American Academy of Dermatology Guidelines for Managing Atopic Dermatitis.

The American Academy of Dermatology first published a series of guidelines for diagnosing and managing atopic dermatitis in 2014. Twelve clinicians were selected to review, grade, and offer clinical insight on available data regarding the clinical features, symptomology, pathophysiology, education, treatment, and emerging clinical studies on atopic dermatitis (AD). Based on these findings, the AAD released a guideline to streamline information on atopic dermatitis for physicians, recommending using clinical evidence to diagnose and first treating with nonpharmacologic therapies to restore the natural skin barrier. Topical pharmacologic therapies were recommended for improving pruritus and inflammation and newer systemic agents for clinically relevant moderate-to-severe cases. Evidence-based practices were emphasized in comparison to those that lacked therapeutic data. To highlight the emerging evidence and pharmacologic breakthroughs in atopic dermatitis, the AAD produced an updated set of guidelines educating physicians on new agents and their role in treatment. This chapter reviews the AAD guidelines as a tool for managing atopic dermatitis and staying up to date on disease advancements.

The Future of Atopic Dermatitis Treatment.

This chapter thoroughly examines recent breakthroughs in atopic dermatitis (AD) treatment, with a primary focus on the medications in the development pipeline. Biologics agents targeting new interleukin receptors like interleukin-31, interleukin-22, and interleukin-2 are discussed along with the novel pathway looking at the OX40-OX40L interaction. Oral agents and small molecule therapies like Janus kinase inhibitors, sphingosine-1-phosphate modulators, and Bruton's tyrosine kinase inhibitors are also discussed along with the various new topical medications. Newly approved topicals like phosphodiesterase-4 and JAK inhibitors are highlighted while also discussing the potential of tapinarof and emerging microbiome-targeted therapies. Beyond conventional approaches, the chapter touches upon unconventional therapies currently being studied. The goal of this chapter is to discuss new advances in AD treatment from medications in the initial stages of development to those nearing FDA approval.

Review of Tralokinumab in the Treatment of Atopic Dermatitis.

OBJECTIVE: To review pharmacokinetics, efficacy, and safety of tralokinumab in treatment of atopic dermatitis (AD). DATA SOURCES: Literature review was conducted using MEDLINE (PubMed), EMBASE, and ClinicalTrials.gov for articles published between January 2010 and May 2022. STUDY SELECTION AND DATA EXTRACTION: Articles in English discussing tralokinumab in AD were included. DATA SYNTHESIS: In one phase 2 trial, more subjects treated with tralokinumab 150 and 300 mg achieved an Investigator's Global Assessment (IGA) of 0/1 with minimum ≥2 point IGA reduction (23%), versus placebo (11.8%, P = 0.10). During 2 phase 3 trials, more subjects treated with tralokinumab achieved IGA success (ECZTRA 1: 15.8% and ECZTRA 2: 22.2%), versus placebo (7.1% and 10.9%, respectively; P = 0.002 and P < 0.001). During one phase 3 trial, in conjunction with topical corticosteroids (TCS), more subjects treated with tralokinumab 300 mg achieved IGA success (ECZTRA 3: 38.9%), versus placebo (26.2%, P = 0.015). During another phase 3 trial in subjects with resistance or contraindication to oral cyclosporine, more subjects treated with tralokinumab 300 mg achieved an Eczema Area Severity Index 75 (64.2%), versus placebo (50.5%, P = 0.018). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Tralokinumab is efficacious for moderate-to-severe AD, as monotherapy, in conjunction with TCS, and resistance or contraindication to cyclosporine. Although IL-4 and IL-13 are both implicated in AD's pathogenesis, IL-13 is overexpressed, and head-to-head trials are needed to assess efficacy of tralokinumab, versus dupilumab. Compared with upadacitinib and abrocitinib, tralokinumab is not associated with black-box warnings. CONCLUSIONS: Tralokinumab is an efficacious and safe systemic treatment for moderate-to-severe AD.

Characterizing the burden of calciphylaxis: a qualitative analysis.

Calciphylaxis is a debilitating disease associated with high mortality and morbidity secondary to pain, nonhealing wounds and frequent hospital admissions. We qualitatively assessed the burden of calciphylaxis on patient quality of life through semi-structured interviews with nine adult participants. Participants identified an inability to complete activities of daily living because of mobility impairment and decreased strength, although most denied complete dependence on others. All participants described pain as the worst aspect of disease, citing a variable course, unpredictability in severity and poor control despite medical therapy. Calciphylaxis also caused feelings of sadness and anger, having a negative impact on self-confidence. Supportive care needs to address the pervasive and severe nature of pain, mobility impairment and psychiatric comorbidities; such interventions may decrease the overall burden for patients with calciphylaxis.

