Dermatología en Costa Rica

Thursday, June 29, 2017

TWEAK mediates inflammation in experimental atopic dermatitis and psoriasis | Nature Communications

TWEAK mediates inflammation in experimental atopic dermatitis and psoriasis | Nature Communications

TWEAK mediates inflammation in experimental atopic dermatitis and psoriasis

Atopic dermatitis (AD) and psoriasis are driven by alternate type 2 and type 17 immune responses, but some proteins might be critical to both diseases. Here we show that a deficiency of the TNF superfamily molecule TWEAK (TNFSF12) in mice results in defective maintenance of AD-specific T helper type 2 (Th2) and psoriasis-specific Th17 cells in the skin, and impaired expression of disease-characteristic chemokines and cytokines, such as CCL17 and TSLP in AD, and CCL20 and IL-19 in psoriasis. The TWEAK receptor, Fn14, is upregulated in keratinocytes and dermal fibroblasts, and TWEAK induces these cytokines and chemokines alone and in synergy with the signature T helper cytokines of either disease, IL-13 and IL-17. Furthermore, subcutaneous injection of recombinant TWEAK into naive mice induces cutaneous inflammation with histological and molecular signs of both diseases. TWEAK is therefore a critical contributor to skin inflammation and a possible therapeutic target in AD and psoriasis.



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Development and validation of IHS4, a novel dynamic scoring system to assess hidradenitis suppurativa/acne inversa severity - Zouboulis - 2017 - British Journal of Dermatology - Wiley Online Library

Development and validation of IHS4, a novel dynamic scoring system to assess hidradenitis suppurativa/acne inversa severity - Zouboulis - 2017 - British Journal of Dermatology - Wiley Online Library

Development and validation of IHS4, a novel dynamic scoring system to assess hidradenitis suppurativa/acne inversa severity

Original Article

Authors

  • The EHSF Investigator Group

  • This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/bjd.15748

Abstract

Background

A validated tool for the dynamic severity assessment of hidradenitis suppurativa (HS) is lacking. The aim of this study was to develop and validate such a novel scoring system.

Methods

A Delphi voting procedure was conducted among the members of the European Hidradenitis Suppurativa Foundation (EHSF) to achieve consensus towards an initial HS Severity Score System (HS4). Strengths and weaknesses of HS4 were examined by a multicenter prospective study. Multivariate logistic regression, discriminant analysis and receiver operating characteristic curves and examination for correlation (Spearman's rho) and agreement (Cohen's kappa) with existing scores were engaged to recognize the variables for a new International HS Severity Scoring System (IHS4) that was established by a 2nd Delphi round.

Results

Consensus HS4 was based on the number of skin lesions, the number of skin areas involved and the Dermatology Life Quality Index and was evaluated by a sample of 236 patients from 11 centers. Subsequently, a multivariate regression model calculated adjusted odds ratios for several clinical signs. Nodules, abscesses and draining tunnels resulted as the scoring variables. Three candidate scores were presented to the 2nd Delphi round. The resulting IHS4 score is calculated by the number of nodules (multiplied by 1) + the number of abscesses (multiplied by 2) + the number of draining tunnels (multiplied by 4). A total score of 3 or less signifies mild, 4-10 signifies moderate and 11 or higher signifies severe disease. Cohen's kappa was fair (κ=0.317) compared with Hurley classification and moderate (κ=0.493) compared with Expert Opinion. Correlation was good (rho>0.6) with Hurley classification, Expert Opinion, Physician's Global Assessment and Modified Sartorius score and moderate for Dermatology Life Quality Index (rho=0.356).

Conclusion

The novel IHS4 is a validated tool to dynamically assess HS severity and can be used both in real-life and the clinical trials setting.

This article is protected by copyright. All rights reserved.

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Benjamin Hidalgo-Matlock
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Injectable DaxibotulinumtoxinA for the Treatment of Glabella... : Dermatologic Surgery

Injectable DaxibotulinumtoxinA for the Treatment of Glabella... : Dermatologic Surgery

Injectable DaxibotulinumtoxinA for the Treatment of Glabellar Lines: A Phase 2, Randomized, Dose-Ranging, Double-Blind, Multicenter Comparison With OnabotulinumtoxinA and Placebo.

