Prurito genitales y perianal

Journal Scan / Research · January 24, 2021

Iatrogenic ACD in the Perianal and Genital Area

Contact Dermatitis

TAKE-HOME MESSAGE

• The authors evaluated data from patch-tested patients who presented with eczematous dermatitis to a tertiary referral center in Belgium from 2000 to 2018. Forty-four patients (30 women and 14 men; average age 51 years) were identified as having vulvar, penile and/or scrotal, or perianal and/or anal dermatitis, which was felt to be an iatrogenic cause of allergic contact dermatitis (ACD). Thirteen patients (30%) had a history of atopic dermatitis. The most common location for the iatrogenic ACD was vulvar skin in women (61% of women) and the perianal area in men (35% of men); however, 19 patients had more than one location involved. The single most identified allergens were lidocaine (n = 4) and budesonide (n = 3). Neomycin (n = 2), betamethasone dipropionate (n = 2), and hydrocortisone (n = 2) were also noted allergens. Wool alcohols (n = 5) were the most common vehicle component, and benzoic acid (n = 4) was the most common preservative agent noted.

• Topical corticosteroids and local anesthetics were the most common allergens identified in this study. It is important to keep in mind that the anogenital area can become sensitized to various topical medications typically used to treat skin conditions in this region.

– Alex Noble, MD

Written by

Kelly H. Tyler MD, FACOG, FAAD

Moisture, occlusion, friction, oh my!! Is anyone brave enough to meet and tackle the mighty anogenital dermatosis? Well, don't be a coward. Just heed the helpful advice of these authors who identified the most prevalent causative ingredients and products in Belgian patients with allergic contact dermatitis of the vulva, penis, scrotum, anus, and perianal areas. 

Not surprisingly, patients with dermatitis in this region will do anything to alleviate their symptoms. They not only apply prescribed medications such as topical steroids, but they often utilize a multitude of over-the-counter preparations such as topical anesthetics and personal care wipes. That being said, the results of this study are not surprising. Of the 9% of patients with anogenital dermatoses and positive patch tests, the most common relevant allergens were local anesthetics, corticosteroids (often combined with antifungals or antimicrobials), the vehicle component wood alcohol, and the preservative benzoic acid. 

As dermatologists, we are constantly on the lookout for over-the-counter products with fragrances and certain preservatives as causes of allergic contact dermatitis; however, because sensitization is more frequent in occluded and permeable anogenital skin, it is equally important to consider prescribed medications such as topical steroids. This study reminds us to keep iatrogenic causes of allergic contact dermatitis in mind for patients who don't respond as expected to appropriate treatment regimens.

Abstract

BACKGROUND

Allergic contact dermatitis (ACD) from topical medication often occurs in occluded areas, for example, with wound treatment, but also in certain body locations, such as the anogenital area.

OBJECTIVES

To investigate the demographics and specific lesion location of patients with ACD from topical drugs applied onto the (peri)anal/genital area, and to identify the respective causal topical pharmaceutical products and ingredients involved.

METHODS

From January 2000 to December 10, 2018, 532 patients were tested with the baseline series, sometimes with additional series, and the topical medication used along with the ingredients. The relevant data were extracted from our electronic databases developed in-house.

RESULTS

Forty-four patients (9%) out of 473 patients suffering from lesions in the (peri)anal/genital area had positive patch test results to topical drug preparations and/or their ingredients, sometimes in association with cosmetics for intimate hygiene. The most frequent sensitizing active principles were local anaesthetics and corticosteroids, while wool alcohols and to a minor extent benzoic acid were the most frequent culprits among the vehicle components and preservative agents, respectively.

CONCLUSIONS

The local conditions (eg, occlusion, sweating, moist) in the anogenital area may favour skin sensitization to topical medication used to treat various skin diseases.

Contact Dermatitis

Iatrogenic Allergic Contact Dermatitis in the (Peri)Anal and Genital Area

Contact Derm 2020 Dec 22;[EPub Ahead of Print], L Gilissen, I Schollaert, S Huygens, A Goossens

Ocular Comorbidities in Patients With Hidradenitis Suppurativa

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• A total of 31,400 patients with hidradenitis suppurativa (HS) and 51,517,730 control patients were included in this study to compare ocular comorbidities in these populations. The authors found that 4360 (13.89%) of the HS patients had ocular comorbidities, whereas 1,654,320 (3.2%) of the control patients had ocular comorbidities (P < .001). A statistically significant odds ratio (OR) was noted for anterior uveitis in patients with HS (OR, 1.41; P < .001), along with episcleritis (OR, 2.06; P < .001), keratitis (OR, 1.54; P < .001), and conjunctivitis (OR, 1.27; P < .001). There was no statistically significant increased OR in HS patients for posterior uveitis, chronic uveitis, scleritis, or interstitial keratitis.