Assessing clinical competence: a multitrait-multimethod matrix construct validity study.

Education in Doctor of Medicine programs has moved towards an emphasis on clinical competency, with entrustable professional activities providing a framework of learning objectives and outcomes to be assessed within the clinical environment. While the identification and structured definition of objectives and outcomes have evolved, many methods employed to assess clerkship students' clinical skills remain relatively unchanged. There is a paucity of medical education research applying advanced statistical design and analytic techniques to investigate the validity of clinical skills assessment. One robust statistical method, multitrait-multimethod matrix analysis, can be applied to investigate construct validity across multiple assessment instruments and settings. Four traits were operationalized to represent the construct of critical clinical skills (professionalism, data gathering, data synthesis, and data delivery). The traits were assessed using three methods (direct observations by faculty coaches, clinical workplace-based evaluations, and objective structured clinical examination type clinical practice examinations). The four traits and three methods were intercorrelated for the multitrait-multimethod matrix analysis. The results indicated reliability values in the adequate to good range across the three methods with the majority of the validity coefficients demonstrating statistical significance. The clearest evidence for convergent and divergent validity was with the professionalism trait. The correlations on the same method/different traits analyses indicated substantial method effect; particularly on clinical workplace-based assessments. The multitrait-multimethod matrix approach, currently underutilized in medical education, could be employed to explore validity evidence of complex constructs such as clinical skills. These results can inform faculty development programs to improve the reliability and validity of assessments within the clinical environment.

A Case Series on the Use of Brentuximab Vedotin for the Treatment of Mycosis Fungoides.

BACKGROUND: Brentuximab vedotin (BV) is an anti-CD30 monoclonal antibody that appears to be more effective against CD30-expressing cutaneous T-cell lymphoma (CTCL) compared to current standard-of-care treatments.   Objective: To determine the real-world efficacy and adverse effects of BV use in patients with mycosis fungoides (MF) who were treated with BV at Atrium Health Wake Forest Baptist Medical Center. METHODS: Study staff performed a retrospective chart review of patients diagnosed with MF who were prescribed BV at Atrium Health Wake Forest Baptist Comprehensive Cancer Center. RESULTS:   Regardless of their response to BV, all patients in our cohort had higher CD30 positivity on subsequent biopsies compared to their initial skin biopsy.  Conclusions: Improved understanding of appropriate CD30 testing and evaluation will allow for quicker invention of patients with BV responsive CTCL.  J Drugs Dermatol. 2023;22(12):e33-e34.    doi:10.36849/JDD.6981e.

Dermatology through the lens of social media: A qualitative study among adolescents.

Social media (SM) use has accelerated at an unprecedented pace and dermatology literature evaluating SM use is primarily centered on the quality and quantity of dermatologic content, with minimal research on how adolescent patients experience such content. We recruited 15 patients between the ages of 13-18 years from the Atrium Health Wake Forest Baptist Department of Dermatology to interview regarding their experience with dermatologic content on SM. Despite most participants' insightful comments on SM use and the relative lack of dermatologic content validation on SM, many participants adopted skin care advice from SM. Adolescents are particularly vulnerable to social influence and it is important dermatologists understand how pervasive skin-related content is on these platforms.

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease.

BACKGROUND: Patient outcomes are improved when dermatologists provide inpatient consultations. Inpatient access to dermatologists is limited, illustrating an opportunity to use teledermatology. Little is known about the ability of dermatologists to accurately diagnose disease and manage inpatients with teledermatology, particularly when using nondermatologist-generated clinical data. METHODS: This prospective study assessed the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care center, using internal medicine referral documentation and photographs. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the κ statistic. RESULTS: There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ = 0.83), substantial agreement in laboratory evaluation decisions (median κ = 0.67), almost perfect agreement in imaging decisions (median κ = 1.0), and moderate agreement in biopsy decisions (median κ = 0.43). There was almost perfect agreement in treatment (median κ = 1.0), but no agreement in follow-up planning (median κ = 0.0). There was no association between raw photograph quality and the primary plus differential diagnosis or primary diagnosis alone. LIMITATIONS: Selection bias and single-center nature. CONCLUSIONS: Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.

Multidermatomal herpes zoster: a pain in the neck?

