Dupilumab for Lichen Planus Cutaneous Medicine for the Practitioner
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In this case report, a 52-year-old man with biopsy-proven lichen planus (LP) was treated off-label with dupilumab after failing halobetasol ointment, tacrolimus ointment, oral prednisone, and acitretin. Itch intensity improved from 9/10 prior to therapy to 1/10 after 3 months of treatment with dupilumab.
While LP is thought to be regulated primarily by the TH1 pathway, this patient's response to dupilumab suggests that there could be some underlying TH2-mediated inflammation. Further studies with additional patients are needed to determine the extent of TH2 involvement and utility of dupilumab for treating refractory LP.
Lichen planus (LP) is an inflammatory mucocutaneous disorder that primarily affects adults aged 30 to 60 years.1 It can present across various regions such as the skin, scalp, oral cavity, genitalia, nails, and hair. It classically presents with pruritic, purple, polygonal papules or plaques. The proposed pathogenesis of this condition involves autoimmune destruction of epidermal basal keratinocytes.2Management involves a stepwise approach, beginning with topical therapies such as corticosteroids and phototherapy and proceeding to systemic therapy including oral corticosteroids and retinoids. Additional medications with reported positive results include immunomodulators such as cyclosporine, tacrolimus, and mycophenolate mofetil.2-4Dupilumab is a biologic immunomodulator and antagonist to the IL-4Rα on helper T cells (TH1). Although indicated for the treatment of moderate to severe atopic dermatitis, this medication's immunomodulatory properties have been shown to aid various inflammatory cutaneous conditions, including prurigo nodularis.5-9 We present a case of dupilumab therapy for treatment-refractory LP.
Cutaneous Medicine for the Practitioner
Dupilumab for the Treatment of Lichen Planus
Cutis 2021 Apr 01;107(4)E8-E10, BT Pousti, A Jin, L Sklovar, KT Savage, LL Zhai, NK Mollanazar, CR Heath
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Checkpoint Inhibitor Skin Side Effects More Common in Women
Women had about a twofold higher risk than men of developing dermatologic adverse events while taking immune checkpoint inhibitors for metastatic melanoma in a review of 235 patients at Dana Farber Cancer Center, Boston, Massachusetts.
Overall, 62.4% of the 93 women in the review and 48.6% of the 142 men experienced confirmed skin reactions, for an odds ratio (OR) of 2.11 for women compared with men (P = .01).
"Clinicians should consider these results in counseling female patients regarding an elevated risk of dermatologic adverse events" when taking checkpoint inhibitors, said investigators led by Harvard University medical student Jordan Said, who presented the results at the American Academy of Dermatology Virtual Meeting Experience.
Autoimmune-like adverse events are common with checkpoint inhibitors. Dermatologic side effects occur in about half of people receiving monotherapy and more than that among patients receiving combination therapy.
Skin reactions can include psoriasiform dermatitis, lichenoid reactions, vitiligo, and bullous pemphigoid and may require hospitalization and prolonged steroid treatment.
Not much is known about risk factors for these reactions. A higher incidence among women has been previously reported. A 2019 study found a higher risk for pneumonitis and endocrinopathy, including hypophysitis, among women who underwent treatment for non–small cell lung cancer or metastatic melanoma.
The 2019 study found that the risk was higher among premenopausal women than postmenopausal women, which led some to suggest that estrogen may play a role.
The results of the Dana Farber review argue against that notion. In their review, the investigators found that the risk was similarly elevated among the 27 premenopausal women (OR, 1.97; P = .40) and the 66 postmenopausal women (OR, 2.17, P = .05). In the study, women who were aged 52 years or older at the start of treatment were considered to be postmenopausal.
"This suggests that factors beyond sex hormones are likely contributory" to the difference in risk between men and women. It's known that women are at higher risk for autoimmune disease overall, which might be related to the increased odds of autoimmune-like reactions, and it may be that sex-related differences in innate and adoptive immunity are at work, Said noted.
