Rethinking the Inflammatory Balance in Psoriasis and Atherosclerosis.

Guénin S, Kazemi A, Cline A, et al. Rethinking the inflammatory balance in psoriasis and atherosclerosis. J Drugs Dermatol. 2023;22(8):832-833. doi:10.36849/JDD.7082.

Assessment of diversity in skin colour in dermatology medical education resources.

One hundred and fifty-three patient images from the general resources and 3583 images from Dermatology were evaluated. The majority of images were Fitzpatrick Type II (54%), followed by Type III (27%). Our findings demonstrate the lack of skin diversity continues across many medical school resources, with fair skin (Fitzpatrick Type II) accounting for the majority of images.

Why Does Facial Eczema Differ From Body Eczema?

BACKGROUND: The pathophysiology of atopic dermatitis (AD) is multifactorial, influenced by genetics, skin barrier dysfunction, and environmental stressors. There is a lack of research comparing the etiologies and pathologic mechanisms accounting for differences in facial vs body eczema. OBJECTIVES: To explore reasons why facial eczema may differ from body eczema. RESULTS: There are key differences in the environments of the face and body that may lead to AD exacerbation. These include differences in the skin microbiome, sebaceous glands concentration, and levels of natural moisturizing factor. The face is exposed to more environmental stress compared with the rest of the body. These stresses include aeroallergens, ultraviolet radiation, and cosmetic products. Management of facial eczema also differs from that of body eczema due to the avoidance of high potency topical steroids on the face. Topical steroids increase microbiome diversity, and lack of topical steroid use on the face can lead to decreased microbiome diversity and increased AD severity. CONCLUSION: Facial and body eczema differ due to differences seen in anatomical structure and environmental exposures. These differences should be further researched and used in the management of facial vs body eczema and can also be used in the development of new AD treatments. J Drugs Dermatol. 2022;21(10): 1119-1123. doi:10.36849/JDD.6354.

Measuring and Improving Adherence to Crisaborole 2% Ointment in Patients With Atopic Dermatitis.

BACKGROUND: Atopic dermatitis (AD) is an inflammatory skin condition with dry, scaly, and intensely itchy skin. Treatment failure is the result of poor adherence. OBJECTIVE: In this study, we assessed the impact of an internet-based survey on adherence to topical crisaborole 2% ointment in patients with mild AD. METHODS: Participants were randomized to the intervention or control group. The intervention group received weekly email surveys regarding adherence for 6 weeks, then monthly for 12 months. All participants came in for 5 visits over the year. RESULTS: Twenty-eight subjects were recruited for the study (n=19 adults, n=9 pediatrics). Adherence for adults that remained in study (n=6) was 60%. Adherence of the adult control and intervention groups were 49% and 45%, respectively (P>0.05). Adherence for pediatric participants that remained in study (n=2) was 6%. The adherence of the pediatric control and intervention groups were 27% and 29%, respectively (P>0.05). DISCUSSION: Medication adherence was low. The survey intervention did not improve adherence. However, more participants in the intervention group completed the study than in the control group of adults. Regular communication from the provider may help patients feel supported and continue treatment. CLINICALTRIALS: gov identifier: NCT03250663 J Drugs Dermatol. 2022;21(10):1043-1048. doi:10.36849/JDD.6280.

Hair-Loss Perceptions and Treatment Expectations in Young People of Color.

