Impact of Clinical Photographs on the Accuracy and Confidence in the Histopathologic Diagnosis of Mycosis Fungoides Journal of Cutaneous Pathology

TAKE-HOME MESSAGE

• This study utilized 50 cases of mycosis fungoides (MF) and 49 distractor cases (lichen planus, lichenoid drug, connective tissue disease, psoriasis, or spongiotic dermatitis), and 7 participants were given a survey in which each case was presented twice—once with only histologic images and once with both histologic and corresponding clinical images. Significantly more MF cases were diagnosed correctly when histology was combined with clinical images, and a similar trend was seen for distractor diagnoses.

• This study highlights the importance of clinical–pathologic correlation in diagnosing MF and underscores the utility of providing clinical photos to the pathologist both in diagnosis and exclusion of MF.

– Caroline K. Crabtree, MD

Abstract

BACKGROUND

The histopathologic diagnosis of MF is challenging, and there is significant overlap with benign inflammatory processes. Clinical features may be relevant in the assessment of skin biopsies.

METHODS

We provided photomicrographs to board-certified dermatopathologists and one hematopathologist with and without accompanying clinical photographs and assessed accuracy and confidence in diagnosing MF.

RESULTS

We found that access to clinical photographs improved diagnostic accuracy in both MF and non-MF (distractors); the degree of improvement was significantly higher in the non-MF/distractor category. Across all categories, diagnostic confidence level was higher when clinical images were available.

CONCLUSION

These findings suggest that clinical images are useful in making an accurate diagnosis of MF, and may be particularly helpful in ruling it out when an inflammatory disorder is clinically suspected. This article is protected by copyright. All rights reserved.

Journal of Cutaneous Pathology

Impact of Clinical Photographs on the Accuracy and Confidence in the Histopathologic Diagnosis of Mycosis Fungoides

J. Cutan. Pathol 2020 Dec 16;[EPub Ahead of Print], R Hadi, TI Miller, C May, JS Lehman, DD Bennett, M Piliang, O Chang, MM Shinohara  

Journal Scan / Research · December 30, 2020 Disseminated Intravascular Coagulopathy in SJS/TEN International Journal of Dermatology

TAKE-HOME MESSAGE

• Among 396 patients with Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) at the Mayo Clinic between July 2012 and January 2020, 5 (1.3%) developed disseminated intravascular coagulopathy (DIC). Of these, 4 patients died, and the fifth was lost to follow-up after a facility transfer.

• Although DIC is an uncommon complication of SJS/TEN, the associated increased mortality risk if patients do have concomitant DIC is substantial. Dermatologists should be aware of this association, and biopsy in SJS/TEN patients in which DIC is a concern should be considered emergent, as demonstration of microthrombi may be helpful in early DIC diagnosis and initiation of interventions such as anticoagulation, dialysis, or other supportive measures.

– Caroline K. Crabtree, MD

Abstract 

BACKGROUND

The purpose of this study was to retrospectively assess clinical characteristics and mortality rate of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in patients who developed disseminated intravascular coagulation (DIC).

METHODS

A systematic retrospective chart review of all patients with concurrent clinical diagnosis of DIC and SJS/TEN between July 1, 2012, and January 1, 2020, at the Mayo Clinic was performed.

RESULTS

The incidence of DIC in patients with SJS/TEN was 1.3% at our institution (5 of 396 DIC patients). Triggers of SJS/TEN included lamotrigine, clofarabine, antibiotics, and sepsis. Two patients diagnosed with SJS and two patients with TEN succumbed to the disease.

CONCLUSION

DIC is a rare underlying risk in patients with SJS/TEN and is associated with increased mortality. Early clinician awareness and aggressive intervention is advised.

International Journal of Dermatology

Disseminated Intravascular Coagulopathy: A Complication of Stevens–Johnson Syndrome/Toxic Epidermal Necrolysis

Int. J. Dermatol 2020 Dec 17;[EPub Ahead of Print], RA El-Azhary, S Nowsheen, LE Gibson, DJ DiCaudo  

Tiroides y AA

Review

Screening of thyroid function and autoantibodies in patients with alopecia areata: A systematic review and meta-analysis

Author links open overlay panelSolamLeeMDYoung BinLeeMDBeom JunKimMDWon-SooLeeMD, PhD

https://doi.org/10.1016/j.jaad.2018.10.066Get rights and content

Background

Several studies have reported associations between alopecia areata and diverse thyroid diseases.