When asked for comment, Douglas Johnson, MD, an assistant professor of hematology/oncology at Vanderbilt University, Nashville, Tennessee, said that although some studies have reported a greater risk for side effects among women, others have not. "Additional research is needed to determine the interactions between sex and effects of immune checkpoint inhibitors, as well as many other possible triggers of immune-related adverse events."
"Continued work in this area will be so important to help determine how to best counsel women and to ensure early recognition and intervention for dermatologic side effects," said Bernice Kwong, MD, director of the Supportive Dermato-Oncology Program at Stanford University, Stanford, California.
The patients in the review were treated from 2011 to 2016 and underwent at least monthly evaluations by their medical team. They were taking either nivolumab, pembrolizumab, or ipilimumab or a nivolumab/ipilimumab combination.
The median age of the men in the study was 65 years; the median age of women was 60 years. Almost 98% of the participants were White. The majority received one to three infusions, most commonly with pembrolizumab monotherapy.
No funding for the study was reported. Said has disclosed no relevant financial relationships.
American Academy of Dermatology Virtual Meeting Experience (AAD VMX) 2021.
M. Alexander Otto is a physician assistant and award-winning medical journalist who has previously worked for several major news outlets, including McClatchy and Bloomberg BNA. He is a former MIT Knight Science Journalism fellow. Email: aotto@mdedge.com.
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Tofacitinib: Small Study Shows Big Cutaneous Sarcoidosis Response
Researchers are reporting impressive results in a small, open-label trial of the JAK inhibitor tofacitinib in cutaneous sarcoidosis: 6 of 10 patients improved so much that they reached a disease activity level of zero, and all patients improved by an average of 83% via a scoring system.
Dr William Damsky
"Not only did patients get better, but they were in many cases able to come off their baseline immunosuppressive regimen, including prednisone and methotrexate. They'd get off prednisone entirely or, in some cases, decrease it substantially," study investigator William Damsky, MD, PhD, reported at the American Academy of Dermatology Virtual Meeting Experience.
Sarcoidosis is a common disease that affects an estimated 1 in 25 Black women and is believed to contribute to the deaths of about 4,000 people in the United States each year, noted Damsky of the department of dermatology, Yale University, New Haven, Conn. One famous patient is comedian Bernie Mac, who died from the condition in 2008.
"Approximately one third of patients have cutaneous involvement," Damsky said, and skin may be the only manifestation of the disease. There is no Food and Drug Administration-approved therapy for cutaneous sarcoidosis, he added. Prednisone, the first-line therapy in skin manifestations, is approved only for pulmonary sarcoidosis.
"Oftentimes, there's an attempt to transition either partially or fully to other therapies, including methotrexate and TNF-alpha blockers. But there's been mixed success in doing that," he said. This is not always possible, "so a lot of patients end up on prednisone."
Earlier, a team at Yale prescribed 5 mg tofacitinib (Xeljanz) for several patients with severe cutaneous sarcoidosis and saw impressive results, Damsky said, including a patient with pulmonary sarcoidosis that also improved. He noted that there are case reports in the medical literature with similar findings.
Those positive results inspired the new study. Researchers recruited 10 patients with cutaneous sarcoidosis (9 with internal organ involvement) with a Cutaneous Sarcoidosis Activity and Morphology Instrument (CSAMI) score of 10 or higher. Nine patients were in their 50s, one was aged 63 years, and five were men. Skin colors of the patients ranged from Fitzpatrick skin types I to VI, and all had been taking at least two medications, typically methotrexate and prednisone.
The patients received 5 mg of tofacitinib twice a day for 6 months. "Everyone got better during the study, and six patients had a complete response, which we defined as a CSAMI score of zero activity," Damsky said. "It's really quite remarkable to see that." Overall, the patients saw an 83% improvement in CSAMI scores.
In regard to safety, "all patients completed the study," he said. "Tofacitinib was well tolerated, and there were no serious adverse effects or events."
Tofacitinib is approved for treating rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, and polyarticular course juvenile idiopathic arthritis.
A month's supply of twice-daily 5 mg tofacitinib pills would cost $4,900-$5,100 with free coupons, according to information accessed on April 24, 2021, on GoodRx.com. Generics are not available.
