Burning mouth syndrome: patch test results from a large case series.

BACKGROUND: Burning mouth syndrome (BMS) is a burning or sore mouth in the absence of changes in the oral mucosa. It is often difficult to diagnose and treat. Numerous theories of the etiology have been suggested, including contact allergy. OBJECTIVE: To determine the clinical utility of patch testing in patients with BMS. METHODS: We retrospectively reviewed the charts of patients diagnosed with BMS who had patch testing performed between January 1, 2008, and July 31, 2012. RESULTS: Of 142 consecutive patients with BMS, 132 consented to patch testing; 89 (67%) had allergic patch test reactions. Of the patients with positive results, 66 (74%) had results that were deemed to have possible relevance. The most common allergens detected were nickel sulfate 2.5%, dodecyl gallate 0.3%, octyl gallate 0.3%, fragrance mix 8%, benzoyl peroxide 1%, and cinnamic alcohol 1%. CONCLUSIONS: Our findings suggest that contact allergy may be an etiologic factor in some patients with BMS. Patch testing is a useful investigation for BMS patients.

Teaching dermatology to internal medicine residents: needs assessment survey and possible directions.

BACKGROUND: Internal medicine trainees receive limited teaching and training in dermatology and may feel inadequately prepared to assess and manage patients with dermatologic complaints. No study to date has assessed the needs of internal medicine trainees in Canada with regard to dermatology teaching. OBJECTIVE: To determine internal medicine residents' comfort in assessing and managing dermatologic issues and their educational needs in dermatology. METHODS: An electronic survey was conducted of first-, second-, and third-year internal medicine residents at the University of Toronto. RESULTS: Fifty-four of 186 internal medicine trainees responded to our survey (response rate  =  29%). Each respondent did not answer every question. Residents were generally uncomfortable or very uncomfortable assessing and managing dermatologic issues in the emergency department (40 of 47, 85%), ward or intensive care unit (39 of 47, 83%), and ambulatory clinic (40 of 47, 85%). Residents thought that various clinical and didactic dermatology exposures would be useful to their training as internists. Case-based teaching and ambulatory clinical rotations were felt to be particularly valuable. Additionally, 38 of 46 (83%) respondents wanted to learn how to perform punch biopsies. CONCLUSIONS: An effort should be made to increase the availability of relevant dermatology teaching and clinical exposures for internal medicine residents.

Bullous pemphigoid: from bench to bedside.

Bullous pemphigoid (BP) is a chronic, autoimmune, blistering disease observed primarily in the elderly population. Several clinical variants have been described, including classic (bullous), localised, nodular, vegetating, erythrodermic, erosive, childhood and drug-induced forms. Autoantibodies target the BP230 and BP180 antigens, located in the hemidesmosomal complex of the skin basement membrane zone. Subsequent complement activation recruits chemical and cellular immune mediators to the skin, ultimately resulting in blister formation. Both autoantibodies and complement may be detected by various immunofluorescent, immune electron microscopy and molecular biology techniques. Recent trials suggest that potent topical corticosteroids should be considered as first-line therapy. Tetracycline with or without nicotinamide may benefit a subset of patients with mild BP. Oral corticosteroids should rarely exceed 0.75 mg/kg/day and corticosteroid-sparing agents may be useful for recalcitrant disease.

Psoriasis and the new biologic agents: interrupting a T-AP dance.

Psoriasis is an immune-mediated skin disease in which chronic T-cell stimulation by antigen-presenting cells (APC) occurs in the skin. This interplay between the T-cell and APC has been likened to a "T-AP dance" where specific steps must occur in sequence to result in T-cell activation and the disease phenotype; otherwise T-cell anergy would occur. Several novel engineered proteins designed to block specific steps in immune activation (biologic agents) have demonstrated efficacy in the treatment of psoriasis. These agents include fusion proteins, monoclonal antibodies and recombinant cytokines. These medications act at specific steps during the T-AP dance either to inhibit T-cell activation, costimulation and subsequent proliferation of T-cells, lead to immune deviation or induce specific cytokine blockades. The potential increased selectivity for specific pathways in immune activation, clinical efficacy and relative safety of these new agents offers an alternative for the treatment of moderate to severe psoriasis.