BACKGROUND: While much research has been dedicated to hair loss in older patients, little has addressed hair loss perception and treatment expectations among young people of color (POC). This study evaluates disease perceptions, willingness to utilize specific therapies, and treatment expectations in younger versus older POC with any form of hair loss. METHODS: An online survey was utilized to analyze 217 responses to 37 questions assessing perceptions of hair loss, hair care practices, and treatment expectations among others. These parameters were measured on a 1–5 Likert scale. Comparison between groups was be done using Chi-Square tests for proportions and Student t-tests. RESULTS: Included were 52 respondents between the ages of 18 and 29 (POC<30), and 36 respondents greater than 30 years of age (POC>30). The reported average hair loss in POC<30 was 67.0%, compared to POC>30 reporting 60.0% (P<0.05). Average embarrassment was 2.6 for POC<30 versus 3.4 for POC>30 (P<0.001). Average pain was 2.0 for POC<30 versus 1.8 for POC>30 (P<0.05). Average hair thinning was 3.0 for POC<30 versus 3.7 for POC>30 (P<0.001). Average willingness to use topical treatments including creams, solutions, ointments, and gels was 3.0 in POC<30 versus 3.8 in POC>30 (P<0.001). The average perceived effectiveness of topical treatments was 2.9 in POC<30 versus 3.6 in POC>30 (P<0.01). CONCLUSION: Early identification and appropriate management of young POC with hair loss may facilitate follicular rescue. This, in turn, may help reduce the negative consequences of advanced hair loss, such as embarrassment, as seen in older POC. J Drugs Dermatol. 2021;20(7):746-750. doi:10.36849/JDD.5960.

Comparing prescribing patterns for topical corticosteroids based on their FDA indication by age.

BACKGROUND/OBJECTIVES: Atopic dermatitis (AD) affects up to 20% of the pediatric population, with a growing prevalence over the past 30 years. Topical corticosteroids (TCS) are commonly used as a first-line topical therapy for AD and are prescribed in 59% of all AD visits. However, some topical corticosteroids are prescribed outside of their age range indications. This paper aims to explore the frequency with which topical corticosteroids are prescribed for AD outside of their FDA-approved age range. METHODS: Data on prescribing patterns for AD were obtained from the National Ambulatory Medical Care Survey (NAMCS). We assessed the frequency of off-label use of topical corticosteroids with respect to age indications in four specific age-groups, as delineated in the data (0-1, 2-7, 8-18, and 19+ years). RESULTS: All prescribed topical corticosteroids found in the NAMCS database have an indication for AD or other inflammatory dermatoses or pruritic dermatoses. However, some medications were prescribed outside of their FDA-approved age indications. These off-label prescription rates ranged from 52% for desoximetasone to 0% for halobetasol and alclometasone, or rates lower than could be detected by our study. CONCLUSIONS: Much like other medications for AD treatment, TCS are sometimes used off-label. The off-label use of topical corticosteroids to treat pediatric AD highlights a gap between clinical practice and regulating guidelines. Additional pediatric studies would offer a greater body of evidence to maintain or expand label indications for the use of TCS in younger patients.

Treatment of rosacea during pregnancy.

BACKGROUND: Exacerbation of rosacea may occur during pregnancy and there are multiple associated cases of rosacea fulminans (RF). Treatment during pregnancy poses a significant challenge as many rosacea treatments are contraindicated or have limited evidence regarding potential adverse fetal effects. OBJECTIVE: Review the pregnancy categories of various treatments and develop algorithms for treating pregnant patients with rosacea and RF. METHODS: Rosacea treatments showing efficacy in randomized controlled trials were searched through DailyMed to review pregnancy labelling. Searching the PubMed/MEDLINE database for English articles using keywords "rosacea fulminans AND pregnancy" without publishing-time restrictions yielded 8 articles. We summarized treatments used in cases of RF during pregnancy. RESULTS: Topical ivermectin was more effective than metronidazole, but has a more concerning pregnancy category. Three pregnant women with RF were treated successfully with topical metronidazole in combination with other therapies. Azithromycin is the only oral rosacea therapy that is considered safe for pregnant patients and it has been used to treat RF. CONCLUSIONS: This review highlights the challenging aspects of treating pregnant patients with rosacea, as there is limited pregnancy-related treatment efficacy and safety data. The pregnancy categories of therapeutic options are summarized. Further studies are needed to learn which therapies are effective and safe for use during pregnancy.

Assessing the Effect of Clinical Trial Evidence and Anecdote on Caregivers' Willingness to Use Corticosteroids: A Randomized Controlled Trial [Formula: see text].