In an interview, Sotonye Imadojemu, MD, of the department of dermatology, Brigham and Women's Hospital, Boston, praised the study, and said "tofacitinib is a reasonable treatment for treatment-refractory or extensive cutaneous sarcoidosis," although it will be helpful to get results from randomized-controlled trials.
She cautioned that the drug "is a powerful immunosuppressant, so the risk of infection must be discussed with patients before prescribing. Screening for chronic infections such as viral hepatitis, tuberculosis, and HIV should be completed prior to treatment initiation. Blood counts, liver function, and lipid panels should be regularly monitored. The vaccines necessary for those who are immunosuppressed should be administered as able, and age-appropriate cancer screening must be kept up to date."
The study was funded by Pfizer, the Dermatology Foundation, and the Yale Department of Dermatology. Damsky disclosed research support (Pfizer), consulting fees (Eli Lilly, Pfizer, TWi Biotechnology), and licensing fees (EMD Millipore/MillporeSigma). Imadojemu has no disclosures.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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Dermatologists cautioned colleagues to be aware of special hazards facing the LGBTQ community: A higher risk of skin cancer among gay men, possibly because of excess ultraviolet exposure, and acnein transgender people, who are especially vulnerable to acne because of hormone therapy.
In regard to skin cancer, he said, "there seems to be consistently higher rates of skin cancer and certain preventable risk behaviors like indoor tanning among sexual minority men."
Mansh, codirector of the high-risk nonmelanoma skin cancer clinic at the University of Minnesota, highlighted a report, published in JAMA Dermatology in 2020, that used 2014-2018 U.S. survey data of over 870,000 adults to look at the association between sexual orientation and lifetime prevalence of skin cancer. The investigators found that gay and bisexual men had a higher lifetime prevalence of skin cancer compared with heterosexual men (adjusted odds ratio [aOR], 1.25; 95% confidence interval, 1.03-1.50; P = .02; and aOR, 1.46; 95% CI, 1.01-2.10; P = .04; for gay and bisexual men, respectively).
When compared with heterosexual women, risk among bisexual women was lower (aOR, 0.75; 95% CI, 0.60-0.95; P = .02), but not among lesbian women (aOR, 1.01; 95% CI, 0.77-1.33; P = .95, respectively).
Other studies have reached similar conclusions, Mansh said, although there's been fairly little research in this area. What could explain these differences? Factors such as smoking, age, and alcohol use affect skin cancer risk, he said, but these studies control for those variables. Instead, he noted, it's useful to look at studies of ultraviolet exposure.
For example, he highlighted a studypublished in JAMA Dermatology in 2015, which examined 12-month indoor-tanning rates and skin cancer prevalence by sexual orientation, using data from California and national health interview surveys. The study found that compared with heterosexual men, "sexual minority men had higher rates of indoor tanning by roughly three- to sixfold," said Mansh, the lead author. "And this was among respondents who were adults over age 18. People between the ages of 18 and 34 years are important from a skin cancer perspective as it's well established that exposure to tanning beds at a younger age is most associated with an increased risk of skin cancer."
Sexual minority men were also significantly more likely to report having skin cancer, compared with heterosexual men.
In the study, sexual minority women had about half the odds of engaging in indoor tanning compared with heterosexual women, and were less likely to report having been diagnosed with nonmelanoma skin cancer, he added.
Other studies suggest that gay and bisexual men live in neighborhoods with more indoor tanning salons and that they may spend more time in the sun outside too, he said. Some research suggests motivations for tanning include social pressure and the desire to improve appearance, he added.
Overall, "we may be able to use these data to add more appropriate screening and recommendations for these patients, which are sorely lacking in dermatology," and to design targeted behavioral interventions, said Mansh, codirector of the dermatology gender care clinic at the University of Minnesota.
Dr Jon Klint Peebles
What can dermatologists do now? In an interview, dermatologist Jon Klint Peebles, MD, of the mid-Atlantic Permanente Medical Group, in Largo, Md., suggested that colleagues ask patients questions about indoor tanning frequency, the motivations for tanning, exposure to outdoor ultraviolet radiation, sunscreenuse, and use of photoprotective clothing.