• This case–control study shows a higher burden of ocular comorbidities in the HS cohort compared with the control population. The authors suggest asking HS patients about ocular history and symptoms during office visits to determine whether an ophthalmology referral is warranted.

– Alex Noble, MD

Abstract 

Hidradenitis suppurativa (HS) is a chronic systemic inflammatory disorder of the terminal follicular epithelium in the apocrine gland–bearing skin. Clinically, it is characterized by lesions, including comedones, papules, pustules, nodules, and fistulas, that are mainly concentrated in axillae, perineal, and submammary areas.1

Other autoimmune diseases are associated with ocular comorbidities; however, there is a paucity of data on ocular comorbidities in HS.1-4 In this article, we aim to quantify the burden of ocular comorbidities in patients with HS.

JAMA Dermatology

Burden of Ocular Comorbidities in Patients With Hidradenitis Suppurativa

JAMA Dermatol 2021 Jan 06;[EPub Ahead of Print], RRZ Conic, G Fabbrocini, C Marasca, NL Bragazzi, W Abdulla, M Adawi, G Damiani 

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Risk Factors for Surgical Site Infection After Minor Dermatologic Surgery Advances in skin & wound care

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• The authors of this meta-analysis combined data collected from 4 randomized controlled trials conducted in North Queensland, Australia, to ultimately include 3819 patients who underwent surgical excisions by their general practitioners over a 10-year period. Of these patients, 298 (7.8%) developed a surgical site infection (SSI). The authors found a significant risk associated with age (RR, 1.01; P = .008), with patients with SSIs being an average of 6 years older than those without SSIs (P = .004). Other risk factors were excisions from the upper limbs (RR, 3.03; P = .007), excisions from the lower limbs (RR, 3.99; P = .009), and flap/two-layer procedures (RR, 3.23).

• Further elucidation of these findings, especially for the independent risk factor for age, is needed. These risk factors could someday be incorporated into evidence–based guidelines for antibiotic prophylaxis for minor dermatologic surgery.

– Alex Noble, MD

Written by

 

 

Ashish C. Bhatia MD, FAAD

This study by our colleagues in Australia evaluated risk factors for surgical site infections (SSIs) after clean surgical excisions by primary care physicians in the outpatient setting. It was a secondary data analysis from four previous randomized controlled trials.

Only lesions removed by surgical excision were aggregated for inclusion. Excluded from the study were patients taking oral antibiotics or those who required antibiotic prophylaxis or who were on immunosuppressants. Repeat patients as well as patients with any sites beyond the first excision were excluded as well. SSIs were defined as local skin and soft tissue infections within 30 days of the procedure.

Infections occurred in 7.8% (298) of the 3819 excisions. Patients with infections were on average 6 years older than those without infections. The only diagnosis associated with a higher infection rate was skin cancer. Those who took medications of any kind had a statistically higher rate of SSI, although not with any specific medication. Current or ex-smokers had an increased incidence of SSI as well, but this was not statistically significant.

As far as location, the incidence of SSI was higher on the upper limbs (3.03 times) and lower limbs (3.99 times) compared with head and neck lesions. As far as lesion type, squamous cell carcinoma (12.8%), melanocytic lesions (8.5%), and basal cell carcinomas (8.4%) were those with the highest risk of SSI. Complex procedures (such as flaps or two-layer procedures) had a nearly three times higher risk of infection compared with elliptical excisions.

These findings are similar to those found in other such studies. Overall, outpatient surgical excisions have a low rate of SSIs. Being aware of these risk factors for SSIs can help those performing excisions have a higher index of suspicion for SSIs and even help them choose when to prophylactically prescribe topical or oral antibiotics.

Abstract

BACKGROUND

Surgical site infection (SSI) after dermatologic surgery is associated with poor outcomes including increased recovery time, poor cosmesis, and repeat visits to doctors. Prophylactic antibiotics are prescribed to reduce these adverse outcomes. Identifying risk factors for SSI will facilitate judicious antibiotic prophylaxis.

