Atopic Dermatitis: Pathophysiology.

The pathophysiology of atopic dermatitis is complex and multifactorial, involving elements of barrier dysfunction, alterations in cell-mediated immune responses, IgE-mediated hypersensitivity, and environmental factors. Loss-of-function mutations in filaggrin have been implicated in severe atopic dermatitis due to a potential increase in trans-epidermal water loss, pH alterations, and dehydration. Other genetic changes have also been identified, which may alter the skin's barrier function, resulting in an atopic dermatitis phenotype. The imbalance of Th2 to Th1 cytokines observed in atopic dermatitis can create alterations in the cell-mediated immune responses and can promote IgE-mediated hypersensitivity, both of which appear to play a role in the development of atopic dermatitis. One must additionally take into consideration the role of the environment on the causation of atopic dermatitis and the impact of chemicals such as airborne formaldehyde, harsh detergents, fragrances, and preservatives. Use of harsh alkaline detergents in skin care products may also unfavorably alter the skin's pH causing downstream changes in enzyme activity and triggering inflammation. Environmental pollutants can trigger responses from both the innate and adaptive immune pathways. This chapter will discuss the multifaceted etiology of atopic dermatitis, which will help us to elucidate potential therapeutic targets. We will also review existing treatment options and their interaction with the complex inflammatory and molecular triggers of atopic dermatitis.

Guanfacine treatment for a patient with delusional parasitosis causing dermatillomania presenting with shared psychiatric disorders.

Dermatillomania often coexists with delusional parasitosis (DP) and can cause extreme patient morbidity. The standard treatment for DP has been conventional antipsychotic drugs; however, their use is limited by potential adverse effects and monitoring requirements. Guanfacine, an alpha-2 adrenergic receptor agonist, has emerged as a promising alternative for patients with attention deficit hyperactivity disorder with concurrent tics. Although no current research supports guanfacine's efficacy in managing DP or dermatillomania, its pharmacological profile hints at potential benefits. A 58-year-old woman presented to our clinic for DP causing dermatillomania and was started on guanfacine. She reported fewer beliefs about parasites infesting her body and had fewer excoriating lesions on this medication. Additionally, her Patient Health Questionnaire-9 score peaked with a score of 23 at diagnosis and significantly decreased to 13 three months after starting guanfacine. However, further research is needed to ascertain if guanfacine is an effective treatment for DP.

Relation of satisfaction score with payer class in dermatology patients.

As value-based reimbursement continues to grow as a means of compensation in the US healthcare system, ensuring effective evaluation of patient care is becoming increasingly important. The aim of this study was to systematically collect and review data to identify potential patient bias based on a nonmodifiable patient characteristic, payer type, in patient satisfaction scores from an academic dermatology clinic setting. This retrospective study used Press Ganey self-reported, deidentified patient satisfaction surveys completed at Texas Tech University Health Sciences Center's outpatient dermatology clinic between January 1, 2010, and December 21, 2021, with a total of 21,408 surveys included in the study. The results found the self-pay/uncompensated group reported the highest mean satisfaction score (96.25%), followed by other government (94.76%), Medicare (94.34%), commercial (92.82%), workers' comp (88.10%), and Medicaid (82.78%). Analysis of variance resulted in an F value of 3.02 (P < 0.01). This study confirmed the results of existing research suggesting that payer class significantly impacts patient experience scores.

A tale of three common nipple diseases.

Paget's disease of the nipple is a rare breast carcinoma of the nipple-areola complex and is often associated with an underlying in situ or invasive carcinoma. It clinically presents as a thickened, erythematous, weeping or crusted lesion with irregular borders. Paget's cells invading the epidermis are the hallmark histopathologic feature, and cytokeratin 7 staining is positive in nearly all cases. However, the diagnosis of Paget's disease may be delayed or missed in favor of clinically similar benign nipple processes such as nipple adenoma and nipple dermatitis. We present a case of Paget's disease of the nipple in a 73-year-old woman with a brief review of other common nipple diseases.

The clinical evolution of lichen planus pemphigoides.

Lichen planus pemphigoides (LPP) is a rare autoimmune subepidermal blistering disease characterized by lichenoid and bullous lesions. LPP is generally thought to be idiopathic, possibly related to medication or malignancy, or potentially the result of long-standing lichenoid inflammation damaging the basement membrane zone leading to epitope spreading. The histological appearance of lichenoid and bullous lesions in LPP resembles findings of lichen planus and bullous pemphigoid, respectively. We present a case of LPP in a 64-year-old woman with a brief historical review of the establishment of LPP as a separate disease entity and a discussion of similarities and differences of LPP with other lichenoid and blistering dermatoses.

Transfollicular elimination of sebaceous glands in a patient with disseminate and recurrent infundibulofolliculitis.

Disseminate and recurrent infundibulofolliculitis (DRIF) is a rare form of folliculitis characterized by multiple papules widely distributed on the trunk and extremities. We present a 37-year-old man with confirmed DRIF complicated by transfollicular elimination of the sebaceous unit, an additional finding of DRIF that has rarely been reported.

Ixekizumab and herpes zoster in an erythrodermic patient.