Carruthers, Jean MD; Solish, Nowell MD; Humphrey, Shannon MD; Rosen, Nathan MD; Muhn, Channy MD; Bertucci, Vince MD; Swift, Arthur MD; Metelitsa, Andrei MD; Rubio, Roman G. MD; Waugh, Jacob MD; Quiring, John PhD; Shears, Gill PhD; Carruthers, Alastair MD

doi: 10.1097/DSS.0000000000001206

Original Article: PDF Only

  • Abstract

BACKGROUND: Injectable daxibotulinumtoxinA (RT002) is an investigational botulinum toxin Type A in clinical development. It is formulated with a proprietary peptide and offers the potential of a longer acting neurotoxin therapy.

OBJECTIVE: To compare the safety, efficacy, and duration of response of daxibotulinumtoxinA with onabotulinumtoxinA and placebo [ www.clinicaltrials.gov NCT02303002].

METHODS: In this Phase 2, randomized, dose-ranging, parallel-group, double-blind, multicenter study, subjects with moderate or severe glabellar lines at maximum frown were randomly assigned to 20U, 40U, or 60U daxibotulinumtoxinA, 20U onabotulinumtoxinA, or placebo. Glabellar line severity was evaluated by investigators and subjects at least every 4 weeks, for at least 24 weeks.

RESULTS: Overall, 268 subjects enrolled. Statistical and clinical superiority were observed for 40U and 60U daxibotulinumtoxinA over 20U onabotulinumtoxinA for a range of efficacy outcomes despite the study not being powered to detect statistically significant differences between these active treatment groups.

CONCLUSION: The 40U dose of daxibotulinumtoxinA was well tolerated (e.g., absence of ptosis) and had the most favorable risk: benefit profile. Compared with 20U onabotulinumtoxinA, it exhibited a significantly greater response rate and a significantly longer duration of response (median of 24 weeks vs 19 weeks; p = .030).

(C) 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.



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Monday, June 26, 2017

Diabetic Foot Ulcers | NEJM Resident 360 Pie Diabético Ulceras

Diabetic Foot Ulcers | NEJM Resident 360

Diabetic Foot Ulcers

What are some of the recommendations for preventing the recurrence of diabetic foot ulcers?

The lifetime incidence of foot ulcers has previously been estimated to be 15 to 25% among persons with diabetes, but when additional data are considered, between 19% and 34% of persons with diabetes are likely to be affected. Read the latest Review Article on this topic. 

Clinical Pearls

Q. What is the risk of death in a patient with a diabetic foot ulcer?

A. The natural history of diabetes-related foot ulcers is sobering. The risk of death at 5 years for a patient with a diabetic foot ulcer is 2.5 times as high as the risk for a patient with diabetes who does not have a foot ulcer. More than half of diabetic ulcers become infected. Approximately 20% of moderate or severe diabetic foot infections lead to some level of amputation. Mortality after diabetes-related amputation exceeds 70% at 5 years for all patients with diabetes and 74% at 2 years for those receiving renal-replacement therapy.

Q. Do most diabetic foot ulcers heal?

A. With appropriate therapy — surgical débridement, off-loading of pressure, attention to infection, and if necessary, vascular reconstruction — foot ulcers heal in many patients, and the need for amputation is averted. On the basis of outcome data in specialized tertiary care hospitals in Europe, approximately 77% of diabetic foot ulcers heal within 1 year.


Morning Report Questions

Q: What are some of the recommendations for preventing the recurrence of diabetic foot ulcers?

A: Unfortunately, even after the resolution of a foot ulcer, recurrence is common. Prevention of foot ulcer recurrence requires good diabetes control, ongoing professional foot care at intervals of 1 to 3 months, and properly fitting footwear that has a demonstrated effect on the relief of plantar pressure. If preulcerative lesions are identified in a timely manner, treating them is likely to prevent many ulcer recurrences. Biomechanical factors such as the degree of barefoot and in-shoe mechanical stress and the level of adherence to wearing prescribed footwear are also important factors in the recurrence of ulcers of the plantar foot surface, and in-shoe mechanical stress is a factor in the recurrence of nonplantar foot ulcers, mostly through ill-fitting footwear. Repetitive stress can be detected with a pressure platform and in-shoe pressure sensors. Home monitoring of foot skin temperatures, as well as appropriate foot care when the temperature difference between feet exceeds a specified threshold, can effectively reduce the incidence of recurrent plantar ulcers.