Hormone Therapy and Acne
In a related presentation at the meeting, Howa Yeung, MD, of the department of dermatology, Emory University, Atlanta, said that in transgender people, estrogen therapy can actually reduce sebum production and often improves acne, while testosterone therapy frequently has the opposite effect.
Dr Howa Yeung
"We've seen some pretty tough cases of acne in transmasculine patients in my practice," said Yeung, who highlighted a recently published study that tracked 988 transgender patients in Boston who underwent testosterone therapy. Nearly a third were diagnosed with acne, compared with 6% prior to hormone therapy, and those at the highest risk were aged 18-21.
The prevalence of acne was 25% 2 years after initiation of hormone therapy. "Acne remains a very common issue and not just at the beginning of treatment," he said.
In 2020, Yeung and colleagues reportedthe results of a survey of 696 transgender patients in California and Georgia; most were treated with hormone therapy. They found that 14% of transmasculine patients reported currently having moderate to severe acne diagnosed by a physician, compared with 1% of transfeminine patients.
Yeung noted that another survey of transmasculine persons who had received testosterone found that those who had moderate to severe acne were more likely to suffer from depression and anxiety than were those who had never had acne (aOR, 2.4; 95% CI, 1.1-5.4; P = .001, for depression; and aOR, 2.7; 95% CI, 1.2-6.3; P = .002, for anxiety).
Acne treatments in transmasculine patients are complicated by the fact that hormone treatments for acne can have feminizing effects, Yeung said, adding that it's not clear how clascoterone, a new anti-androgen topical therapy for acne, will affect them. For now, many patients will require isotretinoin for treating acne.
Peebles cautioned that with isotretinoin, "we still do not yet have solid data on the optimal dosing or duration in the context of testosterone-induced acne, as well as what individual factors may be predictive of treatment success or failure. It is also important to be aware of any planned surgical procedures, whether as part of gender-affirming care or otherwise, given that some surgeons may view isotretinoin as a barrier for some procedures, despite limited data to support this."
Both Peebles and Yeung noted that the iPledge risk management program for isotretinoin patients who may become pregnant is problematic. "A trans man who is assigned female at birth and identifies as a man and has a uterus and ovaries must be registered as a female with reproductive potential," Yeung said.
"While the program remains inherently discriminatory, it is important to have an honest conversation with patients about these issues in a sensitive way," Peebles noted. "Luckily, there is substantial momentum building around modifying iPLEDGE to become more inclusive. While the mechanics are complicated and involve a variety of entities and advocacy initiatives, we are optimistic that major changes are in the pipeline."
Mansh, Yeung, and Peebles reported no disclosures.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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Emollient Data Discouraging for Atopic Dermatitis Prevention
Emollients don't prevent atopic dermatitis(AD), but they might have untapped potential as treatment, two new studies suggest.
The results of a prevention study, in which parents slathered their babies with petrolatum, are particularly discouraging. Earlier studies had led researchers to hope this approach could stop not only AD but perhaps other related allergic conditions.
Instead, the babies who were in the petrolatum group in the Barrier Enhancement for Eczema Prevention Study (BEEP) were more likely to develop food allergies as well as skin infections than babies who received standard skin care.
"So, the parents of newborn babies should not be advised to use emollients to prevent eczema developing," said Joanne Chalmers, PhD, a senior research fellow at the Center of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom.
In another study, an experimental nanofiber dressing impregnated with palmarosa oil significantly improved symptoms of the condition.
Both studies were presented at the International Society of Atopic Dermatitis (ISAD) 2021 Annual Meeting. The BEEP results were also published in The Lancet.
A "sizeable body of evidence" supports the use of emollients for the treatment of mild AD and flares, Chalmers said. Skin barrier dysfunction precedes the development of AD. Mutations in the filaggrin gene are associated with skin barrier dysfunction and the development of AD. There is no cure, and treatments are burdensome.
On the basis of these data, Chalmers and her colleagues thought applying emollients to babies was worth a try. They approached families with newborn babies who were at high risk of developing AD because they had at least one first-degree relative with AD, allergic rhinitis, or asthma.