Ixekizumab is an injectable monoclonal antibody against IL-17A approved by the US Food and Drug Administration for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis. We present what we believe is the first case of herpes zoster (shingles) in a patient 12 weeks after starting ixekizumab for presumed erythrodermic psoriasis. It is important to be aware of potential side effects of immunomodulatory medications, particularly those that are new to the market.

Value of Dermatology Nights at a student-run free clinic.

The Free Clinic at Lubbock Impact is a student-run free clinic affiliated with the Texas Tech University Health Sciences Center in Lubbock, Texas. Every Wednesday, the clinic provides free health services to the uninsured patient population of Lubbock and the surrounding West Texas regions. In addition to the weekly essential primary care services, "Dermatology Night" is held once a month for patients in need of dermatologic care. The study presents a cost analysis of the dermatologic procedures performed at The Free Clinic Dermatology Nights over a 2-year period from February 2018 through January 2020 using current procedural terminology codes and Medicare reimbursement rates. The dermatologic procedures performed in this time were valued at $8412.37. The study emphasizes the value of Dermatology Nights at a free clinic and reflects the dermatologic-specific needs of the uninsured Lubbock and West Texas patient population.

Classic features of primary systemic amyloidosis (AL amyloidosis) leading to diagnosis of plasma cell myeloma.

The diagnosis of primary systemic amyloidosis, also known as AL (amyloid light-chain) amyloidosis, is often delayed owing to its nonspecific manifestations as well as its rarity. A 64-year-old woman presented with an eight-month history of significant weight loss, anemia, fatigue, and progressive painful cutaneous lesions on her hands, lips, back, perianal, and vulvar area that were originally treated unsuccessfully with antimalarials and systemic corticosteroids. Histopathological examination revealed an amorphous dermis with pale pink material that demonstrated positive birefringence with Congo red staining. Subsequently, the patient underwent a bone marrow biopsy, which uncovered a plasma cell myeloma, the source of her amyloidogenic protein production.

Atopic Dermatitis: Pathophysiology.

The pathophysiology of atopic dermatitis is complex and multifactorial, involving elements of barrier dysfunction, alterations in cell mediated immune responses, IgE mediated hypersensitivity, and environmental factors. Loss of function mutations in filaggrin have been implicated in severe atopic dermatitis due to a potential increase in trans-epidermal water loss, pH alterations, and dehydration. Other genetic changes have also been identified which may alter the skin's barrier function, resulting in an atopic dermatitis phenotype. The imbalance of Th2 to Th1 cytokines observed in atopic dermatitis can create alterations in the cell mediated immune responses and can promote IgE mediated hypersensitivity, both of which appear to play a role in the development of atopic dermatitis. One must additionally take into consideration the role of the environment on the causation of atopic dermatitis and the impact of chemicals such as airborne formaldehyde, harsh detergents, fragrances, and preservatives. Use of harsh alkaline detergents in skin care products may also unfavorably alter the skin's pH causing downstream changes in enzyme activity and triggering inflammation. Environmental pollutants can trigger responses from both the innate and adaptive immune pathways. This chapter will discuss the multifaceted etiology of atopic dermatitis which will help us to elucidate potential therapeutic targets. We will also review existing treatment options and their interaction with the complex inflammatory and molecular triggers of atopic dermatitis.

Leukocytoclastic vasculitis resolution with topical dapsone.

Leukocytoclastic vasculitis (LCV) is a disease characterized by inflammation of small vessels presenting with petechiae and palpable purpura. Leukocytoclastic vasculitis often spontaneously resolves within weeks and requires only symptomatic treatment. Chronic or severe disease can require systemic treatment with agents such as colchicine, dapsone, or corticosteroids, which are effective but carry a risk for serious adverse events. These side effects and/or medical contraindications preclude some patients from taking systemic medications for LCV. We present a case of biopsy-proven LCV in a 60-year-old woman that resolved after treatment with topical dapsone. Systemic dapsone is effective at treating LCV but requires screening for glucose-6-phosphate dehydrogenase deficiency and routine monitoring of blood counts, and its possible adverse effects include neuropathy, blood dyscrasia, and hypersensitivity syndrome. Topical dapsone may provide similar efficacy with far fewer adverse effects. Given this drug's favorable side-effect profile compared to the currently available alternatives, we believe it is a reasonable option in selected patients.

Squamous Cell Carcinoma In Situ Overlying Merkel Cell Carcinoma.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous neoplasm that has exhibited an exponential increase in incidence in the past 3 decades. Combined MCC and cutaneous squamous cell carcinoma (SCC/MCC) is an uncommon variant of MCC that exhibits worse prognosis than pure MCC. OBJECTIVE: To describe the clinical presentation, dermoscopy, and histology of an unusual subtype of combined SCC/MCC. METHODS AND RESULTS: A 73-year-old white woman presented with an ulcerated and violaceous 10-mm plaque on her right jawline that had been present for 2 to 3 months. On dermoscopy, the lesion was predominantly milky pink to red with peripheral crusting and large-caliber polymorphous vessels. Histology revealed SCC in situ above and adjacent to MCC. The tumor was excised with clear margins, and sentinel lymph node scintography was negative for nodal involvement.