OBJECTIVE

To identify risk factors for SSI after minor dermatologic surgery.

METHODS

Individual patient data from four large randomized controlled trials were combined to increase statistical power. A total of 3,819 adult patients requiring minor skin procedures at a single facility were recruited over a 10-year period. The main outcome measure was SSI.

MAIN RESULTS

A total of 298 infections occurred, resulting in an overall incidence of 7.8% (95% confidence interval [CI], 5.8–9.6), although the incidence varied across the four studies (P = .042). Significant risk factors identified were age (relative risk [RR], 1.01; 95% CI, 1.001–1.020; P = .008), excisions from the upper limbs (RR, 3.03; 95% CI, 1.76–5.22; P = .007) or lower limbs (RR, 3.99; 95% CI, 1.93–8.23; P = .009), and flap/two-layer procedures (RR, 3.23; 95% CI, 1.79–5.85; P = .008). Histology of the excised lesion was not a significant independent risk factor for infection.

CONCLUSIONS

This study demonstrated that patients who were older, underwent complex excisions, or had excisions on an extremity were at higher risk of developing an SSI. An awareness of such risk factors will guide evidence-based and targeted antibiotic prophylaxis.

Advances in skin & wound care

Risk Factors for Surgical Site Infection After Minor Dermatologic Surgery

Adv Skin Wound Care 2021 Jan 01;34(1)43-48, M Delpachitra, C Heal, J Banks, D Charles, S Sriharan, P Buttner 

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Journal Scan / Case Study · January 15, 2021 Occipital Fibrosing Alopecia International Journal of Dermatology

TAKE-HOME MESSAGE

• The authors report a series of 14 cases of women with frontal fibrosing alopecia (FFA) limited to the occipital scalp, known as occipital fibrosing alopecia (OFA). The diagnosis of OFA was made clinically with the assistance of trichoscopy but was also confirmed with confocal microscopy (in 9 patients) and on pathology specimens. Interestingly, 9 patients presented for excessive hair shedding and were unaware of the occipital alopecia, which was diagnosed during clinical examination.

• Although occipital involvement with FFA has been previously reported in up to one-third of cases, it generally occurs along with the typical frontoparietal pattern. This represents the first series of patients in whom occipital involvement represented the only scalp involvement in FFA. The authors urge clinicians to be aware of this variation in presentation, as the rapid rise in FFA incidence may mean that this pattern will be seen more frequently in the future.

– Caroline K. Crabtree, MD

Written by

 

 

Paradi Mirmirani MD

Frontal fibrosing alopecia (FFA) was first described in 1994 in 6 post-menopausal women who presented with band-like scarring alopecia along the fontal hairline and loss of eyebrows. Since the initial description, this condition has been seen with increasing frequency worldwide.

Over the years, the clinical manifestations of FFA have expanded beyond just the frontal hairline and eyebrows. It is now recognized that hair loss may also occur along the temporal and occipital hairline (in up to 32% of cases), as well as the eyelashes, beard, and body. Facial papules are another manifestation that indicate inflammation of vellus hairs. This report of 14 women highlights the novel finding that occipital hair loss may be the first and only manifestation of scarring alopecia. 

The takeaway is for clinicians to have a high index of suspicion and be aware of this pattern in order to identify occipital fibrosing alopecia (OFA) in its early stages. A careful history along with trichoscopy and biopsy can be useful in distinguishing OFA from alopecia areata or traction alopecia. Although the paper does not delve into treatment, as the pathologic findings of OFA are the same as FFA, my approach to therapy would be the same.

Interestingly, the authors propose that depilation of the occipital hairline or styling practices may be a contributing factor in some women. This would fit with the prevailing hypothesis that the pathogenesis of FFA involves environmental insults that may lead to pilosebaceous unit dysfunction, collapse of immune privilege, and a lichenoid immune response in predisposed individuals. Thus, it may be helpful to ask about, and eliminate, any potential triggers.

Abstract 

Frontal fibrosing alopecia (FFA) classically results in a band‐like scarring alopecia involving the frontotemporal hairline and eyebrows.1-4 Diagnosis is confirmed by trichoscopy showing the absence of vellus hairs and peripilar casts and pathology showing scarring alopecia with a lichenoid infiltrate. Occipital involvement has been described in up to 32% of cases; however, it usually occurs in association with frontoparietal scarring.5 We report here a case series of 14 women with FFA limited to the occipital scalp.