They assigned 693 infants to the emollient group and 701 to the control group. They gave the families in the emollient group a choice of Doublebase Gel (Dermal Laboratories) or Diprobase Cream (Bayer). Both products contain petrolatum and have no ingredients known to have harmful effects. These products are commonly used in the UK National Health Service.
The researchers asked the families to apply the product they chose to their baby at least once daily. The products were to be applied to the whole body (excluding the scalp) until the baby reached age 1 year. They advised the families to apply emollient after every bath, even if they had already applied it earlier that day.
The control group was given standard advice: avoid harsh soaps and the use emollients unless the baby developed eczema.
Most families in the emollient group adhered to the regimen. Adherence dropped only slightly, from 88% at 3 months to 74% at 12 months, among those for whom complete questionnaire data were available.
This approach did not reduce risk. At 2 years, 23% of the babies in the emollient group and 25% in the control group developed AD, a difference that was not statistically significant (adjusted relative risk [aRR], 0.95; 95% CI, 0.78 – 1,16; P = .61]).
Of the 585 children in the emollient group, 15% developed skin infections during the first year, vs 11% of 589 babies in the control group. This was statistically significant. In the emollient group, the mean number of skin infections per child was 0.23, vs 0.15 in the control group (aRR, 1.55; 95% CI, 1.15 – 2.09).
Furthermore, at age 2 years, food allergies to milk, egg, or peanut were confirmed in 7% of the emollient group and in 5% of the control group. The difference was not statistically significant (aRR, 1.47; 95% CI; 0.93 – 2.33), but it was concerning, the researchers said.
They were surprised because the results contradicted the outcomes of their own pilot studies. They wondered whether newer emollients with better skin barrier properties might work better. They also mused about the possibility of a "complex intervention" involving such measures as low pH cleansers, infrequent washing, or softened water.
They emphasized that nothing about their findings should discourage the use of emollients as treatments for AD.
In a separate study of possible treatments, Seungsin Lee, PhD, and colleagues at Yonsei University, Seoul, South Korea, tried a new take on the traditional approach of wet wrapping.
They put palmarosa oil in nanofibrous bandages made with polyvinyl alcohol. Electrospun nanofibrous membranes have a microporous structure, a high specific surface area, and high porosity. These give the membranes flexibility and breathability, and they protect from external bacteria.
To test this combination as a treatment for AD, the researchers randomly assigned 30 patients with mild or moderate AD into three groups of 10 patients each. One group wore the nanofiber bandages with palmarosa oil, one wore dry bandages without palmarosa oil, and the third wore dry cotton gauze.
The patients wrapped arms or legs with the bandages and secured them with paper tape for 8 hours a night for 14 days. The Investigator's Global Assessment (IGA) was used to assess effectiveness. Among both groups that wore the nanofiber bandages (one with palmarosa oil and one without), IGA scores regarding dermatitis symptoms declined from 2.2 to 1.7. The difference was statistically significant (P = .025).
IGA scores in the group wearing the cotton bandages increased from 1.7 to 1.9, which was not a significant change. Differences among the three groups were not significant, either.
Using the Scoring Atopic Dermatitis (SCORAD) scale, the findings were similar.
For the next 14 days, the researchers gave everyone in the study the nanofiber bandages. Symptoms improved significantly for all three groups.
Using the nanofiber bandages allowed the patients to reduce their use of steroid ointments. In surveys, the patients said they experienced less itching but that the bandages themselves were uncomfortable.
"In the future work, it would be useful to compare the atopic dermatitis relief effect of different types of essential oils known to be effective against atopic dermatitis when they are incorporated into nanofibrous membranes," Lee said in an email. "In addition, further study is needed to improve the wearing comfort."
Lee and Chalmers have disclosed no relevant financial relationships.
International Society of Atopic Dermatitis (ISAD) 2021 Annual Meeting: Abstract PT9 and oral session. Presented April 29, 2021.
Laird Harrison writes about science, health and culture. His work has appeared in magazines, newspapers , and online publications. He is at work on a novel about alternate realities in physics. Harrison has taught writing at San Francisco State University, UC Berkeley Extension and the Writers Grotto. Visit him at lairdharrison.com or follow him on Twitter: @LairdH.
