Effect of weekly vitamin D supplementation on the severity of atopic dermatitis and type 2 immunity biomarkers in children: A randomized controlled trial.

BACKGROUND: Vitamin D (VD) deficiency is common among patients with atopic dermatitis (AD) and often associated with severity. However, randomized trials of VD supplementation in AD have had equivocal results, and there is little information regarding the effect of VD supplementation on type 2 immunity in AD patients. OBJECTIVES: To investigate the efficacy of VD supplementation to decrease severity of AD and to alter type 2 immunity biomarkers. METHODS: We performed a randomized, double-blind, placebo-controlled trial. We randomly assigned 101 children with AD to weekly oral vitamin D3 (VD3) or placebo for 6 weeks. The primary outcome was the change in the Severity Scoring of AD (SCORAD). RESULTS: Mean age of subjects was 6.3 ± 4.0 years, and baseline SCORAD was 32 ± 29. At baseline, 57% of children were VD deficient, with no difference between groups. Change in 25(OH)D was significantly greater with VD3 than placebo (+43.4 ± 34.5 nmol/L vs. +2.3 ± 21.2 nmol/L, p < 0.001). SCORAD change at 6 weeks was not different between VD and placebo (-5.3 ± 11.6 vs. -5.5 ± 9.9, p = 0.91). There were no significant between-group differences in change of eosinophil counts, total IgE, Staphylococcal enterotoxin specific IgE, CCL17, CCL22, CCL27, LL-37 or Staphylococcus aureus lesional skin colonization. Vitamin D receptor (VDR) gene single nucleotide polymorphisms FokI, ApaI and TaqI did not modify subjects' response to VD supplementation. CONCLUSIONS: Among children with AD, weekly VD supplementation improved VD status but did not modify AD severity or type 2 immunity biomarkers compared to placebo (ClinicalTrials.gov NCT01996423).

Vernix caseosa reveals mechanistic clues linking maternal obesity to atopic dermatitis pathogenesis.

BACKGROUND: Maternal overweight and obesity have been associated with an increased risk of atopic dermatitis (AD) in the offspring, but the underlying mechanisms are unclear. Vernix caseosa (VC) is a proteolipid material covering the fetus produced during skin development. However, whether maternal prepregnancy weight excess influences fetal skin development is unknown. Characterizing the VC of newborns from mothers with prepregnancy overweight and obesity might reveal AD-prone alterations during fetal skin development. OBJECTIVE: We sought to explore AD biomarkers and staphylococcal loads in VC from the offspring of mothers who were overweight/obese (O/O) before pregnancy versus in those from offspring of normal weight mothers. METHODS: The VC of newborns of 14 O/O and 12 normal weight mothers were collected immediately after birth. Biomarkers were determined by ELISA and staphylococcal species by quantitative PCR. RESULTS: The VC from the O/O group showed decreased expression of skin barrier proteins (filaggrin and loricrin) and increased levels of proinflammatory biomarkers (IgA, thymic stromal lymphopoietin [TSLP], S100A8, IL-25, and IL-33). No differences in concentrations of antimicrobial peptides and enzymes were detected. The VC from the O/O group had a lower Staphylococcus epidermidis and Staphylococcus hominis commensal bacterial load, whereas Staphylococcus aureus bacterial load was not significantly different between the 2 groups. Maternal body mass index was negatively correlated with VC filaggrin expression and S epidermidis load and was positively associated with TSLP concentration. One-year follow-up established that the offspring of O/O mothers had a higher incidence of AD that was specifically linked with decreased VC filaggrin expression and lower S epidermidis load. CONCLUSIONS: VC from neonates of mothers with prepregnancy overweight and obesity exhibit skin barrier molecular alterations and staphylococcal dysbiosis that suggest early mechanistic clues to this population's increased risk of AD.

Color Doppler Ultrasound Assessment of Subclinical Activity With Scoring of Morphea.