Q: How do factors such as patient education and adherence to treatment recommendations affect outcomes?

A: Patient education is considered important and can improve patients' knowledge of diabetes-related foot problems and foot care. When given in only one or two sessions, however, patient education does not effectively prevent ulcer recurrence at 6 or 12 months. This apparent lack of efficacy provides an opportunity to strengthen clinician-to-patient educational efforts, through more continuous education or the use of specific educational techniques, but also to do more to promote and measure outcomes associated with clinician training in diabetic foot care and counseling. Adherence to treatment has now been confirmed to play an important role in the clinical outcome. The problem of nonadherence should guide clinical practice much more than is currently the case, with a focus on identifying patients who are nonadherent or are anticipated to be nonadherent and aiming to improve adherence in conjunction with providing proper evidence-based foot care. An understanding of the reasons for nonadherence and the development of ways to improve adherence are urgently needed to help clinicians in this effort.

Browse more Clinical Pearls & Morning Reports »



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Wednesday, June 21, 2017

Uso de antibacteriales No es tan bueno.

Scientists, Medical Professionals Call On International Community To Restrict Production, Use Of Triclosan And Triclocarban.

In "To Your Health," the Washington Post (6/20, Cha) reports that late in 2016, "the Food and Drug Administration took the bold step...of banning 19 chemicals in hand and body soap because of questions about their benefits and concerns about their impact on human health and the environment." On June 20, "a group of 200 scientists and medical professionals called on the international community to further restrict the production and use of two chemicals – triclosan and triclocarban – citing 'extensive peer-reviewed research' that shows potential harm from both." The experts, "in a statement published in the journal Environmental Health Perspectives...said the chemicals, which have been around for decades, should only be used when there is an 'evidence-based health benefit' going forward."

        Forbes (6/20) contributor Rita Rubin writes, "More than 2,000 products contain triclosan or triclocarban, according to the statement." The statement said, "In personal care products like hand soap, there is no evidence that use of triclosan or triclocarban improves consumer or patient health or prevents disease." The statement's authors also "said, there is evidence that the chemicals persist for years in the environment." Rubin notes that both triclosan and triclocarban are endocrine disruptors, according to the statement.

        HealthDay (6/20, Mozes) reports research from the FDA "suggests triclosan may cause levels of thyroid hormone to drop, lead to antibiotic resistance and increase the risk of skin cancer." But, the "FDA says there is no evidence that soaps with the chemical have stronger antibacterial properties than normal soap," nor did the agency find "any proof that triclosan improves antiseptic performance."


Benjamin Hidalgo-Matlock
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Friday, June 16, 2017

Interesante

Horseback-Riding, Music Therapies May Help Stroke Survivors

By Amy Orciari Herman

Edited by William E. Chavey, MD, MS

Horse-riding and music-and-rhythm therapies may help improve function and perceived recovery in patients years after they've experienced a stroke, suggests a study in Stroke.

Some 120 adults in Sweden who'd had a stroke 10 months to 5 years earlier were randomized to horse-riding therapy, structured music-and-rhythm-therapy, or standard care. Both active-treatments were delivered during two sessions a week for 12 weeks.

After the intervention period, the proportion of adults who reported a meaningful improvement on a stroke recovery scale was significantly higher with music-and-rhythm therapy (38%) and horse-riding therapy (56%) than with standard care (17%). Differences between active treatment and standard care persisted at 6 months. Secondary outcomes, such as gait and balance, also favored the active treatments.

The researchers conclude, "These results support long-term engagement in multimodal rehabilitation programs for individuals with persistent disabilities after stroke."

Stroke article (Free PDF)

Background: NEJM Journal Watch Neurology coverage of virtual reality rehab after stroke (Your NEJM Journal Watch registration required)


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Thursday, June 15, 2017

Consumo de maní, más temprano...