BACKGROUND: Treatment of childhood atopic dermatitis (AD) is hindered by nonadherence, but caregiver reassurance may help overcome this hurdle. OBJECTIVES: To assess caregivers' willingness to treat childhood AD with a corticosteroid when presented with clinical trial evidence, anecdote, or both. METHODS: A total of 476 caregivers were recruited through a dermatology clinic and online crowdsourcing platform. Subjects were randomized to receive clinical trial evidence, anecdote, or both, using either the term "medication" or "topical steroid." Additional caregivers were queried about their willingness to treat with the doctor's recommendation or without knowledge of its safety information. Responses were recorded on a 10-point Likert scale. RESULTS: Caregivers' willingness to treat was higher in all information assignment groups compared to those not provided with safety information: clinical trial evidence of a "medication" (P = .003; Cohen's d = 0.83) or "topical steroid" (P = .030; d = 0.55), anecdote of a "medication" (P < .0001; d = 1.37) or "topical steroid" (P < .0001; d = 0.85), both clinical trial evidence and anecdote of a "medication" (P < .0001; d = 1.00) or "topical steroid" (P = .000; d = 0.89), and simply the doctor's recommendation (P < .0001; d = 0.92). Significance was corrected for multiple comparisons to 0.0018. There were no differences between caregivers of children with and without AD (P = .36). CONCLUSIONS: Providing anecdotal reassurance, even in the setting of reported high willingness to treat with the doctor's recommendation, may be an effective strategy to improve caregivers' perceptions of starting new medications.

Representation of Fitzpatrick skin type in dermatology textbooks compared with national percentiles.

As time progresses, more patients with skin of color will be seen by dermatologists. To meet the needs of the ever-changing population, medical education needs to analyze how residents are trained in recognizing dermatological disorders in patients with skin of color. The aim of this study was to analyze dermatology textbooks to evaluate how well skin of color patients are represented compared to the current national distributions. The most common skin types depicted in the textbooks were Fitzpatrick skin types II and III, whereas the least common skin types depicted were skin types V and VI. There was a significant difference between a national distribution of skin types when compared to photographs in each of the textbooks (P<0.001). These findings emphasize the need to better represent patients with skin of color in medical textbooks.

Review of the use of gentian violet in dermatology practice.

OBJECTIVE: To review the use of gentian violet in dermatology. DESIGN: A comprehensive literature search on gentian violet in dermatology practice was performed through PubMed. RESULTS: Gentian violet is effective in treating methicillin-resistant Staphylococcus aureus-colonized skin lesions; mean number of days for complete eradication was 9.1 days. Gentian violet is almost as effective as ketoconazole and more effective than nystatin in the treatment of oral thrush in AIDS patients. In an in vitro study on cutaneous T cell lymphoma cell lines, there was no difference between nitrogen mustard and gentian violet in stimulating apoptosis. When comparing gentian violet to silver sulfadiazine dressings in healing burn wounds, the gentian violet treatment group reported less pain, fewer febrile episodes, and decreased bacterial growth compared to control. In atopic dermatitis subjects, gentian violet decreased Staphylococcus aureus colonization and improved disease severity in lesional skin compared to non-lesional skin. CONCLUSION: Studies have investigated gentian violet's antibacterial, antifungal, antiviral, antiparasitic, anti-angiogenic, antitumor, and wound healing properties. Gentian violet is a low cost and well-tolerated topical agent with the potential for widespread applications in dermatology.

A review of intralesional wart therapy.

BACKGROUND: New treatment options for warts include intralesional wart injection with agents such as vitamin D, measles, mumps, and rubella (MMR) vaccine antigen, Bacillus Calmette-Guerin (BCG) antigen, and candida antigen but there have been limited studies to compare their efficacies. OBJECTIVE: The purpose of this systematic review is to compare the efficacy and safety of injectable agents used for the treatment of warts. METHODS: A PubMed search included terms "intralesional wart therapy," "wart injection" and "verruca injection." Articles reviewed were published over 10 years. RESULTS: A total of 43 articles were reviewed; 30 covered studies with more than 10 participants and 13 were case reports, case series, and reviews. In comparison studies intralesional agents have equal or superior efficacy (66%-94.9%) compared to first-line salicylic acid or cryotherapy (65.5-76.5%). One advantage of intralesional injections is the rate of complete resolution of distant warts. LIMITATIONS: Each study varied in their agents, treatment interval, and treatment dose, making comparisons difficult. CONCLUSIONS: Intralesional wart injections are safe, affordable, and efficacious treatments for warts. Physicians should consider intralesional injections for patients with refractory warts, multiple warts, or warts in sensitive areas.

