Rosacea: Practical Guidance and Challenges for Clinical Management.

Rosacea is a common chronic dermatosis. Clinically, rosacea can present with flushing, erythema, papules, pustules, telangiectasias, phymatous changes, pruritus, burning, and stinging. In 2017, the National Rosacea Society Expert Committee recommended a phenotype-based classification for therapy. In this review, we identify monotherapies and multimodal treatment approaches for the clinical management of rosacea including topical, systemic, laser and light, alternative, and combination therapies.

Skin-Related Quality of Life During Autoimmune Bullous Disease Course.

Importance: Autoimmune bullous diseases (AIBDs) are chronic relapsing-remitting conditions with significant morbidity. Skin-related quality of life (SRQL) may vary by AIBD subtype and disease type. Disease severity and flare severity can be difficult to define; SRQL can offer a key insight. Objectives: To investigate the Skindex-16 score as an SRQL measure in AIBD subtypes during flare and nonflare states and to evaluate Skindex-16 construct validity. Design, Setting, and Participants: This retrospective cross-sectional study was conducted from September 1, 2016, to February 1, 2020, among 192 patients at the University of Utah Health autoimmune dermatology clinic with pemphigoid, pemphigus, dermatitis herpetiformis, and linear immunoglobulin A disease. Patients had an encounter-associated diagnosis, Skindex-16 scores, and self-reported flare status. Statistical analysis was performed from March 2022 to June 2023. Exposure: Autoimmune bullous disease subtype and patient-reported flare status. Main Outcomes and Measures: Skindex-16 domain scores (emotions, symptoms, and functioning; range, 0-100, where 0 indicates no effect on SRQL and 100 maximum effect) and individual item scores were described by disease and flare status. Flare scores were expected to be higher by at least the standard error of measurement (SEm). Convergent validity was assessed using Spearman correlation among Skindex-16 scores, serologic titers, and other patient-reported outcome measures. Floor or ceiling domain scores (<20% of sample scoring either lowest or highest possible domain scores, respectively) were assessed for Skindex-16. Structural validity was assessed using confirmatory factor analysis (CFA). Results: The study included 192 patients with 212 visits (median age, 68 years [IQR, 58-76 years]; 123 of 212 women [58.0%]) with Skindex-16 scores (64 in flare state and 148 in nonflare state). Median Skindex-16 domain scores were higher for all disease categories among patients in the flare state compared with those in the nonflare state (pemphigoid [emotions: flare, 52.4 (IQR, 38.1-69.0); nonflare, 7 (IQR, 0-17); symptoms: flare, 37.5 (IQR, 29.2-58.0); nonflare, 13 (IQR, 0-25); functioning: flare, 26.7 (IQR, 10.0-56.7); nonflare, 0 (IQR, 0-3)]; pemphigus [emotions: flare, 54.8 (IQR, 31.0-81.0; nonflare, 0 (IQR, 0-19); symptoms: flare, 58.3 (IQR, 41.7-70.8); nonflare, 4 (IQR, 0-12.5); functioning: flare, 26.7 (IQR, 13.3-83.3); nonflare, 0 (IQR, 0-3.33)]; dermatitis herpetiformis [emotions: flare, 72.6 (IQR, 34.7-90.5); nonflare, 14.3 (IQR, 2.4-26.2); symptoms: flare, 69 (IQR, 31.3-85.4); nonflare, 12.5 (IQR, 0-29.2); functioning: flare, 38.3 (IQR, 5.0-63.2); nonflare, 0 (IQR, 0-13.3)]. This difference exceeded SEm cut points. Cronbach α was greater than 0.80 for all domains and AIBDs. Moderate or low correlations were seen with desmoglein 1 and bullous pemphigoid 180 titers. Moderate correlation existed between Skindex-16 and Patient-Reported Outcomes Measurement Information System Depression scores (emotions: ρ = 0.40; symptoms: ρ = 0.41; functioning: ρ = 0.48), and strong correlation existed between Skindex-16 and patient-reported disease severity (emotions: ρ = 0.71; symptoms: ρ = 0.73; functioning: ρ = 0.66). Floor domain scores greater than 20% were seen among patients in the nonflare state, but ceiling domain scores were rare (<10% for all domains); CFA model fit was poor. Conclusions and Relevance: In this cross-sectional study, SRQL was highly associated with flare of AIBDs. Skin-related quality of life was worse during periods without flare among patients with pemphigoid and dermatitis herpetiformis compared with pemphigus, highlighting residual SRQL morbidity. Skindex-16 showed good construct validity, but the poor CFA model fit needs further research. Clinical measurement of SRQL in AIBDs can add critical disease-severity information.