BACKGROUND: Detection of activity in morphea is paramount for adequately managing the disease. Subclinical ultrasound involvement on inactive lesions or healthy skin areas adjacent to morphea has not been described to date. OBJECTIVES: The study aimed to detect morphea's subclinical activity by Color Doppler ultrasound not identified with the clinical scorings. MATERIALS & METHODS: This cross-sectional retrospective study was done from January 2014 to July 2019 in patients with a clinicopathological diagnosis of morphea. The modified Localized Scleroderma Skin Severity Index (mLoSSI) and The Ultrasound Morphea Activity Score (US-MAS) were used to correlate clinical and subclinical activity. RESULTS: A total of 36 patients met the inclusion criteria. 54% of cases presented subclinical activity in areas adjacent to the clinically active lesion, 23% in nonadjacent regions, and 23% demonstrated activity at a clinically inactive lesion site.100% of patients with morphea "en coup de sabre" involving the frontal region of the face concomitantly presented both subclinical activities of morphea on the frontal facial region and the scalp following the same axis.A positive relationship was observed between the degree of clinical activity measured by mLoSSI and US-MAS scoring.The main limitations of our study were the low number of patients and the inability to detect alterations < 0.1 mm. CONCLUSIONS: Subclinical activity is frequent in morphea, can extend beyond the lesional areas, including apparently noninvolved adjacent and distant corporal regions, and can be detected by color Doppler ultrasound.

Ultrasound Morphea Activity Scoring (US-MAS): Modified US-MAS.

Morphea, an autoimmune connective tissue disease that affects the skin, can be supported by color Doppler ultrasound in its diagnosis and assessment of activity. To date, there are no reliable laboratory parameters to track activity, and ultrasound presents a higher axial spatial resolution than magnetic resonance imaging and computed tomography, which is critical for studying the superficial layers. The quality of the ultrasonographic assessment of activity in morphea depends on the standardization and features of the acquisition of the anatomical data. We propose a detailed ultrasound morphea activity scoring called modified US-MAS (mUS-MAS) that could allow us to systematically register the cutaneous abnormalities in the corporal regions and their subregions. The selection of the scanning sites will depend on the corporal regions of involvement and their adjacent segments. Through systematic and sequential ultrasound data analysis, we propose that this scoring system can better support description and activity tracking accuracy.

Trichoscopic, oral, and periungual fold findings as activity and damage markers in dermatomyositis patients and their correlation with myositis antibodies.

There is little clarity about the clinical manifestations of dermatomyositis (DM) in the periungual folds, scalp, and oral cavity and their association with disease activity and damage. The objective of this study was to compare the prevalence of trichoscopic, oral, and periungual changes between DM and healthy patients and assess their possible association with disease activity and damage. We conducted an observational, transversal, and analytical study between 2020 and 2021. Forty DM patients were matched by sex and age with 40 healthy individuals. On the same day, all patients had a clinical evaluation of the hands, periungual folds, scalp, and oral cavity. Photographs of these areas and peripheral venous blood tests, including myositis-associated (MAAs) and myositis-specific antibodies (MSAs), were taken. Two dermatologists blinded to their diagnosis, damage, and activity levels registered the lesions. The disease activity and damage were evaluated using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). The presence of mechanic's hands, Gottron's sign, and Gottron's papules in hands; capillary dilation, capillary tortuosity, cuticular hemorrhage, avascular areas, and cuticular hyperkeratosis in periungual folds; thick tortuous capillaries in scalp; gingival telangiectasias in the oral cavity; and positive MSAs associated with severe cutaneous involvement in DM patients (Anti-TIF1g, Anti-MDA5, Anti-SAE1/2) were associated with a higher CDASI activity score. The presence of MSAs associated with intense muscle involvement in DM patients (Anti-Mi2a, Anti-Mi2b, Anti-NPX2, and Anti-SAE1/2) was related to a lower CDASI activity score. Gottron's sign and Gottron's papules in hands; capillary dilation, capillary tortuosity, cuticular hemorrhage, avascular areas, and cuticular hyperkeratosis in periungual folds; basal erythema in scalp; and gingival telangiectasias in the oral cavity were associated with a higher CDASI damage score. There are trichoscopic, oral and periungual fold findings and some myositis-specific antibodies that correlate with disease activity and damage in DM patients.

Access to psoriasis treatment in Brazil and Chile: A cross-sectional multicentre Global Healthcare Study on Psoriasis.