Patients use more topical medication when the medications come in a larger container.

INTRODUCTION: Research shows that individuals consume more calories when provided with a larger portion size. It is unclear if similar behavior translates to topical medication use. The impact of container size and provider instructions on patient usage of topical medications has yet to be assessed. METHODS: Data was collected from 128 participants in an IRB randomized, controlled trial. To a marked 3cmx8cm rectangle on the forearm, patients applied petroleum jelly from either a large container or a small tube. Pre and post application container weights were measured. RESULTS: Patients applied more topical medication from the large container compared to the small tube. CONCLUSION: Topical medication usage is influenced by the size of the container provided. It is beneficial to consider container size when prescribing topical medications and greater application is desired.

Tildrakizumab: A Review of Phase II and III Clinical Trials.

OBJECTIVE: Tildrakizumab, an inhibitor of the p19 subunit of interleukin (IL)-23, was recently Food and Drug Administration (FDA) approved for patients with moderate to severe psoriasis. This article will review the phase II and III clinical trial data of tildrakizumab. DATA SOURCES: A PubMed search from January 2000 to September 2018 was done with the search terms tildrakizumab, guselkumab, risankizumab, p19, interleukin-23, and psoriasis. STUDY SELECTION AND DATA EXTRACTION: Articles discussing phase II and III clinical trial data for tildrakizumab were selected. DATA SYNTHESIS: In phase II and phase III trials, tildrakizumab was safe and efficacious compared with placebo and etanercept. More patients achieved Psoriasis Area and Severity Index 75 receiving tildrakizumab (200 mg, 62%-74%; 100 mg, 61%-66%; 25 mg, 64%; 5 mg, 33%) compared with placebo (4%-6%, P < 0.0001) and etanercept (48%, P = 0.01). More patients achieved Physician Global Assessment (PGA) response of "clear" or "minimal" receiving tildrakizumab (200 mg, 59%; 100 mg, 55%-58%) than the placebo group (4%-7%, P < 0.0001). 59% of patients who received tildrakizumab 200 mg achieved a PGA response of "clear" or "minimal" compared with etanercept (48%, P = 0.0031). The most common adverse effect was infection. Relevance to Patient Care and Clinical Practice: Tildrakizumab is a new, FDA-approved, physician-administered biological therapy for patients with moderate to severe psoriasis. It appears to be efficacious and safe so far. CONCLUSION: Tildrakizumab is efficacious and safe for the treatment of patients with moderate to severe psoriasis. IL-23/p19 inhibitors are a promising class of biological therapy.

Review of future insights of Dragon's Blood in dermatology.

To assess the possible clinical implication of Dragon's Blood in dermatology, a PubMed search was conducted using the keyword "Dragon's Blood," "Croton lechleri," and more. Dragon's Blood from C. lechleri is an Amazonian medicinal plant with a characteristic red sap. Its array of phytochemical action in preclinical studies include anti-inflammatory, antioxidant, antimicrobial, antifungal, and antineoplastic properties. Clinical studies reflect wound healing and antiviral properties. Although its popularity is rising in western medicine, C. lechleri offers limited use in dermatology and further investigation is necessary to gain further insight into its potential clinical implication.