Mycophenolate mofetil-induced hyperlipidemia with cutaneous manifestations.

We report a case of a 49 year old woman who developed biopsy-proven xanthomas on her hands and arms after initiation of Mycophenolate mofetil therapy for systemic lupus erythematosus (SLE) and subsequently went into remission upon cessation of the medication.

Sebaceous Carcinoma of the Penis: A Rare, Dangerous Clinical Entity and the Importance of Immunohistochemistry in Diagnosis.

We report a very rare case of pathologically confirmed sebaceous carcinoma of the glans penis with multiple areas of lymphovascular and perineural invasion and multiple lymph node metastases. The importance of immunohistochemical staining in diagnosis is also reviewed.

Beyond Competency: A Student Perspective on Growth Through Clerkship Feedback.

This article proposes a paradigm shift from the competency-based model of clerkship feedback using checklists to a coaching-based, action plan-oriented process that centers on individualized student-oriented goals. Using a student perspective, the authors examine the feedback literature and put forward a proposal to use an impact model whose emphasis is to improve the learning climate for students. Several techniques are reviewed which include goal generation and creation of dynamic action plans. By intentionally focusing on coaching relationships as a platform for feedback, the learners and mentors share goals and the result of feedback becomes action-based behaviors which may help negate personal attribution and bias in the feedback process.

1% Tirbanibulin Ointment for the Treatment of Actinic Keratoses.

OBJECTIVE: Actinic keratoses (AKs) are cutaneous lesions that arise in sun-damaged skin. AKs may transform into squamous cell carcinoma in situ. Tirbanibulin 1% ointment is a new topical treatment for AKs, recently approved by the Food and Drug Administration. DATA SOURCES: The PubMed database was searched for articles published from 1960 to March 31, 2021, using the keywords tirbanibulin and Klisyri. DATA EXTRACTION: Phase 2 and phase 3 clinical trials were reviewed. DATA SYNTHESIS: In phase 2 clinical trials, 43% of patients treated with tirbanibulin experienced complete clearance by day 57 (43% [95% CI = 32, 54]). Across two phase 3 clinical trials (pooled data), complete (100%) clearance occurred in 49% of patients in tirbanibulin groups and in only 9% of the vehicle groups (difference, 41% points; 95% CI = 35 to 47; P < 0.001). Although no comparative studies are available, tirbanibulin is applied for a shorter duration (5 days) compared with diclofenac 3% gel, fluorouracil 5% cream, and imiquimod 3.75% cream. Adverse events were mild and included pruritus, application site pain, and local skin reactions. Systemic adverse events such as necrosis and angioedema, observed with other AK treatments such as fluorouracil and imiquimod, were not observed with tirbanibulin, thus giving tirbanibulin a favorable safety profile. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Tirbanibulin effectively reduces AK burden and recurrence and has a favorable safety profile with mild adverse events. In comparison, imiquimod, 5-flourouracil, and diclofenac can result in necrosis, angioedema, and arthralgias. CONCLUSION: With a favorable safety profile and short regimen, tirbanibulin is an efficacious treatment for clinicians to utilize in their treatment toolbox when treating AKs on the face and scalp.

The evolving atopic dermatitis management landscape.

INTRODUCTION: Atopic dermatitis is a common dermatologic condition that affects millions of people worldwide, and a standardized approach to treatment was published by the American Academy of Dermatology (AAD) in 2013-14. Since 2014, new FDA-approved treatment options such as dupilumab and crisaborole have changed the landscape of AD management, and future therapies such as JAK inhibitors and anti-interleukin 13 and 31 antibodies appear effective, emphasizing the need for a comprehensive review to give clinicians an updated toolbox to aid in pharmacologic management. AREAS COVERED: In this review, the authors explore the updated efficacy and safety data on established therapeutic options for AD including topical corticosteroids, topical calcineurin inhibitors, cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil. In addition, the authors also explore trial data and studies on dupilumab, crisaborole, omalizumab, tofacitinib, ruxolinitib, abrocitinib, baricitinib, upadacitinib, delgocitinib, nemoliuzumab, and tralokinumab. EXPERT OPINION: The AAD guidelines must be updated in the future to include several new treatment modalities that have revolutionized the pharmacologic management of patients with AD, including dupilumab and crisaborole. The future of AD treatment is also extremely bright, as JAK inhibitors and Il-13/31 antibodies have shown convincing results in the improvement of AD patients' lives in various trials and studies that have been examined in this paper.