BACKGROUND: Sufficient data on access to systemic treatment for patients with psoriasis living in Latin America (LA) including Brazil and Chile are lacking. Understanding the availability and limiting factors of access to treatments can help to improve patient care and decrease long-term healthcare costs. OBJECTIVES: In association with the Global Psoriasis Atlas, this cross-sectional survey study analysed the availability and insurance reimbursement of systemic treatments for adult patients with psoriasis in Brazil and Chile. METHODS: A multicentre, cross-sectional Global Healthcare Study on Psoriasis was performed in Brazil and Chile in 2020. For each eligible adult patient with psoriasis, doctors and nurses completed a 48-item questionnaire about clinical aspects of psoriasis including the Psoriasis Area Severity Index (PASI), body surface area (BSA) score and the Dermatology Life Quality Index (DLQI), as well as the availability of systemic treatments and insurance reimbursement status. Between-country differences were compared with Wilcoxon rank sum tests for continuous variables, and a χ2-test or Fisher's exact test, where appropriate, for categorical variables. The median and interquartile range (IQR) was calculated for non-normal distributed data. RESULTS: A total of 1424 patients with psoriasis from 43 centres [27 centres in Brazil (n = 826) and 16 in Chile (n = 598)], were included with a mean (SD) age of 49.1 (16.3) and 49.2 (15.1) years, respectively. Unstratified analyses revealed that patients with psoriasis in Chile had more severe disease than those in Brazil [PASI 11.6 vs. 8.4 (P < 0.001) and BSA 14.7 vs. 12.0 (P = 0.003), respectively]. For patients with moderate-to-severe psoriasis, defined as PASI and/or BSA ≥ 10, systemic nonbiologic drugs were available (81.2% in Brazil and 65.3% in Chile, P ≤ 0.001), but only 37.0% of patients in Brazil and 27.3% in Chile received biologics (P = 0.01). Lack of availability and/or lack of insurance reimbursement for biologic drugs for patients with moderate-to-severe psoriasis was reported for 22.2% (50 of 225) in Brazil and 67.9% (148 of 218) in Chile (P < 0.001). Patients with no access to biologic therapies due to lack of availability/insurance reimbursement had a median PASI of 9.15 (IQR 3.00-14.25) in Brazil and 12.0 (IQR 5.00-19.00) in Chile (P = 0.007), as well as a median BSA of 7.0 (IQR 3.00-15.00) and 12.0 (IQR 5.00-22.50) (P = 0.002), and median DLQI of 11.0 (6.00-15.00) and 21.0 (6.50-25.00) (P = 0.007), respectively. CONCLUSIONS: Chilean patients had significantly more severe psoriasis compared with Brazilian patients in our study. While nonbiologic treatments for moderate-to-severe psoriasis were available in both LA countries, there is a high need for improvement in access to more effective psoriasis treatments including biologics. Our results highlight a significant gap between treatment recommendations in international psoriasis guidelines and real-world situations in Brazil and Chile.

Association between obesity and atopic dermatitis in children: A case-control study in a high obesity prevalence population.

BACKGROUND/OBJECTIVE: Atopic dermatitis (AD) is a chronic inflammatory skin disease. Research suggests an association between obesity and AD, although evidence is lacking from Latin American populations. This study evaluated the association of obesity with AD in children from Chile, a country with high obesity prevalence. METHODS: A case-control study was performed in children with active AD (cases) and healthy controls (HCs) from Santiago, Chile. Body mass index was evaluated by z-score (z-BMI), with overweight defined as z-BMI ≥+1 and <+2, and obesity as z-BMI ≥+2. Abdominal obesity was defined by a waist circumference-to-height ratio (WHR) ≥0.5. AD severity was evaluated by Scoring AD (SCORAD) index. RESULTS: A total of 174 children with AD and 101 controls were included. AD patients had similar overweight (27% vs. 28%) and obesity (21% vs. 26%) rates as HCs (p = .65). Abdominal obesity rates were also comparable (64% vs. 62%, p = .81). In sex-specific analyses, girls with AD had higher abdominal obesity rates than HCs (71% vs. 53%, p < .05) while boys with AD had lower abdominal obesity rates than HCs (53% vs. 75%, p = .03). Among children with AD, higher z-BMI or WHR did not correlate with higher SCORAD, eosinophil counts or total IgE. CONCLUSION: In our study, Chilean children with AD had high but similar rates of obesity as HCs, but showed sex-specific associations of abdominal obesity and AD. Further research is needed to evaluate these associations and the roles that weight excess and weight loss could play in the pathogenesis and treatment of AD.