Objective

To investigate the odds ratio and prevalence rate of thyroid dysfunction and autoimmune thyroid diseases in patients with alopecia areata.

Methods

A systematic review of the studies published before March 20, 2018, was performed by using the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The clinical and laboratory findings associated with thyroid dysfunction and autoimmunity were extracted for quantitative analysis.

Results

A total of 50 studies were analyzed. Patients with alopecia areata had higher odds of abnormal findings on thyroid function tests, thyroid dysfunction, positive thyroid autoantibodies, and autoimmune thyroid diseases. Moreover, their prevalence rate was much higher than that in the general population.

Limitations

The heterogeneity in baseline characteristics and outcome reporting across the studies.

Conclusion

Current evidence suggests that thyroid dysfunction and autoimmune thyroid diseases are more prevalent in patients with alopecia areata. Clinicians may be encouraged to screen for the associated signs and symptoms to achieve better outcomes.

AA y tx complementario

Complementary & Alternative Medicine for Alopecia Areata: A Systematic Review

Author links open overlay panelElizabethTkachenkoBS¹⁴Jean-PhillipOkhovatMD MPH²PriyaManjaly³⁴Kathie P.HuangMD⁴Maryanne M.SennaMD²ArashMostaghimiMD MPA MPH⁴

https://doi.org/10.1016/j.jaad.2019.12.027Get rights and content

Abstract

Background

Despite high utilization of complementary and alternative medicine (CAM) for alopecia areata (AA), efficacy and safety remain unclear.

Objective

To identify all CAM therapies studied for treatment of AA. Outcomes of interest included disease course and psychological well-being.

Methods

PubMed and Embase were searched to identify English articles containing original data investigating CAM in human subjects with AA from 1950-2018. Quality was assessed with Oxford Centre for Evidence Based Medicine criteria.

Results

Of 1,015 initial citations, 16 articles met inclusion criteria: 5 randomized controlled trials, 5 prospective controlled cohorts, 4 prospective non-controlled cohorts, 1 retrospective cohort, and 1 case series. CAM therapies with best evidence and efficacy for hair growth in AA include essential oil aromatherapy, topical garlic, and oral glucosides of peony with compound glycyrrhizin. Hypnosis and mindfulness psychotherapy represent low quality evidence for improvement of psychological and quality of life outcomes. Adverse events were rare and mild for all therapies evaluated.

Limitations

Inconsistent or poorly reported study methodology and non-standardized outcomes limit the conclusions that can be made from these studies.

Conclusions

This work serves to inform physician management of patients with AA seeking CAM, while encouraging further investigation into these therapies to address some of the therapeutic challenges of AA.

Funding sources: None

Conflicts of interest: Dr. Mostaghimi has received royalty payments from Pfizer for licensing of the ALTO tool, participated in clinical trials related to alopecia from Incyte and Aclaris, and received consulting fees from Pfizer. He is a medical advisor for hims and has received payments and equity in exchange for consulting work. Dr. Senna has participated in alopecia clinical trials related from Eli Lilly and Concert, received consulting fees from Concert, and is on the scientific advisory board of Cassiopea. Dr. Huang receives royalty payments from Pfizer for licensing the ALTO tool, participated in clinical trials related to alopecia from Incyte, Aclaris, and Concert, and received consulting fees from Pfizer.

CAPSULE SUMMARY

•The complementary and alternative therapies with highest quality and efficacy for hair growth in alopecia areata include essential oil aromatherapy, topical garlic, and oral glucosides of peony with compound glycyrrhizin.

•Low quality studies reveal that hypnosis and mindfulness are effective for improving psychological outcomes and quality of life.

