Leukocytoclastic Vasculitic Rash Following Second Dose of Moderna COVID-19 Vaccine.

The immunization against coronavirus disease (COVID-19) via vaccination serves as a significant milestone in the fight against the pandemic. Rapid introduction of various COVID-19 vaccines to stem the spread of virus has researchers scrambling to document the adverse effects left in its wake. Thus far, there have been singular examples of cutaneous vasculitis associated with COVID-19. A history of vasculitis leaves little error to miss its inclusion in diagnostic differentials. It also invokes the physiologic possibility that afflicted patients possess a more susceptible landscape for recurrence that was then triggered by the vaccine when compared with those who lack similar history. In our case report, we build on those findings with one of the first documented examples of vaccination-induced vasculitic rash in a previously asymptomatic patient.

Vascular obliteration because of endothelial and myointimal growth in COVID-19 patients.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a systemic multi-organ viral illness. Previous studies have found that many patients had a procoagulant state and/or severe hypoxemia with relatively well-preserved lung mechanics. Mechanisms underlying the damage to vascular tissues are not well-elucidated yet. Histological data in COVID-19 patients are still limited and are mainly focused on post-mortem analysis. Given that the skin is affected by COVID-19 and the relative ease of its histological examination, we aimed to examine the histology of skin lesions in COVID-19 patients to better understand the disease's pathology. METHODS: Five skin lesions from COVID-19 adult patients were selected for a deep histological tissue examination. RESULTS: A strong vasculopathic reaction pattern based on prominent vascular endothelial and myointimal cell growth was identified. Endothelial cell distortion generated vascular lumen obliteration and striking erythrocyte and serum extravasation. Significant deposition of C4d and C3 throughout the vascular cell wall was also identified. A regenerative epidermal hyperplasia with tissue structure preservation was also observed. CONCLUSIONS: COVID-19 could comprise an obliterative microangiopathy consisting on endothelial and myointimal growth with complement activation. This mechanism, together with the increased vascular permeability identified, could contribute to obliteration of the vascular lumen and hemorrhage in COVID-19. Thus, anticoagulation by itself could not completely reverse vascular lumen obliteration, with consequent increased risk of hemorrhage. Findings of this study could contribute to a better understanding of physiopathological mechanisms underlying COVID-19 on living patients and could help further studies find potential targets for specific therapeutic interventions in severe cases.

Current and emerging biologic and small molecule therapies for atopic dermatitis.

INTRODUCTION: Atopic dermatitis (AD) is the most common inflammatory skin disease, yet until recently there were no safe systemic therapies approved for the long-term management of AD in adult patients. A deeper understanding of disease pathogenesis and identification of molecular and cellular changes has resulted in a rapidly evolving pipeline of therapeutics that holds promise for safer long-term control. AREAS COVERED: In this review, we highlight the growing arsenal of biologic and small molecule antagonists that target pathways implicated in AD pathogenesis. Evidence that AD is driven by multiple immune axes extending beyond the Th2 polarization has resulted in therapies targeting additional pathways, including the Th22, Th17/IL-23, and JAK-STAT pathways. Pruritus, a hallmark of AD, has been linked to multiple mechanisms and various therapeutics have emerged in response to alternative hypotheses. EXPERT OPINION: Despite the assumption that AD has a common disease mechanism, recent studies indicate that the disorder is characterized by several phenotypes and therapy may need to be tailored to the unique immune traits of specific phenotypes. Targeted therapy should complement and expand our molecular map of AD across the various phenotypic iterations and help push AD pharmacotherapy into a new era of personalized medicine.

Use of 308 nm excimer laser for the treatment of chronic hand and foot eczema.

BACKGROUND: Chronic hand and foot eczema (CHFE), a prevalent debilitating disorder affecting approximately 15% of the population, presents a socioeconomic and psychosocial burden for patients and often follows a chronic course, refractory to conventional therapies. Thus, a large need exists for more effective therapeutics; the excimer laser (308 nm) is effective for some inflammatory skin diseases, but its efficacy has not been evaluated for CHFE. METHODS: The study is a retrospective chart review conducted on 30 patients with recalcitrant CHFE (19 with hand involvement, four with foot involvement, and seven with both) treated twice weekly with excimer laser (308 nm) single wavelength ultraviolet (UV)B radiation between January 2013 and December 2014. RESULTS: Improvements in clinical scores included a 69% reduction in average physician's global assessment (PGA) scores (from 2.77 at baseline to 0.87 after treatment, P < 0.0001) with a parallel reduction in average modified total lesion/symptom scores of 70% (from 10.2 to 3.1, P < 0.0001). Only mild sunburn-like reactions were observed. CONCLUSION: This report evaluates excimer laser for patients with refractory CHFE and shows excellent and sustained efficacy for this treatment. Compared to other UV therapies, excimer laser offers lower cumulative doses of UV radiation by targeting specific areas. This effective treatment should be considered alone or in combination with other established or newer therapies.