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Main Causes of Food-Induced Anaphylaxis Identified
From Medscape
Allergen disclosure legislation accurately covers the main triggers ofanaphylaxisin different countries, according to a systematic review of food anaphylaxis studies.
This "first global snapshot" of regional differences in food anaphylaxis fills "a significant evidence gap" in ensuring safe global trade of food, said the study's senior author Professor Paul Turner, from the National Heart & Lung Institute, Imperial College London, United Kingdom.
"We undertook this review and analysis to inform the current Codex [Alimentarius] review by the Food and Agricultural Organization of the United Nations (FAO) and World Health Organization," Professor Turner told Medscape Medical News.
The Codex, a set of international food standards, includes labeling requirements for eight food groups (wheat, crustacea, egg, fish, peanut, soybean, milk, and tree nut) that are generally considered to cause over 90% of food-induced allergic reactions in most regions.
But these food groups "were decided over a decade ago, often on the basis of very limited data," he explained.
The systematic review will inform the Codex Committee on Food Labelling as it updates allergen labeling guidelines around the world.
The review included 65 studies that provided details of specific triggers for food anaphylaxis in 41 countries among patients who either presented to a medical facility or were entered in a central registry.
The studies were from all six regions of the world as defined by the FAO: Western Europe, Central and Eastern Europe, Asia, Africa, the Mediterranean and the Middle East, and the Americas.
Data from the studies showed "significant inter-regional and intra-regional differences" in the most common triggers for food anaphylaxis. Some allergens are a common cause of anaphylaxis in multiple regions, while others are a common trigger in only some.
Overall, the study found that cow's milk, shellfish/crustacea, peanut, and tree nuts are important causes of anaphylaxis globally, but while peanut and tree nuts are a common cause of anaphylaxis in the European, North American, and Southwest Pacific regions, these are less important causes of anaphylaxis in Asia. Additionally, while wheat is generally less common as a cause of anaphylaxis, it accounts for a disproportionate number of anaphylaxis presentations in China.
"It is reassuring that in general there was good agreement between local legislative requirements for allergen disclosure and the most common allergens causing anaphylaxis in that locality," note the study authors, adding that "these data support the use of location-specific epidemiology to guide both public health policy and research" on food allergy.
"The study is the first to apply the robust systematic review approach to understand the types of foods that trigger anaphylaxis in different regions around the world, and whether local/regional food labeling laws cover the most common causes of serious allergic reactions in each region," Mimi Tang, MD, PhD, commented to Medscape Medical News.She was not involved in the research. "It's important because we should always aim for the highest quality evidence to base policy decisions on."
Tang, who is from the University of Melbourne and the Murdoch Children's Research Institute, Australia, said the findings are in line with previous reports and reviews of food allergy and anaphylaxis, confirming that "in all regions, the Codex covers the major allergens, which is reassuring."
"We know that the foods causing allergy differ by region, with crustacea and fish being more common in Asia than, say, in the US, and peanut being prevalent in the US," she said. "Interestingly, soy was not a major cause of food anaphylaxis in any region, which raises the question of whether its inclusion in the list of allergens might warrant review."
The research was funded by a UK Medical Research Council Clinician Scientist Award to Turner, who is supported through the National Institute for Health Research Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London. He also reported grants from the UK Food Standards Agency and JM Charitable Foundation during the conduct of the study. He has received personal fees from the UK Food Standards Agency, Aimmune Therapeutics, AllerGenis, and ILSI Europe outside the submitted work. The other authors and Tang have declared no competing interests.
J Allergy Clin Immunol. Published online April 30, 2021. Full text
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Más de dos tercios del público ahora pueden tener dermatitis en las manos debido al estricto lavado de manos y al uso de desinfectantes a base de alcohol durante la pandemia de COVID-19.
El impacto dermatológico de COVID-19 es un tema candente en el Simposio de primavera de 2021 de EADV. Una nueva investigación presentada hoy destaca el efecto que la estricta higiene de las manos durante la pandemia ha tenido en la salud de la piel de las manos.