Comorbidities in Chilean patients with psoriasis: a Global Healthcare Study on Psoriasis.

BACKGROUND: Psoriasis is a chronic inflammatory skin disease associated with several important medical comorbidities. There are scant data available on the comorbidities of patients with psoriasis in South America. AIM: To examine the comorbidity profile of adult patients with psoriasis in Chile and its association with severity of psoriasis. METHODS: This was a multicentre, cross-sectional study involving 16 hospitals and clinics in Chile, which used a 48-item questionnaire to study clinician- and patient-reported outcomes and comorbidities. Inferential analyses were performed by psoriasis severity, using Fisher exact test, Student t-test and multivariable logistic regression. RESULTS: In total, 598 adult patients with psoriasis were included (51.1% male; mean age 49.2 ± 15.1 years); 48.5% mild and 51.4% moderate to severe; Psoriasis Area and Severity Index 11.6 ± 11.5; body surface area 14.7 ± 18.2%. Plaque psoriasis was the most common phenotype (90.2%), followed by guttate (13.4%). Psoriatic arthritis occurred in 27.3% of patients. Comorbidities were reported in 60.2% of all patients with psoriasis. Frequent concomitant diseases were obesity (25.3%), hypertension (24.3%), Type 2 diabetes mellitus (T2DM) (18.7%), dyslipidaemia (17.4%), metabolic syndrome (16.7%) and depression (14.4%). After adjustment, significant associations were found between moderate to severe psoriasis and obesity, T2DM and nonalcoholic fatty liver disease (NAFLD) compared with mild psoriasis. CONCLUSIONS: We report a large study of comorbidities, including depression, dyslipidaemia, T2DM and NAFLD, in people with psoriasis in Chile. The prevalence of comorbidities with psoriasis in Chile appears similar to that found in Western countries, and emphasizes the importance of assessing patients with psoriasis for risk factors for and presence of, comorbid disease in a multidisciplinary setting.

Morphea After Liposuction Ultrasonography.

Liposuction is a common aesthetic procedure; however, to date, liposuction has not been linked to morphea. The aim was to review cases with a history of liposuction that presented active morphea lesions in the same surgery regions and were confirmed by ultrasound and histology. A retrospective descriptive analysis of the clinical, ultrasonographic, and pathology database took place (2014-2020). Eleven patients met the criteria. Ultrasound supported the diagnosis, and the ultrasonographic signs of activity in these cases matched the features described in the literature in 100% of cases. In summary, morphea may appear after liposuction and ultrasound can support its early detection.

Sun Sign in the Ultrasound Diagnosis and Activity Assessment of Morphea.

Morphea, a localized form of scleroderma, is a chronic inflammatory autoimmune disease of the skin. Color Doppler Ultrasound has been reported as a reliable tool to assess the activity of the disease. With histologically confirmed cases, this case series describes a new ultrasound sign consisting of a hyperechoic halo surrounding superficial subcutaneous veins of the extremities in transverse view, named the sun sign. This sign can help diagnose morphea in the inflammatory phase and correlate in pathology with perivascular infiltrates surrounding superficial subcutaneous veins.

Small plaque psoriasis re-visited: A type of psoriasis mediated by a type-I interferon pathway.

