Undergarment and Fabric Selection in the Management of Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition manifesting as recurrent and exquisitely painful nodules in intertriginous regions. The role of mechanical stress in HS pathogenesis is gaining attention, as factors including intertriginous distribution of lesions, obesity, sweating, and suboptimal clothing contribute to increased friction and exacerbation of disease. Undergarment and clothing selection are often-overlooked components of HS management and should be addressed with patients as practical lifestyle changes that can decrease the frequency of disease flares and reduce symptoms of pain and irritation at involved sites. Selection of breathable and absorbent fabrics can also aid in reducing microbial colonization, sweat retention, and odor. This discussion is based on expert recommendations and aims to provide practitioners with the rationale for appropriate undergarment and clothing selection for HS patients. We propose practical principles for choosing undergarment design and fabrics for breathability, absorbency, and skin pressure reduction.

A Comparison of International Management Guidelines for Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis that imparts a significant burden on patients and presents a management challenge for healthcare providers. As attention to this debilitating condition has grown over recent years, our understanding of HS pathogenesis and optimal treatment approaches continues to evolve. Nine HS treatment guidelines developed by various expert organizations have been published, encompassing therapeutic modalities ranging from topical agents to systemic therapies to procedural interventions. These guidelines demonstrate significant overlap in treatment recommendations and have all been published within the last 5 years. Therefore, we aim to compare and synthesize the recommendations of international HS treatment guidelines and to encourage inter-organizational communication for the development of consensus or staggered publication of recommendations for HS management.

Alleviating and exacerbating foods in hidradenitis suppurativa.

While dietary triggers have been investigated in acne and other inflammatory follicular dermatoses, there is a paucity of data on diet and hidradenitis suppurativa (HS). We sought to identify exacerbating and alleviating foods in HS patients. An anonymous survey was distributed via HS Facebook support groups and in person at HS specialty clinics. Participants were asked to select all that apply from a list to indicate foods that worsen and make HS better including sweet foods, breads and pasta, red meat, chicken, fish, canned foods, fruits, vegetables, dairy, high-fat foods, I do not know, and no. Only 12.0% (n = 89/744) identified alleviating foods while 32.6% (n = 237/728) identified HS-symptom-exacerbating foods. The most commonly reported exacerbating foods were sweets (67.9%), bread/pasta/rice (51.1%), dairy (50.6%), and high-fat foods (44.2%). The most commonly reported alleviating foods included vegetables (78.7%), fruit (56.2%), chicken (51.7%), and fish (42.7%). Further studies are required to evaluate the mechanistic links between diet and HS. HS patients may benefit from receiving dietary counseling as part of a comprehensive HS management plan.

Growing Patient Education in Dermatology: An Upside-Down Tree Analogy for Immunomodulatory Therapies

As patient autonomy gains momentum in the era of readily accessible health information, dermatologists bear a growing responsibility in patient education. With the rapid evolution and development of targeted therapies for dermatologic conditions, clinicians are faced with questions from patients regarding the mechanisms of action and side effects of novel therapeutic agents. We present an educational aid to be used in patient counseling to describe and compare the mechanisms of traditional immunosuppressive medications and targeted agents such as biologics and small molecule inhibitors. Using an upside-down tree as an analogy for the immune system, traditional immunosuppressives can be represented by an axe, chopping at large branches (ie, upstream immune pathways), while targeted immunomodulators can be represented by pruning shears, trimming select small branches and leaves (ie, specific downstream effectors). This approachable visual aid can guide practitioners in explaining the complexities of the immune system and immunomodulatory therapies with the goal of augmenting patient understanding and addressing patient concerns regarding new medications. J Drugs Dermatol. 2020;19(1):28-29.

Widespread pustular eruption following probiotic use.

A 26-year-old woman with Crohn disease and palmoplantar psoriasis on ustekinumab presented with a diffuse and intensely pruritic rash with a few pin-point pustules within days after initiation of an over-the-counter Align brand probiotic. Biopsy revealed psoriasiform and spongiotic dermatitis with spongiform subcorneal pustules and scattered eosinophils, consistent with acute generalized exanthematous pustulosis. Our case highlights a unique presentation of acute generalized exanthematous pustulosis following probiotic exposure with fewer than usual pustular lesions. IL23 suppression by ustekinumab may have contributed to the patient's reduced pustular presentation.