International Journal of Dermatology

Occipital Fibrosing Alopecia

Int. J. Dermatol 2020 Dec 20;[EPub Ahead of Print], MA Martinez-Velasco, B Burroway, C Thompson, T Silyuk, A Tosti 

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Covid-19 y panza

Gut Microbiome Altered in COVID-19 Patients

By Kelly Young

Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD

The gut microbiome appears to be altered in patients with COVID-19, finds a study in Gut.

Researchers compared blood and stool samples of roughly 100 patients with COVID-19 in Hong Kong with samples from other people taken before the pandemic. Nearly half the COVID-19 patients had mild disease.

Several bacteria species were associated with disease severity after adjustment for antibiotic use. For instance, compared with controls, patients with COVID-19 had smaller populations of Faecalibacterium prausnitzii and Eubacterium rectale, which have known immunomodulatory potential. Even among those who'd recovered from COVID-19, the gut remained distinct from non-COVID patients a median of 6 days after testing negative.

The authors say that their results "suggest that gut microbiota composition is associated with the magnitude of immune response to COVID-19 and subsequent tissue damage and thus could play a role in regulating disease severity." They add, "Bolstering of beneficial gut species depleted in COVID-19 could serve as a novel avenue to mitigate severe disease, underscoring importance of managing patients' gut microbiota during and after COVID-19."

Gut article (Free abstract)

NEJM Journal Watch COVID-19 page (Free)

NEJM COVID-19 page (Free)

PCR para escabiosis

TCHING TO SEE IF POLYMERASE CHAIN REACTION MITE BE THE FUTURE OF DIAGNOSING SCABIES

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By Warren R. Heymann, MD
January 6, 2021
Vol. 3, No. 1

The scourge of scabies has been plaguing mankind for millennia. The causal relationship of the itch mite causing scabies was discovered by Bonomo and Cestoni in 1687, earning the distinction of being the first to discover a proven etiology for a human disease. (1)

Scabies is an infestation of the skin by the miteSarcoptes scabiei. Transmission is by direct skin-to-skin contact or indirectly through fomites. Symptoms typically appear 3 to 6 weeks after an infestation. In patients with a prior exposure to the mite, symptoms can appear as early as 24 hours post exposure. Lesions consist of pruritic erythematous papules with excoriations. They're usually symmetrical and involve the interdigital webs, the flexural aspect of wrists, the axillae, the peri-umbilical area, elbows, buttocks, feet, genital area in men, and the peri-areolar area in women (called the circle of Hebra). The entire integument, including the face and the scalp, can be involved in infants, the elderly, and immunosuppressed patients. The pathognomonic sign is the burrow, representing the tunnel that the female mite digs to lay her eggs. Crusted scabies (CS) is a severe form that occurs in immunosuppressed individuals such as patients with AIDS, manifesting with extensive hyperkeratosis, predominantly over the scalp and the extremities. (2)

JAAD 2008; 59: 530.

The brilliance of Bonomo and Cestoni is magnified by my own difficulty in identifying mites, eggs, or scybala within skin scrapings. Thinking of scabies in a differential diagnosis is easy (except in atypical cases!) — securing the diagnosis is another issue. 

A Delphi study of the International Alliance for the Control of Scabies (IACS) has proposed the following criteria for the diagnosis of scabies (the diagnosis may be rendered on any of the levels; for levels B and C, scabies should be diagnosed after ruling out other disorders in the differential diagnosis) (3):

• A: Confirmed scabies having at least one of: (A1) — mites, eggs, or feces on light microscopy of skin samples; (A2) — mites, eggs, or feces visualized on individual using a high-powered imaging device; (A3) — mite visualized on individual using dermoscopy.

• B: Clinical scabies having at least one of: (B1) — scabies burrows; (B2) — typical lesions affecting male genitalia; (B3) — typical lesions in a typical distribution and two history features (itch or close contact with pruritus or a typical case of scabies).

• C: Suspected scabies having one of: (C1) — typical lesions in a typical distribution and one history feature; (C2) — atypical lesions or atypical distribution and two history features.

I am almost embarrassed to admit it, but I would add a "D" category — pruritic patients with no obvious lesions or laboratory findings, for whom I prescribe either empiric permethrin or oral ivermectin, hoping that it would cure the patient. I'd be willing to wager that I'm not the only dermatologist who has resorted to this dermatological chicanery. 