New Guidelines Recommend Peanut Introduction at a Younger Age

The National Institute of Allergy and Infectious Disease's guidelines for peanut allergies in children were updated after the LEAP trial was published. In the LEAP trial, the consumption versus the avoidance of peanut-containing foods in infants 4 to 11 months of age with severe eczema and/or egg allergy was evaluated, and it was found that the prevalence of peanut allergy was significantly lower in the consumption group compared with the avoidance group. The updated guidelines include three focused recommendations based on risk factors.

abstract

This abstract is available on the publisher's site.

Access this abstract now

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Un articulo bueno en popular science sobre filtro solar.

Why some people worry that sunscreen might be bad for you

The bottom line: Cover up.

The science on sun exposure is clear: too much of the sun's ultraviolet radiation leads to sunburns, rapidly aging skin, and potentially, skin cancer. And that risk? It isn't minimal. An estimated 20 percent of Americans will develop skin cancer during their lifetimes, making it the most common form of cancer in the country. To lower their risk, many Americans turn to sunscreens—sprays, lotions, and even powders—to protect their skin from the worst of the sun's effects. But what do scientists have to say about sunscreen? Unfortunately, while the choice to protect yourself from the sun is a no-brainer, the question of how best to do so is a little more contentious.

Reports in recent years (most notably the Environmental Working Group's(EWG) annual sunscreen safety rating) have raised concern that the thing we turn to for protection might actually be causing us harm. Is sunscreen secretly bad for us?

Sunscreens were originally introduced as cosmetics, but after they began making health claims (like that whole stopping sunburns thing) the Food and Drug Administration made the decision to regulate them as drugs in 1978. But sunscreens that had been in use before1978 weren't subject to the battery of tests faced by new drugs. As long as companies could prove efficacy, their products were more or less grandfathered in, with ingredients occupying a category called Generally Recognized as Safe (GRAS). But growing awareness of the subtle, previously overlooked impacts of some GRAS chemicals—like bisphenol A (BPA) in plastic—has lead to increased scrutiny and study over the past decade or so. In other words, it's not surprising that sunscreens we've relied on for decades are under the microscope.

Three little words

At the center of the controversy rests the use of three ingredients—avobenzone, retinyl palmitate, and oxybenzone—in chemical sunscreens. Chemical sunscreens are the most common type of sunscreen and work by creating a layer that absorbs the sun's rays. Oxybenzone is a chemical ultraviolet filter which absorbs the sun's rays, sparing our skin the same fate. The EWG's most recent survey says that oxybenzone is used in 65 percent of the chemical sunscreens in its database because in addition to blocking some Ultraviolet A (UVA) rays, it protects against Ultraviolet B (UVB) rays, the form of solar radiation linked to sunburns. Given its partial UVA coverage, it's usually used in tandem with avobenzone. But rather than go into detail on all three contentious chemicals, we'll just focus on oxybenzone (otherwise known as benzonephenone-3). The debate over this UVB blocker is emblematic of the difficulty in assessing the impacts of chemicals—from skincare products to pesticides—on human health.

It's not difficult to assess the toxicity of a chemical that kills us quickly. We know that cyanide gas is deadly, for example, because people who are exposed tend to drop dead within minutes. Asbestos, on the other hand, takes years to kill. And when it does, death can come courtesy of mesothelioma, lung cancer, ovarian cancer, and a host of other illnesses. Is it any wonder it took us a while to realize that the stuff was harmful? And then there are chemicals like lead,—ones that don't necessarily kill us, but cause a host of health issues and cognitive declines. The gap between exposure and emergence of a disease is known as latency, and it's just one of the many issues that makes it tough to determine a chemical's safety.

Consider, too, that we aren't exposed to chemicals in a vacuum—but rather in tandem with each other. Imagine you're a construction worker who's handled asbestos and smoked cigarettes all your adult life. When you're diagnoses with lung cancer, do doctors blame your job or your smoking habit? Maybe both risk factors are to blame; maybe neither. This is partly why epidemiologists tend to reference risk in probabilities, not absolutes. It is possible (though quite improbable) to be a chain smoking asbestos installer who never gets lung cancer. These exposures make your underlying risk higher, but nothing guarantees health or illness.

