Safety of dermatologic medications in pregnancy and lactation: An Update - Part I: Pregnancy.

The breadth of therapeutic options for the management of dermatologic skin conditions continues to expand rapidly as exemplified by biologics and small molecule drug development. While dermatologists and healthcare providers are aware of the underlying mechanisms and indications for these therapeutics, there is a recognized practice gap due to an incomplete understanding of the safety of these medications in women of childbearing age during the prepartum, antepartum and postpartum phases. Although a two-part continuing medical education review was published regarding the prescribing practices and safety profiles of these new therapeutics in women of childbearing age while pregnant or lactating in 20141,2, many new medications have been approved since then. Herein, we will update the safety of dermatologic therapies during pregnancy and Part II will review the safety of medications during lactation.

Safety of dermatologic medications in pregnancy and lactation: An Update - Part II: Lactation.

Multiple recently approved medications have been added to our treatment armamentarium for various dermatologic conditions. Herein, we have reviewed the literature, consolidated available safety data, and offered recommendations based upon available evidence as a reference guide for clinicians treating patients for dermatologic conditions during lactation.

Perceptions of skincare ingredients and product labels in pediatric eczema care.

Educating pediatric eczema patients and caregivers on appropriate product selection and avoidance of common irritants or allergens is a crucial aspect of eczema management. This study surveyed 80 pediatric caregivers in an academic pediatric dermatology clinic to assess influential factors in caregivers' selection of pediatric eczema-care products and identify ways to improve patient counseling on appropriate product selection and avoidance of common irritants or allergens. Caregivers frequently reported positive perceptions of commonly recommended ingredients for eczema but had inconsistent perceptions of fragrant plant oils and extracts, regardless of previous counseling on fragrance avoidance. These findings demonstrate uncertainty and misperceptions perpetuated by product labeling and a need for improved counseling strategies for avoiding fragrance and excessive product costs.

The ocular and periocular involvement of psoriasis.

Ocular manifestations of psoriasis are generally underrepresented in the literature and can often be missed by clinicians. Appreciation of eye involvement in psoriasis is especially important for dermatologists and ophthalmologists who may be closely involved with treating afflicted patients. Depending on the involved site and severity of the condition, signs and symptoms of ocular psoriasis can vary from asymptomatic erythema to debilitating scarring and vision loss. Treatment is critical to prevent disease progression and to improve the quality of life for these patients. We discuss the various clinical manifestations and treatment options for ocular complications in patients with psoriasis, including specific circumstances that should trigger immediate referral to our ophthalmology colleagues.

Nutrition and psoriasis.

Nutrition and dietary supplements are commonly used in the management of psoriasis; however, evidence of their efficacy is inconsistent. Although some dietary interventions have been shown to improve psoriasis consistently, others have little evidence supporting their use. We review common dietary interventions for the management of psoriasis and the evidence behind them. Caloric restriction, especially in overweight and obese individuals, has been shown to consistently diminish psoriatic activity. Evidence about other supplements and dietary interventions is inconsistent. Given the cost and side effects of pharmaceutical treatments for psoriasis, larger, long-term studies on the use of nutrition for the management of psoriasis are necessary.

Art of prevention: Our approach to the measles-mumps-rubella vaccine in adult patients vaccinated against measles before 1968 on biologic therapy for the treatment of psoriasis.

BACKGROUND: In response to the evolving measles epidemic in the United States, the Centers for Disease Control and Prevention recommended that some adults be revaccinated against measles because they may have inadequate immunity against the virus. Patients receiving biologic medications for psoriasis face a clinical dilemma because they may be at an increased risk of developing severe measles; however, vaccination with the measles-mumps-rubella (MMR) vaccine is not recommended for those on biologic therapy according to the American Academy of Dermatology-National Psoriasis Foundation guidelines. OBJECTIVES: This study aimed to review available research on the safety and efficacy of live-attenuated vaccines in individuals receiving biologic therapy for psoriasis and to discuss our approach to vaccinating individuals on biologic agents for psoriasis with the MMR vaccine. METHODS: A review of the literature was performed via PubMed search. Our institution's anecdotal experiences are also discussed. RESULTS: Data, although limited, are available suggesting that live-attenuated vaccines may be safe for individuals on tumor necrosis factor-alpha inhibitors for psoriasis. Inadequate data are available for patients receiving other biologic medications. CONCLUSION: Providers should engage in shared decision-making to determine whether patients on tumor necrosis factor-alpha inhibitors for psoriasis should receive the MMR vaccine without an interruption in biologic therapy.

