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.

Assessment of sun-safety education behavior via spectrophotometric evaluation: A preliminary study.

BACKGROUND: Biases inherent in self-assessment of sun exposure and sun-safe behavior may lead to inaccurate conclusions about the effectiveness of sun-safety educational programs. OBJECTIVES: We aimed to compare self-reports to objective measures of sun exposure, when examining the effectiveness of passive versus active educational interventions. METHODS: From May to June 2018, 73 participants recruited at a dermatology clinic were sequentially assigned to receive sun-safety education through one of 3 modes: interactive online module, video, or no education. A baseline Sun Exposure and Behavior Inventory (SEBI) questionnaire was administered, and spectrophotometric measurements of sun-exposed and sun-protected areas were taken and reported in the CIE L*a*b* color space. Participants were followed 4-8 and 16 weeks after the initial visit where the SEBI was re-administered, and serial measurements of skin color were taken. The change in SEBI scores and L*a*b values, as calculated by the individual typology angle (ITA°), was analyzed. RESULTS: There was a significant increase in skin darkening in all the groups at 4-8 and 16 weeks follow-up. There was no statistically significant difference between the groups in the magnitude of color change. However, subjectively at 4-8 weeks post-intervention, participants in the interactive module and video groups had significantly improved self-reported SEBI scores compared to control (p < .05, Kruskal-Wallis). By 16 weeks, only the interactive module group showed significant improvement in SEBI scores compared to control (p < .05, ANOVA). CONCLUSION: In determining the effectiveness of sun-safety programs, spectrophotometric evaluation of sun-induced skin pigmentation can allow for a more complete evaluation of self-reported sun exposure and sun-protective behavior.

An Added Benefit of Masks During the COVID-19 Pandemic: Ultraviolet Protection.

The widespread use of masks during the COVID-19 pandemic presents a new avenue for protecting the lower half of the face from the harms of sun exposure. The increased social acceptability of masks, which may persist post-pandemic, has the potential to impact prevention of photosensitive disorders, photoaging, and skin cancer. The authors sought to review clinically relevant information on the ultraviolet (UV) shielding properties of masks. This synthesis of current research will help physicians counsel patients on optimal mask choices, from both dermatological and public health viewpoints. The variables impacting the UV protection of masks were reviewed, including fabric type, construction, porosity, and color. Other factors related to wear and use such as moisture, stretch, laundering, and sanitization are discussed in the context of the pandemic. Black, tightly woven, triple-layered polyester cloth masks were determined to be optimal for UV protection. The most protective choice against both SARS-CoV-2 and UV radiation is a medical mask worn underneath the aforementioned cloth mask. In order to preserve the filtration capacity of the fabric, masks should be changed once they have become moist. Washing cotton masks before first use in laundry detergents containing brightening agents increases their UV protection. Overall, cloth masks for the public that are safest against SARS-CoV-2 are generally also the most protective against UV damage. People should be encouraged to procure a high-quality mask to simultaneously help reduce the spread of SARS-CoV-2 and shield against sun exposure. Further investigation is needed on the UV-protective properties of medical masks.

The use of dupilumab in severe atopic dermatitis during pregnancy: a case report.

BACKGROUND: Atopic dermatitis is a common chronic skin disease that can occur in pregnancy. Current treatments include topical and systemic glucocorticoids and cyclosporine. Presently, the only biologic approved for atopic dermatitis is dupilumab with limited data available regarding its safety profile in pregnancy. CASE PRESENTATION: We report a case of severe atopic dermatitis treated safely with dupilumab with no adverse maternal or fetal outcomes and resolution of atopic dermatitis postpartum in the absence of maintenance dupilumab therapy. CONCLUSION: Here we demonstrate the safe use of dupilumab in pregnancy. Further research is needed to elucidate the role of dupilumab in the management of atopic dermatitis during pregnancy.

Indications and diagnostic outcome of antineutrophil cytoplasmic antibody testing in hospital medicine: a pattern of over-screening.

INTRODUCTION/OBJECTIVE: Antineutrophil cytoplasmic antibodies (ANCA) serology can aid in the diagnosis and classification of ANCA-associated vasculitides (AAV). However, it is often ordered in patients without clinical manifestations of vasculitis. In this retrospective chart review, we aim to better understand the clinical practices on ANCA testing. METHODS: We retrospectively reviewed patients' charts for the indications and diagnostic outcomes of ANCA tests. All ANCA tests ordered at two Canadian hospitals (a community hospital and an academic tertiary hospital) between January and December 2016 were included in the study. Descriptive statistics are used. RESULTS: A total of 302 ANCA tests were included. The majority (n = 198, 65.6%) were ordered without an indication for testing. For those patients with at least 1 clinical manifestation of AAV (n = 104), 25% were ANCA positive and 18.3% resulted in a diagnosis of AAV. In comparison, among those without a clinical manifestation of AAV (n = 198), only 1.5% were ANCA positive and none was diagnosed with AAV. All patients diagnosed with AAV had at least 1 indication for ANCA testing. The three most common clinical presentations in patients with a final diagnosis of AAV were glomerulonephritis (81.8%), pulmonary hemorrhage (45.5%), and multiple lung nodules (31.8%). CONCLUSION: To our knowledge, this is the first study that evaluates patients with both positive and negative ANCA test results in an inpatient setting. We demonstrated a low rate of ANCA positivity and AAV diagnosis in patients without clinical manifestations of AAV. Overall, there is a high rate of ANCA testing without an indication at our academic institution. This over-testing may be curbed by strategies such as a gating policy, culture changes, and clinician education. Key Points • AAV is a clinical-pathological diagnosis, and despite the usefulness of ANCA testing, it does not confirm nor rule out AAV. • ANCA testing for the diagnosis of AAV is generally only indicated when there is a clear manifestation of AAV. • Although patients with AAV may occasionally present without classic signs and symptoms, the diagnostic utility of ANCA serology in this setting is low, and testing is more likely to result in a false-positive or false-negative test. • If clinical suspicion remains high despite negative ANCA testing, clinicians should seek consultation with a rheumatologist.

Chronic annular pustular psoriasis resembling subcorneal pustular dermatosis: A case report.

Generalized pustular psoriasis and subcorneal pustular dermatosis are generalized pustular dermatoses that are characterized by the subcorneal accumulation of neutrophils. Careful examination is important in distinguishing these diseases for appropriate management. Patients with acute generalized pustular psoriasis are systemically unwell with discrete pustules as opposed to the chronicity and associated hypopyon lesions in subcorneal pustular dermatosis. Generalized pustular psoriasis lesions demonstrate psoriasiform changes on histology and the increased expression of Th17 cytokines. We describe a middle-aged woman presenting with chronic annular generalized pustular psoriasis, initially mistaken for subcorneal pustular dermatosis due to their clinical and histological semblance. The patient had recurrent skin disease for 6 years despite conventional therapy of oral retinoid, immunosuppressant and biologic therapy. Complete and persistent clearance of her skin lesions was achieved with secukinumab, an interleukin 17A inhibitor.