Atopic Dermatitis: Pathophysiology.

The pathophysiology of atopic dermatitis is complex and multifactorial, involving elements of barrier dysfunction, alterations in cell-mediated immune responses, IgE-mediated hypersensitivity, and environmental factors. Loss-of-function mutations in filaggrin have been implicated in severe atopic dermatitis due to a potential increase in trans-epidermal water loss, pH alterations, and dehydration. Other genetic changes have also been identified, which may alter the skin's barrier function, resulting in an atopic dermatitis phenotype. The imbalance of Th2 to Th1 cytokines observed in atopic dermatitis can create alterations in the cell-mediated immune responses and can promote IgE-mediated hypersensitivity, both of which appear to play a role in the development of atopic dermatitis. One must additionally take into consideration the role of the environment on the causation of atopic dermatitis and the impact of chemicals such as airborne formaldehyde, harsh detergents, fragrances, and preservatives. Use of harsh alkaline detergents in skin care products may also unfavorably alter the skin's pH causing downstream changes in enzyme activity and triggering inflammation. Environmental pollutants can trigger responses from both the innate and adaptive immune pathways. This chapter will discuss the multifaceted etiology of atopic dermatitis, which will help us to elucidate potential therapeutic targets. We will also review existing treatment options and their interaction with the complex inflammatory and molecular triggers of atopic dermatitis.

Common contact allergens implicated in frontal fibrosing alopecia found in over-the-counter hair growth serums and solutions.

Background: Frontal fibrosing alopecia (FFA) is a form of lichen planopilaris with an undetermined etiopathogenesis, predominantly affecting women. There is conflicting evidence as to whether contact allergens may play a role in the underlying etiology or progression of FFA. Objective: The aim of this study is to find the most common products that patients search for online, identify contact allergens present in these advertised over-the-counter hair products, and suggest their role in the development or exacerbation of FFA. Methods: We reviewed current research on this topic and then investigated common allergens found in over-the-counter hair products commonly used for hair regrowth. Results: FFA's exact etiopathogenesis remains vastly unknown, however, current literature has reported an association between inflammatory skin conditions and FFA. Limitations: The lack of published data on the function of contact allergens in FFA placed restrictions on our study. Conclusion: A survey-based analysis with a larger cohort is needed to further interpret the relationship between product use and FFA presentation based on contact allergens. More research on possible etiopathogenesis and the relationship between contact dermatitis and FFA may prevent further progression of a patient's disease, leading to an improvement in their quality of life.

Uncovering Shortcomings in Advertising Strategies for Over-the-Counter Minoxidil Products on Amazon.

Introduction The over-the-counter (OTC) market for hair loss products, particularly those containing minoxidil, has significantly expanded due to the increased prevalence of hair loss. Minoxidil, a vasodilator medication, is known for its potential to stimulate hair growth. However, the rise in OTC formulations has led to misleading advertising and marketing, with some companies exaggerating the benefits of their products while minimizing potential adverse effects. Methods A Google Boolean Search was conducted to identify OTC minoxidil products. The topmost non-sponsored search engine result page was used for analysis. Products not containing any dosage of minoxidil were excluded, resulting in nine products. These were individually searched on Amazon and eight were analyzed for any addressed safety information and adverse effects profile. Results The analysis revealed that only two out of eight products (25%) reported safety information, and none of the products (0%) reported any adverse effects. Significant observations were found surrounding the transparency and accuracy of the advertising and marketing of these products. Many companies made bold claims about their products without providing supporting scientific evidence or studies. Furthermore, many of these OTC hair loss brands did not adequately mention and explain the adverse effects of the product. Conclusions The study highlights the need for greater transparency in the marketing of OTC minoxidil products. Companies should provide clear and accessible information about the safety and potential adverse effects of their products. This will empower consumers to make informed decisions and foster trust between the industry and the consumer. Furthermore, the authenticity and accuracy of marketing images should be ensured to avoid giving false hopes to consumers.

Vitamin C Deficiency Masquerading as Vasculitis in a Patient With Crohn's Disease.

This case study features a 40-year-old male with Crohn's disease (CD) who was initially misdiagnosed with vasculitis but was later shown to have scurvy owing to vitamin C deficiency. The patient's diet was nearly exclusively made up of highly processed fast food, with no fresh fruits or vegetables. A mildly sensitive, violaceous rash on his lower legs, mild gingival hemorrhage and enlargement, and muscle soreness were among his symptoms. Anemia and undetectable vitamin C levels were discovered in laboratory studies. A skin sample revealed follicular hyperkeratosis, coiled hairs, and perifollicular bleeding, eliminating the possibility of vasculitis. Scurvy was confirmed by undetectable vitamin C levels and intramuscular bleeding discovered during a muscle biopsy. After one month of vitamin C administration, the patient's skin was entirely clear. This instance emphasizes the significance of taking vitamin C insufficiency into account in patients with CD and other disorders that can cause malabsorption. Misdiagnosis might result in unneeded treatments and medical expenses. Scurvy must be diagnosed as soon as possible because it might cause gastrointestinal/intracerebral hemorrhage and death.