Finally, there's the question of dosage. Water, for example, is essential for life, but drinking too much—generally more than a gallon in a couple of hours—can cause hyponatremia. Hyponatremia means there's not enough salt in your blood, which makes it hard for the body to maintain its balance. Fluid fills the brain, and you die. And this really does happen: in 2005, a fraternity pledge died from drinking too much water as part of hazing ritual.

Epidemiology tries to unscramble all these risks, and to do that, scientists have to do research. And that takes time.

So what does the research say, exactly?

So far, results on oxybenzone haven't conclusively shown that it's unsafe—studies have been mixed. A 2001 paper in which young rats were fed large doses of oxybenzone found that the female rats emerged with unusually large uteruses, suggesting hormonal effects (which in humans can contribute to risk of cancer). There are some caveats, however: the dose was high, people aren't rats, and animal studies don't always correlate to what happens in people.

A separate study on human cells found that oxybenzone can mimic estrogen and block testosterone, especially in breast cells. Cellular studies don't always translate to what happens in the body—sometimes the body has mechanisms in place to counteract what happens in a Petri dish—so it's not clear if the same thing is actually happening inside sunscreen users. And even if those reactions are occurring, we don't know how they translate to effects on our health.

Another study, this one published in 2004, tried to actually get at those effects by examining the hormone levels of men and women who used sunscreen products. But the study followed only young men and postmenopausal women—women of reproductive age weren't tested, despite the fact that women use sunscreen twice as frequently as men, not to mention the fact that in vitro and animal studies suggest that female reproductive organs might be particularly sensitive to oxybenzone. The study authors wrote that, "Postmenopausal women were selected to achieve a stable hormone level independent of ovarian-menstrual cycle," but in this case the feature is actually a bug. Unfortunately, that's a persistent problem—research often fails to study women as most of them actually function in the world.

But while the jury is still out on oxybenzone's safety, we know that our bodies absorb it. A 2002 study found that adults who put on sunscreen containing four percent oxybenzone (the US allows up to six percent) in the morning and evening—mimicking what they'd do while on vacation—continued to excrete the chemical in their urine for five days afterwards, suggesting that it was being stored in the body.

The authors of that study recommended that parents avoid using sunscreens containing oxybenzone on young children, because it's thought that they haven't yet fully developed the enzymes that are believed to break down oxybenzone.

"We don't know how long it is stored, and we don't know whether it is important, but I suggest that parents of small children should avoid using sunscreens that contain benzophenone-3, to be on the safe side," lead author Helena Gonzalez said in a statement at the time.

Taken together, this might seem to say that sunscreens containing oxybenzones are unsafe. But there really isn't enough information to draw that conclusion, especially given the way most of us interact with sunscreen—we're not exactly mainlining oxybenzones when we apply a coat of sunscreen; our doses are pretty tiny. And even if those small doses do raise our risk of cancer or other health problems, that doesn't automatically mean we should cast them aside. A 2011 review study, which looked at much of the peer reviewed literature (including some of the studies outlined above), determined that the benefits of oxybenzone (reduced basal cell cancer and squamous cell skin carcinoma, but not melanoma) outweighed the known risks. Wearing sunscreen regularly can lead to a 25 percent decreased rate of carcinoma and basal cell skin cancers. A separate study found that daily use of sunscreen reduced melanoma incidence by 50 percent. In other words, even a chemical that technically isn't good for us might be better than less effective methods of sun protection. It's too early to tell.

To understand whether or not oxybenzone was really unsafe—as in, so harmful it outweighed the health benefits of wearing sunscreen—the best thing to do would be to arrange a large, diverse group of newborns and split them in two. One half of the group would wear sunscreen containing oxybenzone regularly for their entire lives. The other wouldn't use sunscreen at all. And actually, if you wanted to be really thorough, you'd probably have a third group that used only sunscreens without oxybenzone—of course, you'd have to be sure their sunscreens didn't contain any other chemicals of unknown toxicity, lest the resulting health problems muck up the results. Then we'd follow them to see what diseases they developed, and when.