Using mineral oil scrapings may be the gold standard for diagnosis, but it takes skill. One of my partners is particularly adept at finding mites, while I often struggle with these preparations. I feel more confident with dermoscopy, looking for the "delta" (the dark brown triangular structure corresponding to the mite's anterior at the end of the burrow). Others advocate the burrow ink test. (4,5)

In that context, I was most intrigued by the study by Delaunay et al who evaluated polymerase chain reaction (PCR) as a diagnostic method for scabies using nonexpert-dependent standardized sampling.

Dry swabs were systematically rubbed across the front of both wrists, the eight interdigital spaces, and on any suspected scabies lesions in all patients referred for scabies. A new PCR-based diagnostic test was run on the samples. All patients underwent clinical and dermoscopic examination. Scabies diagnosis was confirmed when dermoscopic examination was positive or the patient had typical clinical signs of scabies. A total of 164 patients were sampled; 87 had confirmed scabies and 77 did not. Of the 87 patients with proved scabies, 33 patients had positive scabies PCR, resulting in a 37.9% sensitivity and a 61.7% negative predictive value. None of the 77 patients ruled out for scabies had a positive PCR result. The authors concluded that scabies PCR is specific but has poor sensitivity. Regardless, this PCR diagnostic method based on nontraumatic standardized skin sampling is not expert-dependent and is reproducible. This diagnostic method may be relevant as a non-expert sentinel diagnosis tool in large clusters where a scabies outbreak is suspected, such as nursing homes or other long-term care facilities. (6)

As much as I enjoy my consultative practice, I would be fine without seeing patients sent from facilities with the only clinical information being "rule out scabies." I'm itching for the development of a PCR analysis with a higher sensitivity for scabies — that would be a boon for institutional administrators, practitioners, and patients alike. 

Point to Remember: Scabies may be the easiest or hardest diagnosis to render. Perhaps development of novel techniques such as PCR will simplify the process.

Our Expert's Viewpoint

Aileen Y. Chang, MD
Assistant Clinical Professor of Dermatology
University of California, San Francisco 
International Alliance for the Control of Scabies (www.controlscabies.org)

In this day and age, it is hard to believe that we still do not have a sensitive point-of-care test for scabies. While the diagnostic PCR method published by Delauney et al. will not help us with diagnosing individual patients with scabies, it may be a potential diagnostic method for settings where the diagnosis of one individual with scabies would result in treatment of many other individuals. These settings include long-term care facilities, prisons, and childcare facilities, among others. Most of these facilities do not have quick access to a scabies expert and when faced with a potential scabies outbreak, they need to make an informed decision on whether or not to treat. In a large facility, treatment for scabies is expensive and time-intensive, requires development of a structured implementation plan, and can have a significant toll on staff and facility residents. The decision to treat scabies in these settings cannot be taken lightly. This diagnostic method has a sensitivity of 90.8% with five samples and 99.1% with 10 samples. As the authors conclude, their findings need to be validated in the context of an outbreak and with adults, as most individuals in the study were children. Delauney et al.'s work is a step in the right direction. 

1. Arlian LG, Morgan MS. A review of Sarcoptes scabiei: Past, present, and future. Parasit Vectors 2017; 10: 297. 

2. Khalil S, Abbas O, Kibbi AG, Kurban M. Scabies in the age of increasing drug resistance. PLoS Negl Trop Dis 2017: 11 (11): e0005920

3. Engelman D. Fuller LC, Steer AC, International Alliance for the Control of Scabies Delphi panel. Consensus criteria for the diagnosis of scabies: A Delphi study of international experts. PLoS Negl Trop Dis 2018;12(5):e0006549

4. Tang J, You Z, Ran Y. Simple methods to enhance the diagnosis of scabies. J Am Acad Dermatol 2019; 80: e99-100.

5. Leung V, Miller M. Detection of scabies: A systematic review of diagnostic methods. Can J Infect Dis Med Microbiol 2011; 22: 143-146. 

6. Delaunay P, Hérissé AL, Hasseine L, Chiaverini C, et al. Scabies polymerase chain reaction with standard dry swab sampling: An easy tool for cluster diagnosis of human scabies. Br J Dermatol 2020; 182: 197-201. 