Vitamina D en AA

Association of Alopecia Areata with Vitamin D and Calcium Levels: A Systematic Review and Meta-analysis

• Yi Liu,
• Jing Li,
• Guirong Liang,
• Chaojiang Cheng,
• Yue Li &
• Xinfeng Wu 

Dermatology and Therapy volume 10, pages967–983(2020)Cite this article

• 940 Accesses

• Metrics details

Abstract

Introduction

To investigate the associations of alopecia areata (AA) with serum vitamin D and calcium levels.

Methods

A systematic review of all relevant articles published up to February 2020 in PubMed, Embase, and Cochrane Library databases was conducted. Primary endpoints were serum 25-hydroxyvitamin D [25(OH)D] levels and vitamin D deficiency, and the secondary endpoint was serum calcium level. Odds ratio (OR) and standardized mean difference (SMD) with 95% CI across studies were analyzed.

Results

Data on 1585 patients with AA and 1114 controls from 16 case–control studies and three cross-sectional studies were included in this meta-analysis. A pooled meta-analysis was conducted using the random-effects model because of inter-study heterogeneity (vitamin D level, I² = 87.90%; vitamin D deficiency, I² = 81.10%; serum calcium level, I² = 83.80%). A combined analysis revealed that patients with AA had significantly lower mean serum 25(OH)D level compared with control (WMD − 9.08, 95% CI − 11.65, − 6.50, p < 0.001), and were more likely to have vitamin D deficiency (OR 4.14, 95% CI 2.34, 7.35, p < 0.001). However, the pooled analysis revealed that patients with AA did not have significantly lower serum calcium levels compared with control (WMD − 0.17, 95% CI − 0.40, 0.06, p = 0.143). Subgroup analysis suggested that matched control, mean age, and country might contribute to the heterogeneity of serum vitamin D level, while study design, matched control, and country might contribute to the heterogeneity of vitamin D deficiency.

Conclusion

Deficiency of serum 25(OH)D level, rather than calcium level, was present in patients with AA. Screening for vitamin D deficiency and vitamin D supplementation may be beneficial in the treatment of patients with AA.

Key Summary Points

Why carry out this study?

Alopecia areata (AA) is a form of non-scarring hair loss characterized by an autoimmune reaction to hair follicles with disordered, shortened hair cycle

Vitamin D deficiency was considered as a risk factor for the development of AA

The relationship between vitamin D deficiency and AA in patients was reported in two previous meta-analyses but not comprehensively evaluated because five subsequent studies were not considered

What was learned from the study?

Deficiency of serum 25(OH)D level, rather than calcium level, was present in patients with AA. Screening for vitamin D deficiency and vitamin D supplementation may be beneficial in treatment of patients with AA

Alopecia Areata y Minoxidil 5% Sí sirve...

Original Article

Minoxidil for patchy alopecia areata: systematic review and meta‐analysis

P.C.B. Freire

R. Riera

A.L.C. Martimbianco

V. Petri

A.N. Atallah

First published: 05 March 2019

https://doi.org/10.1111/jdv.15545

Abstract

Background

Alopecia areata (AA) is a complex immune and polygenic inflammatory disease that causes hair loss on some or all areas of the body; extent, severity and progression vary widely among individuals. Alopecia areata, considered one of the most frequently occurring immune diseases, affects 0.2% of the world population at any given time. Uncertainty prevails about the most appropriate intervention for AA. The aim is to evaluate the effectiveness and safety of over 80 interventions for AA, including minoxidil – one of the most promising interventions for patchy AA in children and adults of both sexes.

Material and Methods

An extensive search was conducted of international medical literature involving randomized clinical trials (RCTs) of AA interventions. RCTs were evaluated qualitatively and quantitatively according to the previously published protocol and for seven specific outcomes.

Results

The meta‐analysis involving 5% minoxidil vs. placebo presented a significant difference in favor of 5% minoxidil with the moderate quality of evidence in children and adults with patchy AA (RR 8.37 [3.16–22.14], 95% CI). No severe adverse event was reported.

Conclusions

Treatment of patchy AA with 5% minoxidil proved effective, and clinically and statistically safe in studies with limited sample size; quality of evidence was moderate. Further studies with sound methodological quality, more participants and outcome observations lasting longer than 6 months are needed to address remaining uncertainties.