Guanfacine treatment for a patient with delusional parasitosis causing dermatillomania presenting with shared psychiatric disorders.

Dermatillomania often coexists with delusional parasitosis (DP) and can cause extreme patient morbidity. The standard treatment for DP has been conventional antipsychotic drugs; however, their use is limited by potential adverse effects and monitoring requirements. Guanfacine, an alpha-2 adrenergic receptor agonist, has emerged as a promising alternative for patients with attention deficit hyperactivity disorder with concurrent tics. Although no current research supports guanfacine's efficacy in managing DP or dermatillomania, its pharmacological profile hints at potential benefits. A 58-year-old woman presented to our clinic for DP causing dermatillomania and was started on guanfacine. She reported fewer beliefs about parasites infesting her body and had fewer excoriating lesions on this medication. Additionally, her Patient Health Questionnaire-9 score peaked with a score of 23 at diagnosis and significantly decreased to 13 three months after starting guanfacine. However, further research is needed to ascertain if guanfacine is an effective treatment for DP.

Adverse cutaneous reaction to hydroxychloroquine in a patient with anti-SAE-1-positive dermatomyositis and a history of diffuse large B-cell lymphoma.

This case report details the cutaneous findings of a patient with a history of diffuse B-cell lymphoma and SAE-1-positive dermatomyositis who developed an adverse cutaneous reaction after initiation of treatment with hydroxychloroquine. This adds to the sparse literature available detailing the correlation between anti-SAE-1 autoantibodies in dermatomyositis and the unique adverse cutaneous reactions in patients taking hydroxychloroquine. Additionally, our patient developed dermatomyositis years after a diagnosis of lymphoma. This report highlights the utility of the myositis-specific antibody panel to guide diagnosis and management, as well as the potential for developing dermatomyositis years after a lymphoma diagnosis.

Evaluation and Management of Pruritus and Scabies in the Elderly Population.

Pruritus is the most common dermatologic complaint in the geriatric population. Its growing prevalence coincides with the rapid growth of the elderly population (>65 years of age) in the United States. According to the US Census Bureau, 16.9% of the population, or more than 56 million adults 65 years and older, lived in the United States in 2022. Pruritus is a condition that accompanies a diverse array of underlying etiologic factors. The mechanism of normal itch impulse transmission has been recently elucidated. The itch sensation originates from epidermal/dermal receptors connected to unmyelinated, afferent C-fibers that transmit the impulse from the periphery.

Relapsing Polychondritis in a Patient With Rheumatoid Arthritis: Improved With Pentoxifylline.

Relapsing polychondritis (RP) is a rare autoimmune condition that involves the recurrent inflammation of cartilage throughout the body, with a predilection for auricular and nasal cartilage. Given its rarity and diverse clinical presentations, RP is frequently misdiagnosed or left untreated, which can lead to significant morbidity and mortality. When it is correctly diagnosed, there are no standardized guidelines on the treatment of RP to date. Management of this disease requires a multidisciplinary approach, and about 30% of patients with RP have other autoimmune disorders, further complicating the approach to targeted treatment. Biologic agents (including TNF inhibitors) are commonly used. We present a compelling case of a 46-year-old female with rheumatoid arthritis (well-controlled on adalimumab) and hypothyroidism who presented to the dermatology clinic with recurrent episodes of painful, swollen, and erythematous ears, leading to a clinical diagnosis of relapsing polychondritis. Off-label use of oral pentoxifylline, along with topical corticosteroids, led to significant improvement in her symptoms. Dermatologists play an important role in the diagnosis of this rare disorder, as skin manifestations may be the initial presenting sign of RP. Further research into potentially effective treatments is needed. Timely identification and management of RP may prevent the progression of cartilage destruction, thus improving patients' long-term prognosis and overall quality of life.

Cutaneous Intravascular CD-30-Positive Anaplastic Large Cell Lymphoma: A Case Report and Literature Review.

Intravascular cutaneous anaplastic large cell lymphoma (ALCL) is an extremely rare non-Hodgkin lymphoma that proliferates in the lumen of small blood vessels and has a propensity to manifest in the skin. Most reported cases of intravascular lymphoma described in the literature are of large B-cell lymphomas, making T-cell lymphomas incredibly rare. As such, we present the case of an 87-year-old male with primary cutaneous intravascular anaplastic large T-cell lymphoma that initially presented with an erythematous, subcutaneous nodule on the right mid-abdomen. We report the immunohistochemical results showing lymphoma cells staining positively for CD3 and CD30 and lacking expression of anaplastic lymphoma kinase, pan-cytokeratin, CD10, CD20, and SOX10. We also review and compare previously reported cases of intravascular ALCL with primary cutaneous involvement.

Cutaneous carcinosarcoma: a rare diagnosis.