TNFα-inhibitor-induced psoriasis is mediated by the type-I interferon pathway, of which IFNα, LL37 and IL-36γ are major players. A subset of patients treated with TNFα inhibitors develop small plaque psoriatic lesions. Small plaque psoriasis is similarly observed in patients on immune checkpoint inhibitors (ICI), and with concurrent systemic lupus erythematosus (SLE) or positive antinuclear antibody (ANA). Small plaque psoriasis is also the predominant phenotype in Asian populations. The association between small plaque psoriasis morphology in various clinical scenarios and the type-I interferon pathway has not been previously studied. A cross-sectional study was conducted of patients who developed small plaque psoriasis and had a biopsy for diagnostic clarification between 2009 and 2017. We obtained skin specimens from 14 adults with small plaque psoriasis: four patients taking anti-TNFα treatment, four patients with antecedent SLE, three patients with concurrent ANA positivity and three patients taking ICI. Controls included three patients with chronic plaque psoriasis. Histology confirmed psoriasiform epidermal hyperplasia with focal lichenoid and spongiotic features. Immunohistochemical analysis revealed higher expression of IFNα-induced MXA, LL37 and IL-36γ in all clinical scenarios of small plaque psoriasis compared to chronic plaque psoriasis. There was decreased CD8 T-cell migration to the epidermis and variability in the number of LAMP3+ cytoplasmic dendritic cells in the dermis of small plaque psoriasis. The findings suggest that small plaque psoriasis is a unique type of psoriasis with a distinct morphology and immune-phenotype, primarily mediated by the type-I interferon pathway. Associating morphology and disease pathogenesis may help identify therapeutic targets for better disease control.

Rápida implementación de teledermatología durante la pandemia por COVID-19: lecciones aprendidas de un departamento académico de Dermatología

Background: The day after COVID-19 quarantine started, we initiated patient care through Tele-dermatology. Aim: To report the experience of the implementation of Telemedicine in dermatology and to assess its impact on the number of dermatological visits compared with the pre-pandemic period. Material and methods: The study was conducted between March 27th, 2020, and April 30th, 2020. All patients submitted clinical images of their skin condition via secure email before the telemedicine visit. All telemedicine visits were conducted using the Zoom video conferencing platform. Patient demographics and medical history were recorded. If the dermatologist was unable to reach a diagnosis, the patient was sent for an in-person visit, skin biopsy, or additional laboratory workup. Results: We recorded 1,357 Tele dermatology visits from 1,222 patients aged 29 ± 18 years (38% males). Visits increased from 104 to 298 from the first to the last week, corresponding to 17% of the patient volume seen before the pandemic (1,709 in-person patients/week). A preliminary diagnosis was made in 95% of cases. Ninety percent of patients sent photos. Fifty eight percent of cases were chronic diseases, and were classified as inflammatory in 68%, infectious in 15%, neoplastic/tumoral in 7%, or other conditions in 11%. Less than 1% of these visits were COVID-19 related. Conclusions: In this prospective study of Tele-dermatology lasting five weeks, a preliminary diagnosis could be made in approximately 95% of cases and in the first five weeks of implementation, a volume of consultations equivalent to 17% of those made in the pre-pandemic period was carried out. Therefore, Tele-dermatology can be implemented quickly and successfully in practices when healthcare access is limited.

Ultrasonographic Subclinical Signs of Inflammation of the Lacrimal, Parotid, and Submandibular Glands in Users of Cosmetic Fillers.

OBJECTIVES: To detect ultrasonographic inflammatory signs in the lacrimal, parotid, and submandibular glands in cosmetic fillers (CFs) users. METHODS: A prospective and cross-sectional ultrasound study of the glands in cases with CFs was performed. The sample included users of hyaluronic acid, silicone oil, polymethylmethacrylate, polycaprolactone, calcium hydroxyapatite, and polyacrylamide. Abnormalities of the parenchyma and hypervascularity signs of the glands were compared with a control group (n = 10), evaluated by 2 observers, and correlated with the type, number, and location of the facial CFs. Cohen's kappa test and logistic regression models with odds ratios (OR) adjusted by age with 95% CI were performed. RESULTS: Sixty-three patients with CFs met the criteria. Parotid and submandibular glands had the highest percentage of parenchymal involvement: 87.3 and 88.9%, respectively (p <.01). Abnormalities of the echostructure of the parenchyma and hypervascularity of the glands were detected with all kinds of fillers without significant differences per type. A significant substantial interrater kappa (0.61) with an agreement of 90% for all glands among observers was found. CONCLUSION: Users of common types of CFs frequently present subclinical ultrasonographic signs of inflammation of the lacrimal, parotid, and submandibular glands. Further research on the topic seems necessary.