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Use of Hydroxychloroquine and Risk of Major Adverse Cardiovascular Events in Patients With Lupus Erythematosus

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• In this observational cohort study based on Danish registries, cardiovascular outcomes were compared between cutaneous or systemic lupus erythematosus (LE) patients (n=4587) treated with (n=2343, 51%) or without hydroxychloroquine. Based on Cox regression models, there was an inverse association between hydroxychloroquine use and risk of major adverse cardiovascular events (myocardial infarction, stroke, or cardiovascular-associated death). This was statistically significant for systemic LE (HR, 0.65) but not cutaneous LE (HR, 0.71).

• The public awareness of hydroxychloroquine has increased recently during the COVID-19 pandemic. These data demonstrating decreased risk of cardiovascular outcomes in systemic LE patients on hydroxychloroquine may help patients make an informed decision regarding their care.

– Margaret Hammond, MD

Abstract

BACKGROUND

Limited data suggest that hydroxychloroquine may affect risk of cardiovascular disease in patients with lupus erythematosus (LE).

OBJECTIVE

To investigate whether hydroxychloroquine treatment is associated with major adverse cardiovascular events (MACE) (myocardial infarction, ischemic stroke, or cardiovascular-associated death) in patients with cutaneous LE (CLE) or systemic LE (SLE).

METHODS

Based on the Danish nationwide registers, an observational cohort study was conducted including patients with first-time diagnosis of CLE or SLE (between 1997-2017). Cox regression models calculating hazard ratio (HR) analyzing the risk of MACE was performed comparing time on and off hydroxychloroquine (including never-user). The models were adjusted for age, sex, socio-economic status, concomitant treatment, and cardiovascular risk factors.

RESULTS

Among 4587 patients with LE, 51% (n=2343) were treated with HCQ during the study period. An inverse association between use of HCQ and MACE risk was observed among patients with SLE (adjusted HR 0.65; 95% CI 0.46-0.90) and patients with CLE (adjusted HR 0.71; 95% CI 0.42-1.19). Consistent results were found in sensitivity analyses including a case-time-control design.

LIMITATIONS

No information on disease activity/severity was available.

CONCLUSION

Our findings indicate an opportunity to reduce risk of cardiovascular events in patients with LE through use of hydroxychloroquine.

Journal of the American Academy of Dermatology

Use of Hydroxychloroquine and Risk of Major Adverse Cardiovascular Events in Patients With Lupus Erythematosus: A Danish Nationwide Cohort Study

J Am Acad Dermatol 2020 Dec 12;[EPub Ahead of Print], JH Haugaard, L Dreyer, MB Ottosen, G Gislason, K Kofoed, A Egeberg

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Vaccination Against HPV JAMA Dermatology

TAKE-HOME MESSAGE

• The CDC's Advisory Committee on Immunization Practices (ACIP) has issued an update on recommendations regarding HPV vaccination. Catch-up vaccination is now recommended for patients through age 26 years, and the ACIP recommends shared clinical decision-making between patients and their physicians for those aged 27 to 45 years who may benefit from vaccination.

• The ACIP stresses that the HPV vaccination is prophylactic and does not treat already acquired HPV infections. However, vaccination may provide protection against other HPV types not yet acquired. Of note, private insurance plans must cover ACIP–recommended vaccinations.

– Caitlyn T. Reed, MD

 Dermatology

Written by

 

 

Alfredo Siller Jr., MD

Written by

 

 

Joseph Jebain MD

Written by

 

 

Stephen K. Tyring MD, PhD

The Advisory Committee on Immunization Practices (ACIP) now recommends that both men and women aged 26 years or younger who did not receive their routine adolescent human papillomavirus (HPV) vaccine should receive it as a catch-up vaccine, and the clinician should utilize shared decision-making for those patients who are between 27 and 45 years of age. So, how do we as clinicians ultimately help the patient make that informed decision?

We can start the conversation by assuring our patients that the vaccine is safe and effective, but the vaccine is less effective for patients who have already been exposed to vaccine-type HPV. Given that the risk of being already exposed to vaccine-type HPV increases with age, we can then elaborate that the reason the vaccine is not automatically recommended for all adults up to age 45 years is largely because the potential benefit is not worth the cost on a large scale, although it may be worth it for them in particular to receive the vaccine.

The key and next step for evaluating this newly eligible age group of patients is to assess each individual patient's risk factors for acquiring a new HPV infection. If a patient has increased risk factors for acquiring a new HPV infection (eg, multiple sexual partners), then they would likely benefit from receiving the vaccine, and we can recommend they receive it. For patients at low risk for acquiring a new HPV infection, we can recommend that it may not be as beneficial for them to receive the HPV vaccine, unless they anticipate their risk may increase in the future.