Erythrodermic Darier disease associated with metastatic lung adenocarcinoma.

We present a patient with erythrodermic Darier disease occurring in temporal association with diagnosis of metastatic lung adenocarcinoma. The patient presented with eroded and crusted keratotic papules and plaques over greater than 90% body surface area with extensive secondary impetiginization. Given a longstanding history of pruritic eruption, this presentation represents a paraneoplastic flare of an underlying genodermatosis. Near total resolution was achieved with chemotherapy and topical corticosteroids.

Bioactive: A new era of bioactive ingredients in topical formulations for inflammatory dermatoses.

Moisturization is the pillar of daily skin care and has significant benefit in improving hydration, strengthening the skin barrier, and ameliorating inflammatory dermatoses. Bioactive ingredients such as endocannabinoids, bioactive lipids, growth factors, microbiome modulators, and antioxidant enzymes are increasingly being incorporated into moisturizer formulations. These novel ingredients have been shown to improve skin barrier function, upregulate barrier lipid synthesis, decrease itch and inflammation, and have antioxidative properties. In this article, we highlight evidence supporting their mechanisms of action and efficacy in atopic dermatitis, uremic pruritus, asteatotic eczema, acne vulgaris, and vitiligo.

Topical probiotics: the unknowns behind their rising popularity.

OBJECTIVE: Topical probiotics have been used for skin care and treatment since the early 20th century. Over the past decade, there has been a dramatic surge of commercially-available topical probiotic products. We conducted a systematic search of clinical data relating to the use of topical probiotics and identified relevant clinical and regulatory gaps. METHODS: PubMed and Google Scholar searches were conducted for trials and reviews of probiotics. FDA definitions of cosmetics, drugs, and regulation of topical probiotics were reviewed. RESULTS: Topical probiotics have shown efficacy in a number of limited trials, particularly those involving the treatment of acne, atopic dermatitis, and rosacea. However, there is a paucity of literature on the safety profiles, mechanistic action, and therapeutic potential of topical probiotic products. Several regulatory gaps exist, including approval and classification of topical probiotic products by the FDA; currently there are no topical probiotic products the FDA has approved as drugs. CONCLUSION: With increasing popularity among the general public, but insufficient clinical data to demonstrate large-scale effectiveness and a thorough understanding of side effects, there is a need for further mechanistic and clinical investigation, as well as improved regulation and standardization of topical probiotic products.

Dermatologic facial applications of Morpheus8 fractional radiofrequency microneedling.

Dermatologic patients are expressing increasing interest in minimally invasive procedures to address a wide range of common concerns from skin laxity to acne and scarring. Fractional radiofrequency (RF) microneedling offers an effective method for addressing a variety of dermatologic conditions with reduced downtime compared with historically more invasive procedural approaches. This article aims to describe the technology utilized in fractional RF microneedling (Morpheus8, InMode Aesthetics) and its studied applications in dermatology for treatment of the face.

InMode Evoke radiofrequency hands-free facial remodeling for skin rejuvenation.

Demand for facial contouring procedures has increased dramatically in recent years. Common regions of concern for patients seeking a rejuvenated, more youthful appearance include the cheeks, jawline, submental area, and neck. Radiofrequency technology offers a non-invasive and effective method of improving skin laxity and subcutaneous fat in these areas. The Evoke system from InMode Aesthetics is a radiofrequency modality designed to address the lower face and neck that stimulates collagen remodeling for skin tightening and thermal lipolysis for improved facial contour. While alternate technologies for radiofrequency facial remodeling are commercially available, Evoke is the first of its kind in introducing a reliable, operator-independent hands-free device developed based on InMode's proprietary Acquire, Control, and Extend technology targeting the deep fibro-septal network to provide optimal and consistent outcomes.

Dupilumab use in dermatologic conditions beyond atopic dermatitis - a systematic review.

