Clinical Course, Antifungal Susceptibility, and Genomic Sequencing of Trichophyton indotineae.

Importance: Trichophyton indotineae is an emerging dermatophyte causing outbreaks of extensive tinea infections often unresponsive to terbinafine. This species has been detected worldwide and in multiple US states, yet detailed US data on infections with T indotineae are sparse and could improve treatment practices and medical understanding of transmission. Objective: To correlate clinical features of T indotineae infections with in vitro antifungal susceptibility testing results, squalene epoxidase gene sequence variations, and isolate relatedness using whole-genome sequencing. Design, Setting, and Participants: This retrospective cohort study of patients with T indotineae infections in New York City spanned May 2022 to May 2023. Patients with confirmed T indotineae infections were recruited from 6 New York City medical centers. Main Outcome and Measure: Improvement or resolution at the last follow-up assessment. Results: Among 11 patients with T indotineae (6 male and 5 female patients; median [range] age, 39 [10-65] years), 2 were pregnant; 1 had lymphoma; and the remainder were immunocompetent. Nine patients reported previous travel to Bangladesh. All had widespread lesions with variable scale and inflammation, topical antifungal monotherapy failure, and diagnostic delays (range, 3-42 months). Terbinafine treatment failed in 7 patients at standard doses (250 mg daily) for prolonged duration; these patients also had isolates with amino acid substitutions at positions 393 (L393S) or 397 (F397L) in squalene epoxidase that correlated with elevated terbinafine minimum inhibitory concentrations of 0.5 µg/mL or higher. Patients who were treated with fluconazole and griseofulvin improved in 2 of 4 and 2 of 5 instances, respectively, without correlation between outcomes and antifungal minimum inhibitory concentrations. Furthermore, 5 of 7 patients treated with itraconazole cleared or had improvement at the last follow-up, and 2 of 7 were lost to follow-up or stopped treatment. Based on whole-genome sequencing analysis, US isolates formed a cluster distinct from Indian isolates. Conclusion and Relevance: The results of this case series suggest that disease severity, diagnostic delays, and lack of response to typically used doses and durations of antifungals for tinea were common in this primarily immunocompetent patient cohort with T indotineae, consistent with published data. Itraconazole was generally effective, and the acquisition of infection was likely in Bangladesh.

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.

The Application of Dupilumab to Pediatric Patients Aged 6-11yrs with Moderate-to-Severe Atopic Dermatitis Whose Disease is Not Adequately Controlled: The Clinical Data so Far.

Background: While dupilumab has shown efficacy in improving atopic dermatitis, few studies have assessed the long-term clinical data of dupilumab use in pediatric patients. Objective: In the present study, we reviewed the current literature to assess reported efficacies, side effects, and risks of using dupilumab to treat atopic dermatitis in pediatric populations. Methods: Using PRISMA guidelines, the authors searched PubMed/MEDLINE and Embase for studies related to dupilumab treatment for atopic dermatitis in pediatric patients aged 6-11 years old. Results: A total of 512 pediatric patients (ages 6-11) were included. Outcome measures assessed by EASI, SCORAD, P-NRS, IGA and C-DLQI showed significant improvements in scores from those observed at baseline to the last treatment of dupilumab. Most reported adverse effects on dupilumab were conjunctivitis and infection site reactions. All studies reported that dupilumab was well-tolerated. Limitations: Limitations include the low number of studies available and observation periods of up to 16 weeks, which may be too short to evaluate the drug's effectiveness and occurrence of adverse effects. This also limits our knowledge on whether there are sustained benefits and/or diminished efficacy as well as long-term side effects. Conclusion: Thus far, the data demonstrates dupilumab to be safe and effective in the management of moderate-to-severe atopic dermatitis in children aged 6-11 years. Future studies should evaluate long-term dupilumab use and sustained effects.

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.

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.

Internet-based survey intervention improves adherence to methotrexate among psoriasis patients.