Uso de Mascaras en Niños

Experts Discuss Best Cloth Masks For Children To Protect Against COVID-19 

The New York Times (12/18, Szalinski) examined "90 cloth masks for kids, pored over scientific studies, spoke with health experts and researchers, and tested the finalists with a panel of 10 kids, ages 3 to 10." The Times added, "The best mask is the one that fits and that your child will be able to wear for most of the day, experts say." The Times noted, "The American Academy of Pediatrics says children ages 2 and older can safely wear a mask, and that they should do so in a group setting, including at school or in day care." According to AAP spokesperson Jennifer Shu, MD, "the ideal mask for kids is 'one that a child is willing and able to wear for most of the day, put on and remove correctly, and that she won't be constantly touching.'" The Times also highlighted recommendations by the American Academy of Dermatology for children with sensitive skin.  

Gonorrea 2020

CDC Guidelines Recommend Ceftriaxone Monotherapy for Uncomplicated Gonorrhea

By Kelly Young

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

The CDC now recommends treating uncomplicated gonorrhea with a single 500-mg intramuscular dose of ceftriaxone, according to updated guidelines in MMWR. The recommendation applies to urogenital, anorectal, and pharyngeal infections.

Previously, the CDC recommended ceftriaxone plus oral azithromycin. The authors note that azithromycin resistance is "an increasing concern." Nationwide, the percentage of N. gonorrhoeae isolates with reduced susceptibility to azithromycin increased from 0.6% in 2013 to 4.6% in 2018.

Among the recommendations:

• People weighing ≥150 kg should be given a single 1-g dose of ceftriaxone. 
• In patients for whom a chlamydial infection has not been ruled out, doxycycline 100 mg orally twice a day for 7 days is also recommended.
• For patients with cephalosporin allergy, an intramuscular dose of gentamicin (240 mg) plus an oral dose of azithromycin (2 g) may be considered.
• In cases where intramuscular ceftriaxone can't be given, an oral dose of cefixime (800 mg) is an option, but the authors note it may not be as effective.
• For pharyngeal gonorrhea, there are no reliable alternative therapies and test-of-cure is recommended.

MMWR article (Free)

Background: NEJM Journal Watch coverage of gentamicin and ceftriaxone (Your NEJM Journal Watch subscription required)

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Hemangiomas y compromiso hepático si más de 5...

                                 Published in Dermatology

Journal Scan / Research · December 16, 2020

Screening for Infantile Hepatic Hemangioma in Patients With Cutaneous Infantile Hemangioma

Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• In this study, patients with 1 to 2 (n=980) or at least 3 cutaneous hemangiomas (n=676) received abdominal ultrasonography to screen for infantile hepatic hemangioma (IHH). Rates of IHH increased with number of cutaneous infantile hemangiomas (<5: 0.4%, 5–9: 8.3% [P < .001]; 10–30: 24.1% [P = .011]; >30: 33.3%  [P = .701]). ROC curve analysis identified a cutoff point for the number of cutaneous infantile hemangiomas of 5 to screen for IHH. Participants with IHH were also screened for potential complications, including congestive heart failure (present in 1/31 patients with EKG and echocardiogram), consumptive hypothyroidism (present in 3/31 patients with thyroid function tests), and liver dysfunction (present in 2/31 patients with liver function tests), coagulation function, and alpha fetoprotein levels.

• Diffuse IHH can cause hypothyroidism, congestive heart failure, and abdominal compartment syndrome; thus, early identification is paramount. This study demonstrates that the risk of IHH increases with increasing numbers of cutaneous hemangiomas and validates the recommendation that infants with 5 or more cutaneous hemangiomas be screened with abdominal ultrasound for IHH.

– Margaret Hammond, MD

Abstract

BACKGROUND

Abdominal ultrasonography has been proposed for screen infantile hepatic hemangioma (IHH) in patients with multiple cutaneous infantile hemangiomas (IHs).

OBJECTIVES

The aim of this study was to establish the optimal cutoff point for the number of cutaneous IHs needed to screen for IHH.