Aside from the sheer impracticality of such a massive and longterm study, it would probably be pretty unethical: if we suspect that something is harmful—whether that thing be never wearing effective sunscreen or consistently dosing yourself with a potentially dangerous chemical—we can't just sign people up for a lifetime of risk for the good of the rest of us.

How do I protect myself from the sun?

Given all of those unanswered questions, it might be tempting to eschew chemical sunscreens entirely for a less worrisome alternative. For most people, that means using mineral sunscreens, which contain nanoparticalized titanium dioxide and zinc oxide. While chemical sunscreens work by absorbing solar radiation, mineral sunscreens work by reflecting them. They are increasingly the only sunscreens that can be worn in areas near coral reefs, because oxybenzone has also been found to kill coral—just one more reason to switch, right? Not so fast: unfortunately, mineral sunscreens tend to be less effective—they are less likely to actually meet the sun protection rating you see on the bottle.

In other words? ¯_(ツ)_/¯

But there are basic guidelines we should all continue to try to follow. The American Academy of Dermatology (AAD) recommends everyone wear a daily SPF 30 sunscreen (especially children, as early sunburns are strongly correlated with skin cancer later in life). The AAD doesn't care if you use mineral or chemical products, but make sure that whichever you choose has been independently vetted; not all products actually keep the SPF promises they make. Consumer Reports announced that none of the sunscreens they tested in 2017 performed well enough to meet their ratings.

For now, it's important to remember that no one has proven that oxybenzone is bad for you. And the best evidence we have still says you should protect yourself from the sun. We may soon have more oxybenzone-free options, as there's been a push to get newer sunscreen ingredients that have already been passed muster in Europe (where sunscreen is treated as a cosmetic and not a drug) legalized on our shores. But until they appear, if you're concerned about sun exposure and sunscreen, you can always just cover up instead. Maybe 2017 should be the year you bring big hats and bell sleeves back into style.

"The principal protection against the harmful effects of the sun should be clothes," said Gonzalez, "and sunscreens should be used solely as a supplement."


Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica
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Monday, June 05, 2017

Antibiotico efectivo en infecciones de piel.

Fusidic Acid Noninferior To Linezolid As Treatment Of ABSSSIs, Research Suggests.

Healio (6/4, Gallagher) reports fusidic acid (Taksta) is noninferior to linezolid (Zyvox) "as an oral treatment for acute bacterial skin and skin structure infections, or ABSSSIs, including MRSA," according to phase 3 data presented at the ASM Microbe conference. Researchers recorded early clinical response (ECR) "in 87.2% of patients who received fusidic acid compared with 86.6% in the linezolid arm."


Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica
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Sunday, June 04, 2017

Cuidado con algunos filtros solares...

Harmed by Sunscreen? What Parents Need to Know

It's been more than 3 weeks, and 14-month-old Kyla Fudge is still recovering from a painful, blistering rash that spread over her cheeks and nose, right where her mom had spread a palmful of Banana Boat Kids Free spray sunscreen.

Her story has incensed parents across the internet. Her mom understands why.

"Nobody, adult or child, deserves to go through that. That was insane. That was the hardest couple of weeks of our lives," says Kyla's mom, Rebecca Cannon, 32, of Newfoundland, Canada.

The family had gone to visit Kyla's aunt and cousins. The older kids wanted to play outside. The day was overcast and slightly chilly, but the sun was peeking in and out from behind the clouds, so Cannon dressed her daughter in a coat and hat and dabbed some of the Banana Boat spray on her nose and cheeks, where her face was exposed.

They'd never used the product before, but Rebecca read the label. It said it was safe for babies over the age of 6 months.

Source: courtesy of Rebecca Cannon

"Her face gradually throughout the day got pinker. I thought it was just irritated from a different sunscreen, so I took her home and gave her a bath," Cannon says. "When she woke up the next day she was really swollen and blistering, so I took her to the ER."

There, doctors admitted that because Kyla's face was so swollen, it was hard to make a definite diagnosis. Their best guess, after consulting with a pediatric dermatologist, was a caustic burn, perhaps caused by something in the sunscreen.