Cannabis use and medication nonadherence in bipolar disorder: A nationwide inpatient sample database analysis.

BACKGROUND: Medication nonadherence among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cannabis use disorder (CUD) association with medication noncompliance in hospitalized BD patients. METHODS: Using data on 266,303 BD hospitalizations between 2010 and 2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and CUD. Logistic regression was used to evaluate factors associated with medication noncompliance. RESULTS: Overall mean age, the prevalence of CUD, and medication nonadherence were 41.58 (± 0.11) years, 15.0% and 16.1%, respectively. There were 56.6% females in the overall population. There was a significant difference in the characteristics of those in the medication nonadherence vs adherence groups, including age, sex, race, comorbid substance use, income, insurance type, hospital region, and hospital teaching status (p < 0.001). After adjusting for other variables using multivariate analysis, there remained a statistically significant association of medication nonadherence in BD hospitalization and CUD (OR 1.42, 95% CI 1.36-1.48). LIMITATION: Confounding multiple substance use could not be accounted for, and the retrospective nature of the database which includes only inpatients is prone to possible selection and reporting bias. CONCLUSION: CUD statistically predicts increased rates of medication nonadherence among patients with BD. Given the possible association of CUD with medication nonadherence among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of patients with BD and comorbid CUD.

Disseminate and Recurrent Infundibulofolliculitis: An Under-Recognized Yet Treatable Entity.

Disseminate and recurrent infundibulofolliculitis (DRIF) is a pruritic papular eruption that predominantly affects young adults with Fitzpatrick skin types 4-6. Due to DRIF’s rarity and under-recognition, no standardized treatment guidelines exist. However, several oral agents have been used, including vitamin A, antibiotics, and retinoids. Topical agents, such as calcineurin inhibitors and mid-potency steroids, can also be efficacious. This brief communication summarizes treatments for DRIF in the published literature. J Drugs Dermatol. 2021;20(12):1353-1354. doi:10.36849/JDD.6173.

Bullous Pemphigoid and Other Pemphigoid Dermatoses.

The pemphigoid family of dermatoses is characterized by autoimmune subepidermal blistering. The classic paradigm for pemphigoid, and the most common member, is bullous pemphigoid. Its variable clinical presentation, with or without frank bullae, is linked by significant pruritus afflicting the elderly. Mucous membrane pemphigoid is an umbrella term for a group of subepidermal blistering dermatoses that favor the mucosal membranes and can scar. Epidermolysis bullosa acquisita is a chronic blistering disorder characterized by skin fragility, sensitivity to trauma, and its treatment-refractory nature. Clinicians that encounter these pemphigoid disorders may benefit from an overview of their clinical presentation, diagnostic work-up, and therapeutic management, with an emphasis on the most frequently encountered pemphigoid disease, bullous pemphigoid.

Atypical Fibroxanthoma Demonstrating HMB45+ Staining.

ABSTRACT: Immunohistochemistry is useful and often necessary for the diagnosis of many histopathological entities, including atypical fibroxanthoma (AFX), which is typically considered a diagnosis of exclusion after ruling out spindle cell melanoma, sarcomatoid carcinoma, and other spindle cell tumors. AFX is a superficial fibrohistiocytic tumor previously believed to be related to pleomorphic sarcoma (formerly known as malignant fibrous histiocytoma), but is now considered a distinct clinicopathological entity. AFXs commonly express CD68, smooth muscle actin, and lysozyme and are usually negative for melanocytic markers such as HMB45 and S100. However, immunohistochemistry can sometimes be misleading, especially when used without other relevant markers in making a histopathologic diagnosis. HMB45 is a glycoprotein marker of premelanosomes and is often helpful in identifying melanoma because it stains melanosomes in the epidermis, dermis, and nevi glycocomplexes. We report a case of AFX which was strongly positive for HMB45, but negative for all other melanocytic markers. This case emphasizes the potential pitfall of relying on a single immunohistochemical marker to make the diagnosis, especially of melanoma, and also is one of the only rare reported cases of AFXs which are HMB45+.