METHODS

We performed a prospective, multicenter study to screen for IHH in patients younger than 9 months of age who had multiple cutaneous IHs (n ≥3) on ultrasonography. For comparison, a group of patients with 1 to 2 focal cutaneous IHs was also recruited.

RESULTS

In total, 676 patients with at least 3 cutaneous IHs, and 980 patients with 1 to 2 focal cutaneous IHs were enrolled. Thirty-one patients were found to have IHH. A higher number of cutaneous IHs was associated with an increased risk of IHH (R = 0.973, P < 0.001). Receiver operating characteristic curve analysis revealed that 5 cutaneous IHs was the optimal cutoff point to screen for IHH, with an area under the curve of 0.872 (P <0.001; 95% CI, 0.789-0.955).

LIMITATIONS

This was an uncontrolled study.

CONCLUSIONS

Screening for IHH is recommended in patients younger than 9 months of age who present with 5 or more cutaneous IHs.

TRIAL REGISTRATION

Clinicaltrial.gov identifier: NCT03331744.

Journal of the American Academy of Dermatology

Screening for Infantile Hepatic Hemangioma in Patients With Cutaneous Infantile Hemangioma: A Multicenter Prospective Study

J Am Acad Dermatol 2020 Dec 04;[EPub Ahead of Print], Y Ji, S Chen, K Yang, B Xiang, X Jiang, X Xu, L Li, T Qiu, J Zhou, S Dai, X Zhang, G Lu, F Kong, G Yang, Q Qiu

Efficacy and Safety of Oral Tranexamic Acid as an Adjuvant in Indian Patients With Melasma Journal of the European Academy of Dermatology and Venereology: JEADV

TAKE-HOME MESSAGE

• In this blinded, controlled clinical trial, 120 Indian patients with facial melasma were given either oral tranexamic acid 250 mg and oral ranitidine 150 mg twice daily (n = 61) or placebo tablets (n = 59) for 12 weeks. Both groups also used a triple-combination cream of fluocinolone 0.01%, tretinoin 0.05%, and hydroquinone 2% daily. After 12 weeks, marked improvement in melasma was seen in the intervention group (65.6% vs 27.1%; P = .0001), which was maintained to the 24th week despite stopping all treatment (65.6% vs 11.9%; P = .0001). Gastrointestinal complaints and hypomenorrhea were more common in the intervention group.

• This study suggests that oral tranexamic acid is an effective adjuvant to topical therapy in the treatment of melasma in Indian patients. In this study, the benefit of oral tranexamic acid was also sustained over a treatment-free follow-up period of 12 weeks.

– Margaret Hammond, MD

 Dermatology

Written by

 

 

Peter Rullan MD

This paper contains great news for the dermatologist who treats melasma. The authors answer many of the questions concerning the safety and efficacy of using TXA, alongside a physical sunblock and a "Kligman-type" cream. Most importantly, it places TXA at the core of treating melasma. This well-designed and controlled study convincingly redirects our treatment at the causal dysfunction of the disease, and statistically proves that TXA is much more effective than just using topical creams. Adding 12 weeks of TXA is not only safe and tolerable, but also it significantly clears dyschromia and produces a sustained benefit for at least 12 weeks more after stopping TXA and creams. My clinical experience confirms these results (I also include monthly 20%-30% salicylic acid peels).

With 130 participants randomized in two blinded groups, the authors found that the group treated with oral TXA and a triple combination cream had significantly better results than the group treated with placebo tablets and triple combination cream at the end of 12 weeks of treatment. An additional 12 weeks after treatment ended, there was still a notable difference between the two groups, with sustained improvement in the group treated with oral TXA.

Thromboembolism can be a major concern for patients taking TXA and should be taken into consideration before prescribing this treatment; however, no serious side effects of any kind were seen during the course of this study. The most common side effects are gastrointestinal and can be resolved by discontinuing treatment or using antacids.

Overall, these results offer a valuable new treatment for patients with melasma and should be considered as a primary treatment option. Finally, we have a real hope in helping our patients with melasma.

---

Abstract

BACKGROUND

Melasma is a chronic recalcitrant pigmentary disorder whose treatment frustrates physician and patient alike. Tranexamic acid, a plasmin inhibitor, has demonstrated hypopigmenting properties.