Health Canada, the Canadian counterpart to the U.S. FDA, is investigating.

Renelle Briand, a spokesperson for the agency, says that in addition to Kyla's case, they are aware of three other Canadian children who had reactions to Banana Boat sunscreens in May. That's a tiny fraction of the overall number of people who use this product, but the agency is being cautious, she says, since it's always possible that the manufacturer could have had a bad batch. She says it's too early in the process to even guess at what may have caused the kids' severe reactions.

Cannon posted about the family's ordeal on her Facebook page. One of her friends asked to share Kyla's pictures with her mommy group, and from there, the warning went viral -- generating as many questions from worried parents as answers.

Did Cannon use the product correctly? Cannon says she did, first spraying it into her own hand and then spreading it across the exposed parts of her daughter's face.

Did she simply let Kyla stay out in the sun for too long? She doesn't think so. "Her hands were out in the open, and they didn't burn," Cannon says.

Cannon reported Kyla's reaction to Edgewell, the company that owns Banana Boat. They sent her a check for $10 to reimburse her for the cost of the product.

In a statement to WebMD, the company says their products undergo rigorous testing to ensure safety and quality before they're put on the market. They said all their products have a neutral pH, which means they can't cause chemical burns.

So what happened here?

Alok Vij, MD, a dermatologist at the Cleveland Clinic, thinks Kyla's reaction was something called a photoallergy. That's when sunlight combines with a chemical to bring on an allergic reaction. "It's not very common, but sunscreens are a common cause of that reaction," he says.

"The thing that makes it harder to diagnose is that there are a lot of potential allergens in the chemical sunscreens. Fragrances, preservatives -- a lot of ingredients that sunscreen companies use to make them spread more easily, absorb more quickly, essentially make them more elegant to put on the skin," Vij says.

The company acknowledges that photoallergic reactions can be a possibility with its sunscreens.

"For some, a sensitivity to a product ingredient can be triggered or exacerbated by the sun and result in a photoallergic skin rash or sunburn. In more severe cases, blistering may also develop. A dermatologist can also advise on appropriate treatment," it says in a written statement.

There are several different ingredients in the formula that Cannon used that are known to trigger a reaction in sensitive people. The chemicals avobenzone, octinoxate, and octocrylene have all been linked to cases of photo allergy.

"Banana Boat uses the octocrylene as a base to prevent the sunscreening agent avobenzone from breaking down, says Darrell Rigel, MD, a dermatologist at NYU's Langone Medical Center. He consults with companies on their sunscreen formulations, but he has never worked for Banana Boat.

He says Banana Boat uses octocrylene as a stabilizer. "Different companies have different ways of stabilizing avobenzone. Neutrogena has Helioplex, Aveeno has Active Photo Barrier Complex," he says.

Reactions to octocrylene have been documented in children but also in adults, especially if they are also allergic to the pain reliever ketoprofen.

Still, Rigel wants people to know that reactions to sunscreen ingredients are thought to be rare. "It's only about 1% of the population that gets it," he says.

The FDA agrees. We asked the agency if it is also investigating these reports of severe skin reactions in kids who've recently used Banana Boat.

In an emailed statement, the FDA says it is aware of cases of serious allergic reactions caused by sunscreens. That's why most over-the-counter products advise testing a patch of skin before applying the product over a wider area.

"Although consumers occasionally experience a skin reaction, the potential overall benefits of regular sunscreen use outweigh the potential risks of these reactions. Using sunscreens with other sun protection measures, as directed, can help reduce the risk of skin cancer and premature skin aging caused by the sun," they write.

The agency says people who've had a bad reaction to a sunscreen should stop using it and get medical advice.

As for other measures parents can take to cut the risk of photo allergy in kids, experts say the most important thing to do is to think of sunscreen as your last line of defense against UV rays.

Vij advises parents to:

  • Keep kids out of the sun during the brightest parts of the day, between 11 a.m. and 4 p.m.

  • Use sun-protective clothing. "I recommend it because you're not worried about where you've spread sunscreen on a little squirrelly toddler," he says.