Allergic contact dermatitis: patch testing results at Mount Sinai Medical Center.

Patch testing is an important diagnostic tool commonly used to identify allergens responsible for allergic contact dermatitis, especially in cases where the diagnosis is not clearly apparent. The authors report the patch test results from 2004-2008 and compare the results with the North American Contact Dermatitis Group and Mayo Clinic. Four hundred thirty-four patients with suspected allergic contact dermatitis underwent standardized patch testing with a tray consisting of 50 allergens at Mount Sinai Medical Center. Two hundred ninety patients (66.8%) had positive reactions to at least one allergen. The most frequent contact allergens included nickel sulfate (13%), fragrance mix (9.6%), propylene glycol (7.8%), neomycin sulfate (6.6%), thimerosal (6.4%), bacitracin (6.2%), and sodium gold thiosulfate (5.8%).

The use of the 308-nm excimer laser for the treatment of psoriasis.

OBJECTIVE: The objective was to study the effectiveness of the 308-nm excimer laser for the treatment of various forms of localized stable psoriasis. BACKGROUND: Recent reports show that 308-nm excimer laser may be an effective and safe method for the treatment of localized stable psoriasis. METHODS: A retrospective chart review was performed of a population-based group of 98 patients with various forms of localized stable psoriasis treated with excimer laser. Of these, 41 were male, and 57 were female patients. Ages ranged from 10 to 84 years (mean, 51.4 years). Patients who completed at least 10 sessions were included unless they had achieved >70% improvement in PASI scores before 10 treatments. The initial dose was determined by the MED (minimal erythema dose), and the dose was raised gradually in a stepwise fashion. RESULTS: Significant improvement (≥70%) was achieved by 59 (60.2%) patients; they needed an average cumulative dose of 6.46 J/cm(2), and an average of 17 sessions. Twenty-four (24.5%) patients achieved good improvement (50% to 70%); the average cumulative dose needed was 5.36 J/cm(2), and the average number of sessions required was 12. Side effects were limited to sunburn-like reaction. CONCLUSION: The 308-nm excimer laser is an effective and safe modality for the treatment of psoriasis, with good results achieved in a relatively short time.

Treatment of vitiligo using the 308-nm excimer laser.

OBJECTIVE: The aim of this study was to study the effectiveness of the 308-nm xenon chloride excimer laser in the treatment of vitiligo and to determine factors that favor a good response to treatment. BACKGROUND DATA: Targeted phototherapy using the 308-nm xenon chloride excimer laser represents an effective therapy for the management of vitiligo. However, studies on a large number of patients are few despite the increasing use of the excimer laser to treat patients with vitiligo. METHODS: A retrospective chart review of 97 patients with chronic stable vitiligo was done with a total of 221 vitiligo patches treated. RESULTS: Out of 221 vitiligo patches treated, 50.6% showed 75% pigmentation or more, 25.5% achieved 100% pigmentation of their patches, and 64.3% showed 50% pigmentation or more. Lesions on the face responded better than lesions elsewhere. CONCLUSION: The 308-nm xenon chloride excimer laser is an effective and safe modality for the treatment of vitiligo, with good results achieved in a relatively short duration of time.

Alefacept - a drug review.

Alefacept is an immunobiologic agent that has been recently introduced in the treatment of plaque psoriasis. The author presents a brief review of the drug, its efficacy and safety profile. Recent case reports of the use of alefacept in conjunction with other conditions as well as the drug's possible use for treatment of other conditions are reviewed as well.

Efalizumab: a biological agent for the treatment of psoriasis.

Efalizumab is a humanized, monoclonal IgG1 antibody that binds to the alpha-subunit of lymphocyte function associated antigen (LFA)-1, blocking the interaction between LFA-1 and intercellular adhesion molecule-1. The result is a reduction in T cell activation, an inhibition of the trafficking and recruitment of T cells to the dermis and epidermis, and a decrease in the reactivation of T cells at several steps in the psoriasis pathogenesis. The clinical responses seen in efalizumab trials have demonstrated that this medication is efficacious, especially in long-term treatment. Adverse events observed in efalizumab-treated patients have been minor. Psoriasis rebound following discontinuation of treatment, while serious, has been controlled through transition to other therapies. Subcutaneous injection allows for administration outside the clinic.

A review of the treatment of psoriasis with infliximab.

Patients afflicted with moderate to severe psoriasis experience a reduction in the quality of life. They not only suffer the aggravation associated with the pain, itchiness, and bleeding of the psoriatic lesions, but also experience a negative impact on their daily functions and social well-being. Unfortunately, traditional therapeutic measures have not been effective enough in treating individuals suffering from moderate to severe forms of psoriasis. Most of the conventional medications have produced at best only partial responses. However, the recent chimeric monoclonal TNF-alpha inhibiting antibody, infliximab, has been proven effective for the treatment of patients with moderate to severe psoriasis. Most patients treated with infliximab have shown rapid and remarkable improvement in the clinical manifestations of the disease. This article will closely examine the efficacy and safety of infliximab through the analysis of past case reports and clinical trials.