AIM

To compare safety and efficacy of combination of oral tranexamic acid (TXA) and topical fluocinolone-based combination cream (FbTC) with that of topical FbTC alone in melasma.

METHOD

One hundred and eighty patients patients of facial melasma of either sex attending dermatology OPD were screened. Consenting 130 participants were randomized into two blinded groups with 65 patients in each group. Group A patients received oral tranexamic acid 250 mg and oral ranitidine 150 mg twice daily and applied a triple combination cream containing fluocinolone acetonide 0.01%, tretinoin 0.05% and hydroquinone 2% once daily, and Group B was asked to take placebo tablets (calcium lactate and multivitamin) and apply the cream only for 12 weeks. Response was evaluated using modified melasma area severity index (mMASI) and graded mMASI improvement at 4th, 8th and 12th weeks, and at 24th week for recurrence. Data were analysed using SPSS software.

RESULTS

Results were analysed in 120 patients who completed the study with 61 and 59 patients in group A and B, respectively. Demographic profile was equally distributed in both the groups. In group A, 13.1% patients showed marked improvement (>75%) in mMASI as compared to group B (1.7%) at 4th week. By 12th week, 65.6% patients had marked improvement in group A in contrast to only 27.1% in group B. At 24th week, group A (65.6%) had sustained improvement as compared to group B (11.9%) despite stopping treatment; all of which were statistically significant. Recurrence observed was 18.03% in group A vs. 64.4% in group B at 24th week.

CONCLUSION

Oral tranexamic acid is definitely a boon to the armamentarium of melasma management and should be used as an adjuvant to fluocinolone-based triple combination cream for a faster, sustained improvement and to prevent recurrence.

Copyright © 2020 Elsevier Inc. All rights reserved.

• Article Citation

Journal of the European Academy of Dermatology and Venereology: JEADV

Efficacy and Safety of Oral Tranexamic Acid as an Adjuvant in Indian Patients With Melasma: A Prospective, Interventional, Single-Centre, Triple-Blind, Randomized, Placebo-Control, Parallel Group Study

J Eur Acad Dermatol Venereol 2020 Jun 22;[EPub Ahead of Print], K Minni, S Poojary 

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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Increased Oral Propranolol Dosage for Infantile Hemangiomas

TAKE-HOME MESSAGE

• In this retrospective study, patients treated with propranolol for infantile hemangioma at 2 mg/kg/day versus 2.5 mg/kg/day dosing were compared. Patients receiving the higher dose trended toward having a higher hemangioma severe scale score (11.6 vs 10.4, P = .152), mean length (4.6 cm vs 3.7 cm, P = .178), higher percentage of mixed component tumors (65.9% vs 33.3%, P < .001), and later age at onset (226 days vs 148 days, P = .070). Patients receiving the higher propranolol dose had a mean change in hemangioma activity score of less than 1 point (overall, -0.70, P < .001). Patients treated with the higher dose of propranolol were also more likely to have completed plastic surgery referrals than those treated with the standard dose (24.4% vs 4.9%, P < .001).

• In this study, infantile hemangiomas treated with an increased dose of propranolol (2.5 mg/kg) did not have improved outcomes compared with those treated with a standard dose (2 mg/kg). This finding may have been confounded by hemangioma size, deep component, and age at presentation. However, the authors suggest that the therapeutic benefit of increased propranolol dosing may be limited.

– Margaret Hammond, MD

BACKGROUND

Infantile hemangiomas (IH) are the most common benign tumor of infancy. Although oral propranolol is currently first-line therapy, optimal dosing for treatment of IH remains debated. We sought to identify hemangioma characteristics associated with poor response to standard dosing (2 mg/kg/d) and to assess the therapeutic benefit of higher dosing.

METHODS

Retrospective chart review was conducted of 559 patients with IH seen at Johns Hopkins between 2008 and 2018, of whom 245 (44%) were treated with propranolol. Baseline characteristics were compared between patients who received increased propranolol dosing (≥2.5 mg/kg/d) and those who remained on standard dose (2 mg/kg/d). Changes in the Hemangioma Activity Score (HAS) during the increased dosage period were scored by two trained, blinded pediatric dermatologists.