Importance: While dupilumab has emerged as an effective treatment for moderate-to-severe atopic dermatitis (AD) since its approval in 2017, interleukin-4 and 13 blockade has also demonstrated efficacy in off-label chronic dermatologic conditions.Objective: To identify chronic dermatologic conditions in which dupilumab has demonstrated efficacy.Findings: Thirty-three reports of dupilumab use in non-AD dermatologic conditions were identified through systematic literature review. Effective use of dupilumab has been reported in case reports and case series in the treatment of chronic pruritus, prurigo nodularis, eczematous eruption of aging, allergic contact dermatitis, chronic hand eczema, alopecia areata, urticaria, eosinophilic annular erythema, bullous pemphigoid and papuloerythroderma of Ofuji. Clinical trials are underway evaluating the efficacy of dupilumab in allergic contact dermatitis, chronic hand eczema, alopecia areata, chronic spontaneous urticaria and cholinergic urticaria.Conclusions and relevance: Overlap in immune signaling pathways between AD and chronic pruritus, eczematous eruption of aging, allergic contact dermatitis, chronic hand eczema, alopecia areata, urticaria, eosinophilic annular erythema, bullous pemphigoid and papuloerythroderma of Ofuji make these conditions candidates for dupilumab therapy when standard treatments have failed or are contraindicated. While promising as a therapeutic option, off-label prescribing of dupilumab requires consideration of challenges in insurance authorization and out-of-pocket cost to the patient.

Reactivation of Alopecia Areata After Dupilumab Therapy for Atopic Dermatitis.

We present a case report of a 42-year-old woman with severe atopic dermatitis (AD) and history of alopecia areata (AA), which had been in remission for more than 5 years. She was treated with dupilumab for AD, and 4 months after initiating treatment, she developed a rapidly progressive reactivation of AA in an androgenic alopecia pattern. Alopecia resolved after a single intramuscular triamcinolone injection while the patient remained on dupilumab. This is the seventh report to date of dupilumab-associated alopecia but is the first case documenting reactivation of previous AA. Alopecia occurring after dupilumab initiation raises suspicion for a possible unrecognized adverse effect of dupilumab in AD patients.

Rosacea associated with dupilumab therapy.

Background: Dupilumab is used for treatment of atopic dermatitis through blockade of IL-4 and IL-13 signaling of the Th2 pathway. Recent case reports have described alopecia, psoriasis, persistent facial dermatitis, and recall dermatitis at patch test sites after the initiation of dupilumab therapy.Case report: We describe the case of a 67-year-old female with atopic dermatitis who developed recurrent episodic flares of rosacea temporally associated with dupilumab injections that resolved after dupilumab discontinuation.Conclusion: The cause of rosacea-like reaction associated with dupilumab treatment is unknown. Th2 pathway inhibition by dupilumab may promote Demodex proliferation and increased IL-17-mediated inflammation implicated in the pathophysiology of rosacea.Abbreviations: atopic dermatitis: AD; interleukin: IL; persistent facial dermatitis: PFD; T-helper cell type 1: Th1; T-helper cell type 2: Th2; T-helper cell type 17: Th17; tumor necrosis factor-∝: TNF-∝.

Non-pharmacologic approaches for hidradenitis suppurativa - a systematic review.

Importance: Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition presenting with painful nodules and sinus tracts primarily in intertriginous regions. The persistent nature of HS and challenges in symptom management lead many patients to seek non-pharmacologic approaches due to the paucity and limited efficacy of conventional HS therapeutic options.Objective: To evaluate the existing evidence for non-pharmacologic modalities in treatment of HS.Findings: Discussed in this review are non-pharmacologic modalities with evidence of efficacy in HS treatment, including weight loss, vitamin B12, vitamin D and zinc supplementation, and dietary avoidance of brewer's yeast. Limitations of the available data on non-pharmacologic therapies in HS include the predominance of pilot and single-armed studies, as well as heterogeneity in study design, subject disease severity, concomitant treatment and comorbid conditions.Conclusions and relevance: HS patients are becoming increasingly interested in the use of non-pharmacologic approaches to augment conventional treatments. Strength of evidence for non-pharmacologic therapies in HS is limited by small study size and lack of randomized controlled trials. Future large-scale investigations should be pursued to better establish efficacy and dosing regimens for the use of non-pharmacologic treatments in HS.