  • Use mineral-based sunscreens, like those with zinc or titanium. Vij says these are harder to spread on the skin, but they're less likely to trigger reactions.

  • Avoid spray sunscreens, since it's very hard to see where you've put them or to know how much you've applied.


Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica
4000-1054
2208-8206
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Thursday, June 01, 2017

Vitamina D para verrugas vulgares



Published in Dermatology

Journal Scan / Research · May 31, 2017

Intralesional Vitamin D3 Injection Helpful in the Treatment of Recalcitrant Warts


BACKGROUND

Verruca vulgaris (viral warts) is a fairly common condition with a plethora of treatment options having variable success rates. Recalcitrant warts are refractory to treatment with often disappointing response and high recurrence rates. Lately, treatment with intralesional injections has gained momentum due to its effectiveness in clearing warts by stimulating the cell-mediated immunity. Vitamin D, when applied topically, regulates epidermal cell proliferation and is involved in the formation of antimicrobial peptides. We have attempted to use vitamin D3 to exploit its reported action as an immunotherapeutic molecule in addition to its topical effects. To our knowledge, there are no reports of intralesional vitamin D3 injections used in the treatment of extragenital recalcitrant warts.

METHODS

Sixty-four patients with recalcitrant warts of varying sizes and duration were included in the study. About 0.2- to 0.5-mL vitamin D3 solution (600,000 IU, 15 mg/mL) was injected to the base of the wart. A maximum of 5 warts were injected per session at 3-week intervals until resolution or for a maximum of 4 treatments. Patients were followed up for 6 months after the last injection to detect any recurrence.

RESULTS

Sixty patients completed the study. Complete response was seen in 54 of 60 (90%), partial response in 4 of 60 (6.66%), and no response in 2 of 60 (3.33%). The average number of injections required to achieve a complete resolution was 3.66. Complete resolution of distant warts was noticed in all patients.

CONCLUSIONS

Intralesional vitamin D3 is a safe, effective, and an inexpensive treatment option for recalcitrant warts.


TAKE-HOME MESSAGE



Journal of cutaneous medicine and surgery
Intralesional Vitamin D3 Injection in the Treatment of Recalcitrant Warts: A Novel Proposition
J Cutan Med Surg 2017 Apr 06;[EPub Ahead of Print], S Raghukumar, BC Ravikumar, KN Vinay, MR Suresh, A Aggarwal, DP Yashovardhana 

Alergia

Article in Press

Background

Food allergy prevalence is reported to be increasing, but epidemiological data using patients' electronic health records (EHRs) remain sparse.

Objective

We sought to determine the prevalence of food allergy and intolerance documented in the EHR allergy module.

Methods

Using allergy data from a large health care organization's EHR between 2000 and 2013, we determined the prevalence of food allergy and intolerance by sex, racial/ethnic group, and allergen group. We examined the prevalence of reactions that were potentially IgE-mediated and anaphylactic. Data were validated using radioallergosorbent test and ImmunoCAP results, when available, for patients with reported peanut allergy.

Results

Among 2.7 million patients, we identified 97,482 patients (3.6%) with 1 or more food allergies or intolerances (mean, 1.4 ± 0.1). The prevalence of food allergy and intolerance was higher in females (4.2% vs 2.9%; P < .001) and Asians (4.3% vs 3.6%; P < .001). The most common food allergen groups were shellfish (0.9%), fruit or vegetable (0.7%), dairy (0.5%), and peanut (0.5%). Of the 103,659 identified reactions to foods, 48.1% were potentially IgE-mediated (affecting 50.8% of food allergy or intolerance patients) and 15.9% were anaphylactic. About 20% of patients with reported peanut allergy had a radioallergosorbent test/ImmunoCAP performed, of which 57.3% had an IgE level of grade 3 or higher.

Conclusions

Our findings are consistent with previously validated methods for studying food allergy, suggesting that the EHR's allergy module has the potential to be used for clinical and epidemiological research. The spectrum of severity observed with food allergy highlights the critical need for more allergy evaluations.


Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica
4000-1054
2208-8206
Please excuse the shortness of this message, as it has been sent from a mobile device.