Prescribing Patterns for Atopic Dermatitis in the United States

Introduction: Introduction: Although future atopic dermatitis (AD) clinical research is intended to improve standard-of-care treatment, how patients are currently treated is not well characterized. The purpose of this study was to determine the most frequent medications prescribed in all ages of AD. Methods: The National Ambulatory Medical Care Survey (NAMCS) is a nationally representative survey of United States office-based ambulatory visits and records demographics, diagnoses, and treatments. This is a cross-sectional study using the NAMCS of all AD outpatient office visits from 2006 to 2015. Patient visits with an ICD-9-CM code for AD (691.8) were collected and analyzed. Frequency tables were created for age, race, providers managing AD, and treatment. Results: Patient demographics of AD visits included 51% male (95% Confidence Interval [CI]: 44-58%), 71% white (65-77%), 19% African American (14-25%), and 10% Asian (6-14%). About 31% (24-37%) of visits were to pediatricians and 27% (22-33%) to dermatologists whereas per physician, dermatologists managed more AD visits than pediatricians. Topical corticosteroids (59%; 52-66%) were the most common class of medications prescribed followed by antibiotics (11%; 6-16%) and second generation antihistamines (6%; 3-10%). The most common topical corticosteroid prescribed in AD was triamcinolone (25% of office visits; 18-31%). Hydrocortisone was the most common topical corticosteroid prescribed to children <1 year of age and children aged 8 to 18, whereas triamcinolone was more common in children 2 to 7 years and adults >18 years. Discussion: Topical corticosteroids were the most frequent prescriptions provided at office-based ambulatory visits whereas antibiotics and second-generation antihistamines were the second and third most common prescribed medications, respectively. Although pediatricians manage more AD visits than dermatologists in total visits, dermatologists manage more AD visits than pediatricians per physician. Characterizing how AD patients are currently treated may build a reference for future clinical research investigating novel standard-of-care treatment in AD. J Drugs Dermatol. 2019;18(10):987-990.

Successful treatment of hidradenitis suppurativa in the setting of Crohn disease with combination adalimumab and ustekinumab.

Herein we report the combination of adalimumab and ustekinumab to successfully treat a 39-year-old woman who presented for evaluation of hidradenitis suppurativa in the setting of Crohn disease of both the small and large intestine. The patient reported previous control of her hidradenitis when she was using adalimumab for her Crohn disease. She had recently been started on ustekinumab for Crohn disease and had flaring of her hidradenitis. The patient re-started on adalimumab weekly and ustekinumab every 8 weeks. After one month, the patient reported clear improvement in her hidradenitis and Crohn disease with the combined therapy.

Decreased phototherapy effectiveness on lower body.

Although phototherapy is an effective treatment for many dermatological conditions on the face, trunk, and proximal extremities, a common issue plaguing whole-body phototherapy is its diminished efficacy on the legs. In this commentary, we elaborate on the factors underlying this phenomenon, as well as potential solutions to improve treatment success.

Adherence to a novel home phototherapy system with integrated features.

OBJECTIVE: To measure adherence using a novel home UVB phototherapy system designed to promote adherence. STUDY DESIGN: A retrospective, observational study conducted to evaluate patients' adherence to a prescribed three-times-per-week treatment protocol using a novel home phototherapy system with integrated features designed to improve adherence. METHODS: Data was collected from 18 psoriasis patients, 27 vitiligo patients, and three atopic dermatitis patients using a novel home phototherapy system under normal use conditions. Adherence was also calculated using two alternative methods to allow for comparison between published phototherapy adherence studies. RESULTS: The median patient adherence (N= 48) to treatment with the home phototherapy system was 80%. There were no significant differences in adherence between different ages, genders, or diseases (P>0.05). Early adherence (N=48) to the home phototherapy system was 90% and dichotomous adherence (N=32) was 71%. CONCLUSIONS: By implementing a smartphone application and web-based portal with the home phototherapy system, patients have multiple mechanisms in place to ensure adherence.

Systemic contact dermatitis related to alcoholic beverage consumption.

Systemic contact dermatitis is a rash secondary to systemic exposure to allergens after sensitization. Numerous agents are implicated including Balsam of Peru, a plant-derived compound often used for flavoring and fragrance. Alcoholic beverages can contain many possible allergens, including cinnamon, vanilla, citrus peels, and Balsam of Peru. Herein, we describe two patients presenting with recurrent, diffuse, erythematous, and pruritic cutaneous eruptions suspicious for contact dermatitis. Based on clinical history, exam, and formal and at-home patch testing results, we believe the most likely etiology was Balsam of Peru within the alcohol beverages leading to systemic contact dermatitis. Both patients markedly improved after avoidance of their alcoholic beverages. Overall, systemic contact dermatitis secondary to alcohol consumption is a rare phenomenon, whereas Balsam of Peru is a relatively common allergen. Suspicion must be high to identify possible allergens (including Balsam of Peru) exposure within alcoholic beverages such as artificial flavorings, aromas, and mixtures.