Treatment of rosacea during pregnancy.

BACKGROUND: Exacerbation of rosacea may occur during pregnancy and there are multiple associated cases of rosacea fulminans (RF). Treatment during pregnancy poses a significant challenge as many rosacea treatments are contraindicated or have limited evidence regarding potential adverse fetal effects. OBJECTIVE: Review the pregnancy categories of various treatments and develop algorithms for treating pregnant patients with rosacea and RF. METHODS: Rosacea treatments showing efficacy in randomized controlled trials were searched through DailyMed to review pregnancy labelling. Searching the PubMed/MEDLINE database for English articles using keywords "rosacea fulminans AND pregnancy" without publishing-time restrictions yielded 8 articles. We summarized treatments used in cases of RF during pregnancy. RESULTS: Topical ivermectin was more effective than metronidazole, but has a more concerning pregnancy category. Three pregnant women with RF were treated successfully with topical metronidazole in combination with other therapies. Azithromycin is the only oral rosacea therapy that is considered safe for pregnant patients and it has been used to treat RF. CONCLUSIONS: This review highlights the challenging aspects of treating pregnant patients with rosacea, as there is limited pregnancy-related treatment efficacy and safety data. The pregnancy categories of therapeutic options are summarized. Further studies are needed to learn which therapies are effective and safe for use during pregnancy.

Erythema nodosum and pernicious anemia.

Erythema nodosum (EN) often presents as a sudden onset of tender, erythematous, subcutaneous nodules on the legs and ankles. Although rare, pernicious anemia may be related to vitamin B12 deficiency. Discussion of this association in the context of a particular patient is presented.

Dermatological trends in emergency medicine.

BACKGROUND: Trends in emergency department (ED) visits with a primary dermatologic diagnosis are not well characterized. OBJECTIVE: The goal is to determine how the number of ED visits attributable to dermatologic disease is changing and to characterize the type of dermatologic conditions seen. METHODS: This is a cross-sectional study using the National Hospital Ambulatory Medical Care Survey: Emergency Department Summary Tables 2008-2017. Data were compiled into tables on the amount and type of dermatologic ED visits. RESULTS: The percentage of dermatologic visits ranged from an estimated 3.5% to 4.3%, peaking in 2014. Cellulitis was the most common diagnosis and accounted for an estimated 1.3% of all visits in 2016, and an estimated 1.2% of visits in 2017. The second most common diagnosis was cutaneous abscess, which accounted for an estimated 0.8% in 2016 and 0.9% in 2017. CONCLUSION: The number of ED visits attributed to disease of the skin and subcutaneous tissue has not followed a general trend of increase or decrease. The most common diagnoses are infections. We can best serve these patients by emphasizing the importance of ED provider education on the management of cutaneous infections and by working to increase the accessibility of dermatologic care.

Superantigens in dermatology.

Superantigens (SAgs) are virulent polypeptides that are produced by a variety of infectious organisms. They are capable of causing nonspecific T cell activation by circumventing normal antigen processing in the human host. The genetic makeup of the host plays a role in conferring susceptibility or protection against SAgs. They are linked to a variety of conditions, ranging from toxic shock syndrome to recurrent toxin-mediated perineal erythema. The early recognition of signs and symptoms of SAg-mediated illnesses is important to ensure prompt medical treatment.

Is Clear Always Clear? Comparison of Psoriasis Area and Severity Index (PASI) and the Physician's Global Assessment (PGA) in Psoriasis Clearance.

INTRODUCTION: Psoriasis Area and Severity Index (PASI) and Physician's Global Assessment (PGA) are the most widely used outcome measures in clinical trials of biologics to treat psoriasis; however, these outcome measures vary in both their reliability and validity. As newer biologics approach complete clearance of psoriasis, it becomes important to have standardized, reproducible forms of measure to accurately compare treatment efficacy. The aim of this study was to evaluate the extent of and reasons for variation between PASI and PGA scores used in clinical trials. METHODS: A literature search was conducted of clinical trials meeting the inclusion criteria: phase 2 or 3, evaluation of treatment efficacy in reducing psoriasis severity, and use of PASI 90/100 and sPGA or PGA 0/1 as primary end points. RESULTS: Among the analyzed studies, 8 of 45 trials had a PASI-PGA variance of < 5%, 4 of 45 trials had a variance of 5-10%, and 33 trials had a variance of > 10%. The IMMvent and AMAGINE trials were the only two trials showing 0 variation between the PASI and PGA scores, testing adalimumab and brodalumab, respectively. Ustekinumab showed the highest variance of 61.9% in the IXORA-S trial. Limitations of this paper include a relatively low number of studies assessed because of the paucity of literature available. CONCLUSIONS: The use of both PASI and PGA as equivalent assessment tools for complete clearance is redundant and subject to high variability. Novel severity assessments should be developed that reduce calculation variation and take into account patient-oriented symptoms.

Toxic epidermal necrolysis.

UNLABELLED: Toxic epidermal necrolysis (TEN) is an unpredictable, life-threatening drug reaction associated with a 30% mortality. Massive keratinocyte apoptosis is the hallmark of TEN. Cytotoxic T lymphocytes appear to be the main effector cells and there is experimental evidence for involvement of both the Fas-Fas ligand and perforin/granzyme pathways. Optimal treatment for these patients remains to be clarified. Discontinuation of the offending drug and prompt referral to a burn unit are generally agreed upon steps. Beyond that, however, considerable controversy exists. Evidence both pro and con exists for the use of IVIG, systemic corticosteroid, and other measures. There is also evidence suggesting that combination therapies may be of value. All the clinical data, however, is anecdotal or based on observational or retrospective studies. Definitive answers are not yet available. Given the rarity of TEN and the large number of patients required for a study to be statistically meaningful, placebo controlled trials are logistically difficult to accomplish. The absence of an animal model further hampers research into this condition. This article reviews recent data concerning clinical presentation, pathogenesis and treatment of TEN. LEARNING OBJECTIVES: At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, prognosis, and treatment of TEN.

Idiopathic granulomatous lobular mastitis.

Idiopathic granulomatous lobular mastitis (IGLM) is a rare breast condition with prominent skin findings. It is typically seen in young parous women. Painful breast masses, draining sinuses, scarring, and breast atrophy are the main clinical manifestations. IGLM can resemble a variety of other inflammatory and neoplastic processes of the breast. It is thought to result from obstruction and rupture of breast lobules. Extravasated breast secretions then induce an inflammatory reaction. Corynebacteria have also been implicated in the pathogenesis. Treatment is surgical, but systemic corticosteroids, methotrexate, and antibiotics also play a role.