RESULTS

Of 245 patients, 204 (83%) received standard 2 mg/kg/d propranolol dosing while 41 (17%) received a higher dose of ≥2.5 mg/kg/d. The most common location of IH in both groups was the face. In the increased dosage group, 85.4% of IH were of mixed or deep morphology with a mean greatest diameter of 4.6 cm. IH requiring increased dosing received longer courses of propranolol (mean of 389 vs. 282 days, P < .001) and underwent higher rates of excision by plastic surgery (26.8% vs. 5.9%, P < .001). Mean change in HAS over the period with dosage ≥2.5 mg/kg/d was minimal (-0.70; P < .001).

CONCLUSIONS

Most recalcitrant IH were located on the face, larger in diameter, and of mixed or deep morphology. Patients had little improvement in HAS score with increased propranolol dosing implemented late in the treatment course with over one-fourth ultimately receiving surgical excision.

Pediatric Dermatology

Retrospective Case Series of Increased Oral Propranolol Dosage for Infantile Hemangiomas

Pediatr Dermatol 2020 Aug 31;[EPub Ahead of Print], AH Huang, D Mannschreck, P Aggarwal, M Mahon, BA Cohen 

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Efficacy and Safety of Monotherapies for Tinea Capitis

TAKE-HOME MESSAGE

• The authors performed a network meta-analysis of monotherapies used to treat tinea capitis. Griseofulvin, terbinafine, ketoconazole, itraconazole, and fluconazole were compared. When Microsporum canis was the causative organism, griseofulvin was most efficacious in eliciting mycologic cure (SUCRA = 66.1%) and complete cure (SUCRA = 80.6%). When the causative organism was of the Trichophytongenus, terbinafine was most efficacious (SUCRA, 75.2% and78.2% for mycologic and complete cure, respectively). The relative risk of adverse effects did not differ significantly among the five antifungal medications compared.

• When cure rates alone are considered, this network meta-analysis demonstrated an increased efficacy against Microsporum canis with griseofulvin and against members of the Trichophyton genus with terbinafine. The statistical evaluation used in this meta-analysis did not take into account varied dosing regimens or level of evidence. Factors other than efficacy may also impact a clinician's choice of treatment for tinea capitis. However, the results of this meta-analysis may serve as a guide in choosing an antifungal regimen for tinea capitis.

– Margaret Hammond, MD

Written by

 

 

Karen A. Chernoff MD

This network meta-analysis compares the efficacy of five different systemic monotherapies for tinea capitis. Although no agent showed a statistically significant advantage over its alternatives overall, the pooled data found terbinafine superior for the treatment of tinea capitis due to Trichophyton species and griseofulvin most effective for cases due to Microsporum species. This is consistent with previously published reports. However, due to the heterogeneity of the data analyzed, particularly in terms of duration of treatment, further study is needed to better clarify the optimal use and indications of these medications, ideally through a double-blind randomized trial.

Abstract 

Various monotherapies exist for tinea capitis; however, their relative efficacies have never been determined using a statistical approach which compares treatments' efficacy simultaneously. The goal of this study was to determine the relative efficacy (mycologic and complete cure rates) of monotherapies for the treatment of tinea capitis. On October 5, 2019, searches were performed in Scopus, PubMed, EMBASE, MEDLINE (Ovid), and CINAHL; there were no date restrictions. For the main network meta-analysis, eligible studies were randomized trials that investigated the effect of tinea capitis monotherapies on subjects' mycological and complete cure rates. Network meta-analyses were conducted in accordance with the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for network meta-analyses. Mycological cure rate was the primary outcome; complete cure rate and adverse events were secondary outcomes. Twelve studies met the eligibility criteria for the main network; five systemic monotherapies were identified, griseofulvin, ketoconazole, terbinafine, itraconazole, and fluconazole. When the causative species was of the Microsporum genus, griseofulvin was most efficacious in terms of mycological cure (SUCRA = 66.1%) and complete cure (SUCRA = 80.6%). For tinea capitis caused by the Trichophyton species, terbinafine was the most efficacious in terms of both mycological and complete cure (SUCRA values of 75.2% and 78.2%, respectively). Risk of adverse events did not significantly differ across the interventions. Our results are congruent with those of previous pairwise meta-analyses; our findings also corroborate clinical experience and anecdotal evidence.