Dupilumab as a novel therapy for bullous pemphigoid: A multicenter case series.

BACKGROUND: Bullous pemphigoid (BP) is an autoimmune blistering disorder occurring mostly in the elderly that lacks adequate treatments. OBJECTIVE: To describe our experience using dupilumab in a series of patients with BP. METHODS: This is a case series of patients from 5 academic centers receiving dupilumab for BP. Patients were eligible if they had a clinical diagnosis of BP confirmed by lesional skin biopsy evaluated by one of more of the following: hematoxylin and eosin staining, direct immunofluorescence, or enzyme-linked immunosorbent assay for BP180 or BP230, or both. RESULTS: We identified 13 patients. Patients were an average age of 76.8 years, and the average duration of BP before dupilumab initiation was 28.8 months (range, 1-60 months). Disease clearance or satisfactory response was achieved in 92.3% (12 of 13) of the patients. Satisfactory response was defined as clinician documentation of disease improvement and patient desire to stay on the medication without documentation of disease clearance. Total clearance of the BP was achieved in 53.8% (7of 13) of patients No adverse events were reported. LIMITATIONS: Include small sample size, lack of a control group, lack of a standardized assessment tool, and lack of standardized safety monitoring. CONCLUSION: Dupilumab may be an additional treatment for BP, leading to disease clearance or satisfactory response in 92.3% of patients, including in those in whom previous conventional therapy had failed.

The rash with maculopapules and fever in adults.

There is a broad differential diagnosis for the presentation of fever and maculopapular rash in an adult. Although some causative conditions are benign, others are medical emergencies that require prompt diagnosis. We describe various conditions that result in a fever and maculopapular rash in adults. These include infectious processes (meningococcemia, infectious mononucleosis, West Nile virus, zika virus, rubella, primary human immunodeficiency virus, parvovirus B19, ebolavirus), tick-borne illnesses (Rocky Mountain spotted fever, ehrlichiosis), and hypersensitivity reactions (exanthematous drug reactions). We also provide an algorithm to aid in the diagnosis of the patient with fever and maculopapular rash. Such conditions that can occur in adults but are seen predominantly in children are discussed in the article "Rash with maculopapules and fever in children" of this issue.

The rash with maculopapules and fever in children.

Several medical conditions can cause children to present with fever and a maculopapular rash Although some presentations are benign, others may be medical emergencies, which warrant a prompt diagnosis. We review some of the more common causes of fever and maculopapular dermatitirs, rash including infectious processes (roseola; rubeola; rubella; parvovirus B19; hand, foot, and mouth disease; scarlet fever; meningococcemia; Epstein-Barr virus infection), hypersensitivity reactions (exanthematous drug reactions), and vasculitis syndromes (Kawasaki disease). We have included a diagnostic algorithm to facilitate rapid identification of the etiology of the rash and fever. Those conditions that can occur in children but are seen predominantly in adults are discussed in the contribution "Rash with maculopapules and fever in adults" in this issue.

Putative Intravascular Myofibroma Mimicking a Vascular Malformation With Phleboliths.

Myofibroma is a rare, benign myofibroblastic tumor that commonly presents at birth or in early infancy, usually as a painless, slow-growing, solitary, nodular mass. We present a case of a 40-year-old woman with a painful, solitary, myofibroma on the right elbow. The unique features of this case include age and gender of the patient, site, pain on presentation, tumor morphology, and putative intravascular nature of the tumor.