Use of etanercept in the treatment of psoriasis and psoriatic arthritis.

Psoriasis and psoriatic arthritis are debilitating inflammatory immunemediated diseases which are chronic in nature and often require lifelong attention. Traditional therapies used to combat these diseases lack sufficient long-term efficacy and are associated with a number of toxicities. Failing to adequately satisfy both patients and physicians, traditional therapies have proven insufficient and have left few options. Etanercept is a tumor necrosis factor (TNF) antagonist that reduces elevated TNF levels by competitively binding to both TNF-alpha and TNF-beta and inhibiting the proinflammatory cascade. Providing a valuable treatment option alone, etanercept can also be effectively administered in conjunction with traditional treatments. Etanercept is self administered by subcutaneous (SC) injection, making treatment less of a burden for patients by eliminating the need for frequent office visits and laboratory testing. Etanercept is approved in the US for the treatment of psoriasis, psoriatic arthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, and ankylosing spondylitis.

Patch testing: a retrospective analysis of 103 patients with emphasis on practical aspects for the clinician.

BACKGROUND: Allergic contact dermatitis is a common dermatologic disorder caused by small chemical molecules that can penetrate the skin barrier. Thousands of chemicals capable of inducing allergic contact dermatitis have been identified. To cure allergic contact dermatitis, the allergen should be identified and eliminated from the environment of the patient. Patch testing, utilizing a variety of standard panels of the most frequent allergens, is used to identify the allergen in question. Patch testing is still the gold standard tool used to identify one or more substances that may contribute to the etiology of allergic contact dermatitis. OBJECTIVE: To determine the frequency of patch test positivity and to identify the most common allergens in patients with suspected allergic contact dermatitis. METHODS: A retrospective analysis of files of 103 patients who have been clinically diagnosed to have allergic contact dermatitis and have been patch tested using a standard technique with a Northern American Contact Dermatitis Group series. RESULTS: Sixty-two patients (60.2%) showed positive reactions to one or more substance. The most common allergens were nickel sulfate, fragrance mix, and neomycin sulfate. There was an increased frequency of positive reactions to fragrance mix and a significant decrease of frequency of thimerosal positive reactions. CONCLUSIONS: Increased awareness of allergens and their potential sources may help to limit the usage of these chemicals in manufacturing consumer products. This may have contributed to decreased prevalence rates of certain allergens such as thimerosal and paraphenylenediamine.

The excimer lasers.

The excimer lasers are a group of lasers that have found wide application in a variety of medical fields including dermatology, cardiology, ophthalmology, and orthopedics. The word excimer refers to excited dimer. These lasers operate in the ultraviolet range, and examples include the 193 nm argon-fluroide, 248 nm krypton-fluoride, 351 nm xenon-fluoride, and of particular interest to dermatology, the 308 nm xenon-chloride. These lasers utilize a mixture of a noble gas and a halogen as a lasing material. They were first used in medicine for their ability to produce cold tissue ablation, but more recently have been used in dermatology as a method of non-ablative phototherapy.

The use of the 308-nm excimer laser for the treatment of vitiligo.

BACKGROUND: Recent reports show that 308-nm excimer laser may be an effective and safe method for the treatment of vitiligo, which is usually resistant to other available treatment methods. OBJECTIVE: The objective was to study the effectiveness of the new 308-nm excimer laser for the treatment of vitiligo. METHODS: A retrospective chart review of thirty-two patients with 55 spots of vitiligo were enrolled; a population-based sample was studied that included men and women, adults and children, with different ethnic backgrounds. The treatment was started with the lowest dose, which is 100 mJ/cm(2) (comparable to one minimal erythema dose value and one multiplier). Depending on Fitzpatrick skin type, the dose was raised gradually in a stepwise fashion. In skin types I to II, the same does was repeated twice before going up to avoid burns. Patients were treated for 30 sessions, or 75% repigmentation, whichever comes first. RESULTS: Overall 55 spots were treated: 29 (52.8%) had 75% pigmentation or greater, and 35 (63.7%) had 50% pigmentation or greater. The best results were on the face: of the 21 spots treated 15 (71.5%) had 75% pigmentation, and 16 (76.2%) had 50% pigmentation or greater. Other areas (neck, extremities, trunk, and genitals) had moderate response in comparison to the face. The least response was on the hands and feet; of the 5 spots treated only 20% showed 50% pigmentation or more. CONCLUSION: Slightly more than 50% of the patients tested showed 75% or more pigmentation of their lesions, after 30 treatments or less; most of the responders had Fitzpatrick skin type III and above. All the untreated patches (controls) remained unchanged. This demonstrates that the 308-nm excimer laser is an effective method of treatment for vitiligo.