Use of Reflectance Confocal Microscopy for Hidrocystomas: An Emerging, Cost-Effective, and Powerful Tool.

Reflectance confocal microscopy (RCM) is an emerging and noninvasive imaging tool in dermatological practice. Benefits of this modality include differentiation between benign and malignant skin lesions, prevention of unnecessary biopsies, and cost effectiveness. However, RCM findings for benign lesions are rarely reported in the literature. We describe a case of reflectance confocal microscopy findings of a hidrocystoma and review potential applications of this imaging technique in everyday clinical practice.

Magnetic resonance cholangiopancreatography: current use and future applications.

Magnetic resonance pancreatography (MRCP) is now established as a robust noninvasive tool for the evaluation of biliary and pancreatic pathology. Its diagnostic performance is comparable with endoscopic retrograde cholangiopancreatography without the associated risks. This article aims to familiarize the reader with the technique, clinical indications, and limitations of the investigation. Common pitfalls in interpretation also are addressed. Emerging applications and techniques are discussed that include recent advances in technology and the development of functional imaging.

CT colonography and computer-aided detection: effect of false-positive results on reader specificity and reading efficiency in a low-prevalence screening population.

PURPOSE: To retrospectively evaluate the effect of increasing numbers of computer-aided detection (CAD)-generated false-positive (FP) marks on reader specificity and reporting times by using computed tomographic (CT) colonography in a low-prevalence screening population. MATERIALS AND METHODS: Ethics committee approval and informed consent were obtained for this HIPAA-compliant study. Four readers each read 48 data sets (26 men, 22 women; mean age, 57 years) from a screening population (three containing polyps) without CAD application, followed by review of the CAD output and recorded findings and diagnostic confidence. The 45 data sets that were designated as normal were chosen such that 22 generated 15 or fewer FP CAD marks and 23 generated more than 15 FP CAD marks. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated with and without CAD. The relationships between the number of CAD FP marks and reader confidence, reporting times, and correct data set classification were analyzed by using linear and logistic regression. RESULTS: Across all readers, CAD resulted in four additional FP detections. Overall reader sensitivity and specificity (6-mm polyp threshold) before and after CAD application were 0.75 (95% confidence interval [CI]: 0.43, 0.95) versus 0.83 (95% CI: 0.52, 0.98) and 0.96 (95% CI: 0.91, 0.98) versus 0.93 (95% CI: 0.88, 0.96), respectively. The area under the ROC curve increased from 0.57 (95% CI: 0.34, 0.80) to 0.61 (95% CI: 0.42, 0.80). There was no correlation between an increasing number of CAD FP marks and reader confidence (P = .71) or correct study classification (P = .23), but there was a positive correlation with CAD-assisted reading times (0.06 [95% CI: 0.02, 0.10], P = .002). CONCLUSION: Increasing numbers of CAD FP marks did not adversely influence correct reader study classification or diagnostic confidence, although reporting times did increase.

Which method is best for imaging of perianal fistula?

BACKGROUND: Successful surgery for perianal fistula is contingent upon accurate pre-operative classification of the primary tract and its extensions. We aimed to find, using "evidence based medicine" (EBM) methods, the optimal technique for fistula classification: MRI, anal endosonography (AES) or clinical examination. METHODS: A clinical question was derived, "In patients suspected of having perianal fistula, how does MRI compare to AES and clinical assessment for discriminating simple from complex disease". A search of primary literature and secondary evidence resources was performed and expert opinion sought. Inclusion criteria were blinded prospective studies (level 2b +) of patients undergoing preoperative MRI, clinical examination +/- AES using a clinical outcome based reference standard. Retrieved literature was appraised using EBM methods. RESULTS: The highest-ranking evidence found was level 1b. MRI is more sensitive 0.97(CI 0.92-1.01) than clinical examination, 0.75(0.65-0.86) but comparable to AES, 0.92(0.85-0.99) for discriminating complex from simple disease. The positive LR for MRI confirming complex disease is 22.7 compared to 2.1 and 6.2 for clinical examination and AES, respectively. CONCLUSION: MRI is the optimal technique for discriminating complex from simple perianal fistula, although AES is superior to clinical examination, and may be used if MRI availability is restricted.