Pediatric Dermatology

A Network Meta-Analysis on the Efficacy and Safety of Monotherapies for Tinea Capitis, and an Assessment of Evidence Quality

Pediatr Dermatol 2020 Sep 08;[EPub Ahead of Print], AK Gupta, MA Bamimore, HJ Renaud, NH Shear, V Piguet 

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Changing Spectrum of Suspected Drugs of Epidermal Necrolysis

TAKE-HOME MESSAGE

• Using the WHO global database of individual case safety reports (VigiBase), the authors compared the most common culprit drugs in toxic epidermal necrolysis (TEN) over two periods: 1997–2001 and 2016–2020. Overall, 67 new drugs were newly associated with TEN in the second period. The most striking change was the rise of anti-cancer therapies, including mogamulizumab, pembrolizumab, vemurafenib, and cobimetinib. An additional 11 anti-epileptics, 2 NSAIDs, 11 anti-infectives, and 10 cardiovascular drugs were also seen.

• This study demonstrates the striking therapeutic progress seen over the past 2 decades and the increasing variety of drugs reported to cause TEN over this time. New antiepileptic drugs and anti-cancer therapies seem to carry a high risk and should be added to the spectrum of drugs known to commonly cause TEN.

– Margaret Hammond, MD

Written by

 

 

Lindy Fox MD

Using VigiBase, the WHO global database of individual case safety reports that houses over 20 million reports of adverse medication reactions, this group aimed to identify the medications most commonly associated with toxic epidermal necrolysis (TEN) and how the most frequent offenders might have changed over time. The authors divided the cases of TEN into 2 groups (labeled period 1 and 2): January 1, 1997– December 31, 2001, and January 1, 2016–January 15, 2020.

This study found that the most common causes of TEN in period 1 were allopurinol, aromatic anticonvulsants, lamotrigine, sulfonamides, and nevirapine. Importantly, the period 1 dates correspond to those of the EuroScar study, which, to date, serves as the gold standard of drugs implicated in severe cutaneous adverse reactions and can, in the current report, be thought of as validating the findings for period 1 of this study.

These same medications were also associated with TEN in period 2; but, of note, more recently introduced medications, also stood out. These included zonisamide, nimesulide (an NSAID withdrawn from the market in the United States and some European countries), coxibs, levetiracetam, and anticancer agents, including mogamalizumab, vemurafinib, and cobimetinib.

The strength of this report is its worldwide application. The significance of this report is 3-fold. First, it reinforces that drugs that are well-established culprits should still be considered so, and their ranks have not changed much over time. Secondly, physicians must be vigilant and consider newer agents as well, especially other classes of NSAIDs, anticonvulsants, and cancer therapies as potential causes of TEN. Finally, we are reminded that although some things stay the same, we must constantly reassess as medical therapeutics advance today and in the future.

Abstract 

Epidermal Necrolysis (EN), including Stevens Johnson syndrome and toxic epidermal necrolysis, is a rare life-threatening disease characterised by a diffuse skin and mucosal detachment.1From 70 to 90% of the cases are due to drugs. Prompt identification and discontinuation of the suspected drug(s) are vital.1,2 To assess the changing spectrum of drugs associated with EN, we performed a multicentre retrospective study using VigiBase, the WHO global database of individual case safety reports (Appendix).3

Journal of the American Academy of Dermatology

Changing Spectrum of Suspected Drugs of Epidermal Necrolysis: An WHO Pharmacovigilance Database Analysis From 1997 to 2020

J Am Acad Dermatol 2020 Nov 17;[EPub Ahead of Print], T Bettuzzi, S Ingen-Housz Oro, C Chinchilla Purtillo, L Le Cleach, P Maison, N de Prost, P Wolkenstein, B Lebrun-Vignes, E Sbidian 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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