BACKGROUND: While it is known that psoriasis patients have poor adherence to both topical and systemic medications, adherence to methotrexate is not well-characterized, and ways to improve methotrexate adherence have not been addressed. OBJECTIVE: The aim of this study was to evaluate whether a digital intervention improved adherence to oral methotrexate as measured by electronic monitoring. METHODS: Twenty-nine patients were randomized to receive either weekly digital interventions assessing treatment adherence or no intervention for 24 weeks. Patients received medication bottles with electronic monitoring, and returned at weeks 4, 12, and 24 to evaluate disease severity. RESULTS: The intervention group took methotrexate correctly 77.1% of the weeks observed compared to the control group which averaged 64.5%. More intervention patients took methotrexate as directed compared to the control group (78.3% vs 64.2%, p < 0.0001). Patients were most adherent around follow-up visits, with 100% of digital intervention patients and 80% of control patients taking methotrexate correctly during the week of a follow-up visit (p = 0.02). The digital intervention did not significantly improve disease severity in the intervention group compared to the nonintervention group. CONCLUSIONS: Low cost, scalable digital interventions may have the potential to increase psoriasis patient adherence to methotrexate, although the mechanism for the improvement is not yet well defined.

Apremilast in the Treatment of Plaque Psoriasis: Differential Use in Psoriasis.

Small molecule medications like apremilast are emerging as promising options for patients with psoriasis and other inflammatory conditions. Apremilast was approved by the Food and Drug Administration in 2014 for the management of both psoriasis and psoriatic arthritis. Apremilast inhibits phosphodiesterase-4, which increases the intracellular levels of cyclic AMP, thereby reducing inflammatory cytokine production. This review aims to discuss the published evidence and evaluate the differential use of apremilast in plaque psoriasis of the body and scalp, nail psoriasis, and palmoplantar psoriasis. In clinical trials, apremilast effectively reduced the severity of different dermatological manifestations of psoriasis and improved patients' quality of life. It has an acceptable safety profile and is generally well-tolerated. Oral medications like apremilast offer an alternative route of administration which can be more convenient and appropriate for some patients. Additionally, pharmacoeconomic analyses of available anti-psoriatic systemic agents favor apremilast as a cost-effective therapeutic option.

Dermatological trends in emergency medicine.

BACKGROUND: Trends in emergency department (ED) visits with a primary dermatologic diagnosis are not well characterized. OBJECTIVE: The goal is to determine how the number of ED visits attributable to dermatologic disease is changing and to characterize the type of dermatologic conditions seen. METHODS: This is a cross-sectional study using the National Hospital Ambulatory Medical Care Survey: Emergency Department Summary Tables 2008-2017. Data were compiled into tables on the amount and type of dermatologic ED visits. RESULTS: The percentage of dermatologic visits ranged from an estimated 3.5% to 4.3%, peaking in 2014. Cellulitis was the most common diagnosis and accounted for an estimated 1.3% of all visits in 2016, and an estimated 1.2% of visits in 2017. The second most common diagnosis was cutaneous abscess, which accounted for an estimated 0.8% in 2016 and 0.9% in 2017. CONCLUSION: The number of ED visits attributed to disease of the skin and subcutaneous tissue has not followed a general trend of increase or decrease. The most common diagnoses are infections. We can best serve these patients by emphasizing the importance of ED provider education on the management of cutaneous infections and by working to increase the accessibility of dermatologic care.

Adherence to levetiracetam for management of epilepsy: Assessment with electronic monitors.

INTRODUCTION: Anti-seizure medications are used to manage epilepsy and require long-term adherence to maintain therapeutic drug levels. We assessed adherence to levetiracetam and the use of a digital intervention to improve adherence in patients with epilepsy. METHODS: 30 participants with epilepsy were randomized 1:1 either to a digital email adherence intervention or control group. All patients were provided levetiracetam equipped with electronic monitoring caps to assess patient adherence to medication. Patients were followed for 6 months, with return visits at 1 month, 3 months, and 6 months. RESULTS: Subjects randomized to the control arm (n = 15) took 66% of the prescribed doses compared to the intervention group, who took 65% of prescribed doses (n = 15). Nine participants did not complete the study. Of the twenty-one participants that completed the study, the overall rate of adherence was 72% of prescribed doses taken. Two subjects in the control group and three subjects in the intervention group were adherent every month of the study-taking at least 80% of prescribed doses. Those randomized to the control group took the correct number of doses 44% of days in the study, and those in the intervention group took the correct number of doses 37% of days. DISCUSSION: Poor adherence to levetiracetam is common. An internet-based email survey intervention did not improve adherence to levetiracetam in epilepsy patients. Further advances in adherence are needed to help patients receive the maximum benefit of their medical treatments.