Investigadores del Father Muller Medical College, India, analizaron la pérdida de agua transepidérmica (TEWL, un parámetro esencial para medir la función de la barrera cutánea) de 582 personas (291 profesionales de la salud (HCP) y 291 individuos sanos de la población general).
Los resultados indicaron que la dermatitis de la mano ahora estaba presente entre el 92,6% de los profesionales sanitarios y el 68,7% de la población general, a pesar de que solo ~ 3% de los profesionales sanitarios y el 2,4% del público en general en el estudio habían informado antecedentes de dermatitis de la mano (obtenido a través de historia e historia autoinformada).
También se observó una TEWL (piel seca) más alta en mujeres (65,4 g / m2h) y profesionales de cuidados intensivos (58,2 g / m2h), que se asoció con una alta frecuencia de lavado de manos y uso de desinfectantes para manos a base de alcohol.
Tanto los profesionales sanitarios como los participantes del público en general en este estudio afirmaron que la irritación y sequedad de la piel era la principal barrera para la práctica constante de la higiene de manos (según lo informado por el 72,1% de los profesionales sanitarios y el 50,8% de los voluntarios sanos).
La Dra. Monisha Madhumita, Father Muller Medical College, India, explica: "Esta investigación demuestra verdaderamente el impacto del mayor lavado de manos y la absorción de frotaciones a base de alcohol en la salud de la piel de las manos de los profesionales sanitarios y el público en general. Además, ahora sabemos que el uso de TEWL Medir la función de la barrera cutánea puede ayudarnos a comparar la eficacia de varias medidas de barrera protectora y descubrir modificaciones adecuadas de las prácticas y productos de higiene de manos para ayudar a prevenir el eccema de manos. Encontrar modificaciones adecuadas en las prácticas y productos que puedan aumentar la accesibilidad de una higiene adecuada de las manos es algo de vital importancia para muchos en nuestra comunidad ".
Marie-Aleth Richard, miembro de la junta de EADV y profesora en el Hospital Universitario de La Timone, Marsella, agrega: "Esta investigación muestra que ahora hay una epidemia de enfermedades de la piel dentro de la pandemia de COVID-19. Es prometedor que se reconozca este problema , y estoy emocionado de ver cómo la comunidad dermatológica busca posibles soluciones a este problema".
Madhumita, M.,, Bhat, R., Challenges in curbing SARS-CoV2 - Overzealous Hand Hygiene and the Overlooked Skin Damage. Abstract submitted to EADV Spring Symposium 2021. Data on file.
Topical Corticosteroid Use for Atopic Dermatitis in the Pediatric Emergency Department Pediatric Dermatology
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In this single-institution retrospective review from 2012 to 2017, the pediatric emergency department reported 167 visits for atopic dermatitis. Topical corticosteroids (TCS) were not prescribed in 37.7% of visits while over-the-counter hydrocortisone was recommended in 27.5% of visits. Dermatology consultation was performed in 14 visits. Dermatology consultation was associated with higher rates of TCS prescription, higher class of TCS prescribed, higher rates of systemic antibiotic use, and higher recommendation rates for emollient use.
Children who present to the emergency department for atopic dermatitis have low rates of prescription for appropriate strength TCS, and this may represent an opportunity to improve the management of this population.
Pediatric emergency departments (ED) are used with increased frequency for the care of atopic dermatitis (AD). These authors report 167 ED visits for pediatric patients over a 5-year period. Most patients (70%) had Medicaid insurance and were given over-the-counter or no topical corticosteroids (TCS), 66%. Dermatology consultation resulted in significantly higher rates of TCS prescribing and a higher potency of the TCS given.
This study highlights an important knowledge gap. ED providers are less likely to provide the needed prescriptions and follow the standard of care that is greatly needed by this population. In my experience, primary and ED providers also often misjudge the quantity of medication needed or designate quantity as "one tube," translating into a pharmacy dispensing 15 grams. I applaud the authors and am personally motivated to develop an ED care pathway for our institution.
Abstract
BACKGROUND/OBJECTIVES
To investigate the evaluation and management of atopic dermatitis (AD) in the pediatric emergency department (PED).
