal of the offending agent was most often described as effective in symptom resolution. CONCLUSION: It is important to consider modern-age sources as part of the index of suspicion for diagnosing traditional dermatologic conditions. These manifestations will likely increase over time with the pervasive popularity and use of modern technology. Early recognition of the offending agent will be beneficial in differentiating the etiology for effective management.