Carcinosarcoma is a rare malignant tumor that is a combination of carcinoma (cancer of epithelial tissue) and sarcoma (cancer of mesenchymal tissue). In practice, it is more common to have either carcinoma or sarcoma individually, but it is novel to have a combination of the two; as a result, few cases have been reported. Carcinosarcoma typically occurs in visceral organs and is rare in the skin. We present the case of a 68-year-old man with a lesion on his left zygomatic cheek that was revealed to be a biphasic malignant neoplasm. Multiple stains provided evidence of both epithelial and mesenchymal components within the lesion. Treatment for such a diagnosis typically involves a combination of wide local excision or plastic surgery for reconstruction purposes, both of which were used with this patient. This case describes the identification of cutaneous carcinosarcoma using immunohistochemical tests and emphasizes the uniqueness of such a diagnosis that requires early attention and appropriate selective treatment.

Cutaneous mastocytoma obscured by allergic contact dermatitis in an infant.

The diagnosis of solitary mastocytoma is usually made clinically, however, atypical presentations may obscure the diagnosis. We present a unique case of solitary cutaneous mastocytoma in an 11-month-old male initially misdiagnosed as atopic dermatitis; the diagnosis was obscured due to the development of an allergic contact dermatitis most likely secondary to topical medications that were being applied to the lesion. The diagnosis of solitary cutaneous mastocytoma is made based on lesion morphology, Darier's sign, and lack of systemic involvement. Most solitary cutaneous mastocytomas resolve before puberty; symptomatic treatment and avoidance of triggers are mainstay therapy.

Drug-induced neutrophilic lobular panniculitis secondary to BRAF and MEK inhibitor used for treatment of low-grade glioma and its management.

An 8-year-old boy presented with his mother for evaluation of an erythematous rash 3 weeks after the start of dual BRAF-MEK inhibition with dabrafenib and trametinib for treatment of progression of low-grade glioma. Panniculitis has been reported as a rare adverse cutaneous event induced by BRAF inhibitors, MEK inhibitors, and the combined dual BRAF-MEK therapy. Based on the patient's history, clinical presentation, and histopathological findings, a diagnosis of drug-induced neutrophilic panniculitis was made. This case describes neutrophilic panniculitis as a potential cutaneous manifestation of dual BRAF-MEK inhibitor therapy and describes the management of such side effects. Neutrophilic panniculitis is a relatively rare manifestation, characterized by neutrophilic inflammation in the subcutaneous tissue. Additionally, this case serves as a reminder to consider the cutaneous side effects of such therapies, given that MEK and BRAF inhibitors are increasingly used to treat primary brain tumors in the pediatric population. Routine inspection and early management may improve patients' quality of life and enable continuation of anticancer therapy.

Acute Onset of Bullous Skin Rash and Acute Kidney Injury after Exposure to Radiocontrast: Sweet's Syndrome.

Sweet's syndrome or acute febrile neutrophilic dermatosis is characterized by an acute inflammatory skin eruption of oedematous and erythematous papules, plaques or nodules, accompanied by fever, and leucocytosis with possible extracutaneous involvement. Aetiologies include infections, inflammatory bowel disease, pregnancy or malignancy, or the syndrome may be drug-induced by many classes of medications or very rarely, radiocontrast exposure. Herein, the authors report a case of radiocontrast-induced bullous Sweet's syndrome and contrast-induced acute kidney injury in a woman in her 60s with a complex medical history. LEARNING POINTS: Patients with Sweet's syndrome (SS) typically present with acute-onset fever, leucocytosis, and erythematous, tender plaques with dense neutrophilic infiltration in the dermis. The condition is classified into three subtypes: classic SS, malignancy-associated SS, and drug-induced SS.Drug-induced SS is characterized by an abrupt onset of a painful erythematous rash, dense neutrophilic dermal infiltrate without vasculitis, a temporal relationship between exposure and onset, and resolution of symptoms after drug discontinuation and/or corticosteroid therapy.Treatment options include systemic corticosteroids as first-line therapy, while colchicine, dapsone, indomethacin, naproxen, clofazimine, ciclosporin, α-interferon, and potassium iodide may be considered as second-line therapies in cases resistant to corticosteroids.

​​Longitudinal Erythronychia Secondary to a Wooden Splinter.

Longitudinal erythronychia (LE) is a term for red streaks in the nail which can be caused by a range of diseases. The specific type of longitudinal erythronychia can correlate with certain associated conditions making it important to properly categorize when discovered. A 71-year-old Hispanic male presented to the clinic with a type 1A LE associated with subungual keratosis that had been asymptomatic for approximately 12 months. The patient denied injury, pain, cold sensitivity, or cosmetic distress. The working diagnosis was squamous cell carcinoma in situ (SCCIS) vs. onychopapilloma or glomus tumor. A 4mm punch biopsy from the distal nail matrix was performed, and dermatopathology revealed that the LE was secondary to a wooden splinter. After a literature review, it was discovered that this is the first confirmed case of LE secondary to a splinter. Future providers should keep splinters as a potential differential diagnosis, especially as they evaluate LE, but ultimately all suspicious type IA lesions should be biopsied to rule out potential insidious pathologies, such as SCCIS and malignant melanoma.