Abstract 

CLINICAL QUESTION

Who should receive human papillomavirus (HPV) vaccination?

BOTTOM LINE

Catch-up vaccination is now recommended for all persons through age 26 years. For persons aged 27 through 45 years, clinicians and patients should now jointly decide whether HPV vaccination is appropriate. Routine HPV vaccination at age 11 or 12 years (or as early as age 9 years) continues to be recommended.

JAMA Dermatology

Vaccination Against Human Papillomavirus

JAMA Dermatol 2020 Aug 19;[EPub Ahead of Print], DH Marks, KA Katz 

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Staphylococcal Scalded Skin Syndrome Pediatric Dermatology

TAKE-HOME MESSAGE

• This retrospective review investigated children with staphylococcal scalded skin syndrome (SSSS; N=84) from a single institution. Skin erythema and exfoliation were present in all cases, and skin tenderness (88%), facial edema (75%), and perioral crusting (73%) were also frequently seen. Periorificial cultures most often identified Staphylococcus aureus. No difference in length of admission occurred when clindamycin was used for antitoxin coverage. However, skin debridement was a risk factor for a longer hospitalization stay (5.8 days vs 3.6; P = .03).

• New-onset erythema, exfoliation, and vesiculation should prompt consideration of SSSS. This study also suggests that surgical debridement of the skin in SSSS should be discouraged, as it may lengthen hospital stay. The role of clindamycin as an antitoxin therapy requires further investigation.

– Margaret Hammond, MD

 Dermatology

Written by

 

 

Joyce M. C. Teng MD, PhD

Staphylococcal scalded skin syndrome (SSSS) is one of the emergent dermatologic skin disorders in young children. This retrospective chart review by Liy-Wong et al highlighted dermatologic findings of SSSS characterized by intense tender erythema and skin fragility on the central face and flexural area. Interestingly, most of the children in this cohort did not have preexisting skin conditions. Culture from periorificial as well as nasopharyngeal areas were high-yield. With proper supportive care and medical treatment guided by culture sensitivity, most of the children only required a short hospital stay. Surgical debridement, on the other hand, prolonged hospitalization. Surprisingly, clindamycin resistance is quite common among patients in this study. Therefore, it is important to take into consideration geographical differences when choosing antibiotic therapy.

Abstract

BACKGROUND

Staphylococcal scalded skin syndrome (SSSS) is a toxin-mediated, blistering skin disorder that mainly affects infants and children. There is limited literature regarding pediatric SSSS. The purpose of this study was to describe the epidemiology, clinical features, and management of pediatric SSSS.

METHODS

Retrospective cohort study of pediatric patients with a clinical diagnosis of SSSS seen at the Hospital for Sick Children in Toronto, Ontario, Canada, from January 1994 to March 2016.

RESULTS

We included 84 patients with a clinical diagnosis of SSSS; 49/84 (58%) were male. Mean age of diagnosis was 3.1 ± 2.4 years. All patients presented with erythema and exfoliation, while 64/84 (76%) presented with vesicles/ bullae. Skin tenderness was the most common symptom, present in 68/84 (81%) subjects. Staphylococcus aureus was more commonly isolated from periorificial cultures than from bullae. Mean hospitalization was 4.7 ± 2.3 days. No difference was found in admission duration between children receiving clindamycin and those that did not (3.6 ± 2.2 vs 3.9 ± 2.34 days, P = .63). Skin debridement was the only risk factor leading to more complications and prolonged hospitalization (P = .03). Severe complications were seen in 4 (5%) cases, and no fatalities were observed.

CONCLUSIONS

Healthcare providers should be aware of SSSS and consider it in the differential diagnosis of infants and children with new onset erythema, exfoliation, and/or vesiculation. Suspected culprit pathogens were more often obtained from periorificial swabs; however, these isolates were not tested for exfoliative toxin to confirm causality. Antibiotic treatment should be guided by sensitivity testing. Addition of clindamycin as an anti-toxin agent had no effect on the duration of hospitalization, and this should be further investigated. Surgical debridement of the skin in patients with SSSS should be discouraged.

Pediatric Dermatology

Staphylococcal Scalded Skin Syndrome: An Epidemiological and Clinical Review of 84 Cases

Pediatr Dermatol 2020 Dec 01;[EPub Ahead of Print], C Liy-Wong, E Pope, M Weinstein, I Lara-Corrales 

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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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