METHODS
This retrospective chart review was performed at the PED of a single institution and examined data from 2012 to 2017. Of 335 visits from patients 18 years and younger coded for AD, 167 visits with documented findings that supported a diagnosis of AD according to guidelines from the American Academy of Dermatology were included.
RESULTS
The mean age of presentation was 6.3 years (standard deviation [SD]: 5.9). Of 11 patients with multiple visits, the mean between-visit interval was 31 days (SD: 41). Topical corticosteroids (TCSs) were not prescribed or recommended in 63/167 visits. In an additional 46/167 visits, over-the-counter topical hydrocortisone was recommended. Of prescribed TCS, the mean TCS class was 5.5 (SD: 1.9). 61/104 recommended or prescribed TCSs were weak (Class 7), the most likely used class (P < .001). Dermatology consultation was requested in 14/167 visits and was associated with higher rates of TCS prescriptions (13/14 vs 91/153, P = .018), a higher mean class of TCS prescribed (3.1 vs 5.9, P < .001), higher prescription rates of systemic antibiotics (8/14 vs 10/153, P < .001), and higher recommendation rates for emollient usage (10/14 vs 46/153, P = .005).
CONCLUSIONS
Most patients presenting to the PED for AD were either not prescribed a TCS or were prescribed a weak TCS, often one that is over-the-counter. While there may be a variety of explanations for these findings, it is possible they reveal a practice gap regarding AD management in the PED.
Pediatric Dermatology
Topical Corticosteroid Use for Atopic Dermatitis in the Pediatric Emergency Department
Pediatr Dermatol 2021 Apr 19;[EPub Ahead of Print], JF Wang, TK Young, LE Melnick, SJ Orlow, VS Oza
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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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Demographics and Treatment of Childhood Atopic Dermatitis International Journal of Dermatology Save Recommend Share Get Topic Alerts
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In this study, the authors used the National Ambulatory Medical Care Survey to characterize trends in childhood atopic dermatitis in the United States from 1995 to 2015. Annual outpatient visits for atopic dermatitis nearly tripled over the study period and visits were more common among patients of Asian, black, or Hispanic race compared with white patients. Triamcinolone, hydroxyzine, and pimecrolimus were the most common prescriptions, and hydrocortisone, cetirizine, and Cetaphil were the most commonly utilized over-the-counter agents.
Ambulatory visits for atopic dermatitis are increasing. Despite the advent of new nonsteroidal agents, the rate of prescription of topical steroids is also continuing to rise although the study period predates dupilumab approval.
Atopic dermatitis (AD) is a chronic inflammatory skin disease that frequently starts in childhood. Worldwide, the prevalence varies widely from 0.2% to 24.6% of the pediatric population1; in the United States (U.S.), AD affects approximately 13% of children.2 Among children with AD, determining changes in visit trends and patient demographics are critical to inform decisions on healthcare resource allocation. A substantial gap exists in understanding changes in visit trends for AD affecting children in the U.S. in this decade.3This study aims to determine outpatient clinic trends, patient demographics, and medication prescribing patterns for pediatric visits for AD from 1995 to 2015 in the U.S.
International Journal of Dermatology
Childhood Atopic Dermatitis: Outpatient Visit Trends, Demographics, and Topical Agents in the United States, 1995–2015
Int. J. Dermatol 2021 Apr 12;[EPub Ahead of Print], Y Gutierrez, AJ Borba, DJ Grisafe, AW Armstrong
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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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Pediatric emergency departments (ED) are used with increased frequency for the care of atopic dermatitis (AD). These authors report 167 ED visits for pediatric patients over a 5-year period. Most patients (70%) had Medicaid insurance and were given over-the-counter or no topical corticosteroids (TCS), 66%. Dermatology consultation resulted in significantly higher rates of TCS prescribing and a higher potency of the TCS given.
This study highlights an important knowledge gap. ED providers are less likely to provide the needed prescriptions and follow the standard of care that is greatly needed by this population. In my experience, primary and ED providers also often misjudge the quantity of medication needed or designate quantity as "one tube," translating into a pharmacy dispensing 15 grams. I applaud the authors and am personally motivated to develop an ED care pathway for our institution.