Herpes zoster classically presents as a vesicular eruption along a single dermatome that correlates with the dorsal root ganglion in which varicella zoster virus (VZV) reactivates. Such cases most commonly involve a single thoracic dermatome, but other rare presentations of herpes zoster have been reported including multidermatomal herpes zoster. This letter reports a case of multidermatomal herpes zoster affecting cervical dermatomes C2-C5 and presents all previously published cases of multidermatomal herpes zoster in which involved dermatomes were reported to determine if this condition has a predilection for cervical dermatomes. A total of eight other cases were reviewed and involvement of cervical dermatomes was observed in 6 of 9 cases (66.7%). This suggests a propensity for multidermatomal involvement to affect cervical dermatomes beyond that encountered in classic herpes zoster. Clinicians should be aware of this presentation of herpes zoster especially in the head and neck region where the classic vesicular eruption may not be confined to a single dermatome.

Public Perception of Ethical Issues in Dermatology: Evidenced by New York Times Commenters.

BACKGROUND: A 2017 New York Times (NYT) article questioning the appropriateness of skin cancer treatment modality by dermatology providers stimulated discussion among the public pertaining to ethics in the current state of dermatologic practice. OBJECTIVE: The purpose of this study is to characterize issues raised by the comments on the NYT article, discuss strategies to address these concerns, and encourage reflection on ethics in dermatologic care. MATERIALS AND METHODS: A qualitative analysis was performed on the 309 comments on the NYT article. General themes were identified, resulting in the inclusion of 222 comments. These comments were reviewed and characterized by the type of commenter, his or her stance on health care, and what issues they raised. RESULTS: Providers interested in "profit over patient" was the most common theme, followed by mistrust of APPs, health care system interested in "profit over patient," inadequate supervision by advanced practice providers (APPs), finding the "right" provider, support for coordinated APP and physician care, support for APP credentials, and finally inappropriate elderly care. CONCLUSION: The NYT article raises the concern of identifying quality care and choosing the "right provider"-one who successfully balances the various incentives affecting skin cancer management including appropriate usage of APPs.

Early Congenital Syphilis: Recognising Symptoms of an Increasingly Prevalent Disease.

BACKGROUND: Congenital syphilis (CS) is an infectious disease resulting from transplacental transmission of Treponema pallidum spirochetes from an infected mother to fetus during pregnancy. While uncommon, CS has shown an increased incidence in Canada and the United States since 2001 and 2012, respectively. CASE REPORT: We present the case of a 5-week-old female infant with blistering rash on the palms and soles. The infant displayed decreased movement of the left upper extremity, clinically consistent with Parrot pseudoparalysis. Cutaneous involvement was limited to few tan crusted papules on the palms and soles. Mother reported a "false-positive" result of rapid plasma reagin (RPR) testing at 31 weeks. Cerebrospinal fluid studies of the infant resulted with positive Venereal Disease Research Laboratory (VRDL) test and positive microhemagglutination assay (MHA-TP). Histopathology of a crusted papule revealed a lichenoid infiltrate composed of lymphocytes, histiocytes, and plasma cells. Immunohistochemical staining for T pallidum was negative. The patient completed treatment with a 10-day course of intravenous penicillin. DISCUSSION: While CS is largely considered a historic entity, it has been increasing in incidence in the United States since 2012 and in Canada since the early 2000s. Diagnosis of CS can be difficult as infants may be asymptomatic or present with nonspecific signs. This case highlights the presentation of minimal cutaneous involvement as well as skeletal involvement after birth. RPR testing may result in false negatives or indeterminate results, further complicating diagnosis. Given these difficulties in screening and the increasing incidence of CS, clinicians may need to refamiliarise themselves with its clinical findings.

The Future of Atopic Dermatitis Treatment.

In recent years, there has been a growing movement towards the use of targeted therapies in treating of atopic dermatitis (AD), parallel to that which has occurred in psoriasis. Among the systemic medications being studied are subcutaneous or intravenously administered biologic drugs targeting specific molecules such as IL4, IL13, IL17, and IgE. Non-biologic oral therapies are also being developed for AD and include small molecule drugs targeting phosphodiesterase type IV (PDE4) inhibition or Janus Kinase (JAK) inhibition. Numerous topical formulations are also being studied, with some formulations that are novel therapies that act as topical biologic or small molecule agents with mechanisms of action similar to systemic treatments. Others are being developed as skin barrier repair therapies for reduction of AD symptoms. This chapter will discuss new advances in AD treatment from medications in the initial stages of development to those nearing FDA approval.