Managing dermatology patients who prefer "all natural" treatments.

Dermatology patients are expressing a growing interest in complementary and alternative medicine (CAM) and natural treatment options for management of dermatologic conditions. Counseling on the optimal integration of CAM with conventional therapeutic approaches can be daunting for practitioners who do not feel well-versed in these modalities. A productive conversation between the clinician and patient seeking natural treatments should address the appropriate role and scope of CAM in a therapeutic plan, which is best suited for use as maintenance therapy or to augment traditional pharmaceutical or procedural interventions. Understanding the patient's goals, discussing evidence-based conventional and complementary treatment options, and employing shared decision making can enhance the clinical encounter and strengthen the physician-patient relationship.

A Practical Approach to Recalcitrant Face and Neck Dermatitis in Atopic Dermatitis.

Face and neck dermatitis in the atopic dermatitis patient is a diagnostically challenging entity with broad differential diagnoses. Recent case reports reporting face and neck dermatitis in patients on dupilumab therapy have added further complexity to diagnosis and management. Herein, we discuss a broad diagnostic algorithm and practical management strategy for recalcitrant face and neck dermatitis in the atopic patient with an emphasis on face and neck dermatitis associated with dupilumab therapy. Our aim is to raise awareness about the probable entity of drug-associated face and neck dermatitis and share a practical management strategy that may also be applied broadly to atopic dermatitis patients presenting with face and neck dermatitis.

Menses, pregnancy, delivery, and menopause in hidradenitis suppurativa: A patient survey.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory disorder that primarily affects women of childbearing age. There is a paucity of data on HS disease activity during menstruation, pregnancy, and menopause and the potential impact of HS on the method of delivery. OBJECTIVE: We aimed to characterize the natural history of HS symptoms during menses, pregnancy, and menopause. We also sought to evaluate the potential impact of HS on delivery method and whether there were delivery-related healing complications unique to women with HS. METHODS: An anonymous survey was distributed via social media to international HS support groups and patients at three HS specialty clinics in North America. Responses were collected from March to July 2019. RESULTS: A total of 279 respondents answered questions on disease changes during pregnancy. Menstruation caused worsening of HS symptoms in 76.7%, no change in 22.2%, and improvement in 1.1%. During pregnancy, the distribution between symptoms worsening (34.8%), having no change (28.7%), and improving (36.6%) was relatively even. After menopause, participants typically reported either worsening (39.5%) or no change (44.2%) in HS symptoms. Among respondents with anogenital HS involvement who delivered vaginally, 3.1% believed that HS interfered with vaginal delivery (VD), and 23.5% believed that VD caused an HS flare. Cesarean section (C-section) delivery was reported by 44.2% of participants. Ten participants reported that they were advised by their doctor to have a C-section instead of a VD because of severe anogenital HS. Of those who underwent a C-section, 33.9% reported that HS interfered with incision healing, and 51.2% reported developing new HS lesions in their C-section scar. CONCLUSION: To our knowledge, this is the first study describing the potential influence of HS on a patient's method of delivery. Multidisciplinary collaboration plays a pivotal role in developing individualized treatment and birth plans for pregnant women with HS.

Clinical Pearls on Sleep Management in Atopic Dermatitis.

Multiple etiologies contribute to sleep disturbance in atopic dermatitis (AD) patients, including learned scratching behavior and increased monoamines, cutaneous blood flow, inflammatory cell activities, and cytokines, as well as decreased melatonin, anti-inflammatory cytokines, and skin barrier function. Insomnia impairs cognitive development in children with AD, leading to behavioral problems and learning disabilities. Insomnia in adults with AD impedes work productivity. In this article, we discuss pearls on improving insomnia through both nonpharmacologic modalities, such as environmental adjustments and massage therapy, and pharmaceutical approaches including melatonin, antihistamines, tricyclic antidepressants, mirtazapine, and benzodiazepine and nonbenzodiazepine sedatives. Future investigations should further delineate the mechanistic link between insomnia and AD exacerbation and identify strategies to combat sleep-related disease burden.