Clinical and Histopathological Features of Adult Patients With Dermatomyositis and MDA-5 Autoantibody Seropositivity Status Clinical and Experimental Dermatology
TAKE-HOME MESSAGE
The authors evaluated the results of the commercially available melanoma differentiation-associated (MDA)-5 autoantibodies in 73 patients with a diagnosis of dermatomyositis (DM). MDA-5 autoantibodies were seen in 45% of patients and these patients demonstrated an increased prevalence of Raynaud phenomenon (RP), cutaneous ulcerations, mechanic hands, palmar papules, oral ulcers, and alopecia. Systemic findings such as joint involvement, pulmonary involvement, and dysphagia were more commonly seen in DM patients who were positive for MDA-5. On histopathology, vasculopathy was a significant finding seen only in DM patients positive for MDA-5, while spongiosis was only seen in cases of DM that were negative for MDA-5.
This study confirms some of the previously associated findings with MDA-5 positivity in DM patients, while also adding RP and dysphagia as new associations noted.
Although melanoma differentiation associated (MDA)-5 autoantibodies have been widely explored in dermatomyositis (DM), most studies have relied on MDA-5 autoantibody testing performed in research settings, rather than the now-available commercial laboratory tests.
AIM
To characterize the clinical and histopathological data in patients with DM and circulating MDA-5 autoantibodies, as defined by commercially available testing.
METHODS
This was a retrospective review of patients with DM who underwent MDA-5 antibody testing. All available skin biopsy slides were reviewed.
RESULTS
Cutaneous features more prevalent in MDA-5-positive DM included Raynaud phenomenon (RP) (P < 0.001), cutaneous ulcerations (P = 0.01), mechanic hands (P < 0.02), palmar papules (P < 0.01), oral ulcers (P = 0.024) and alopecia (P = 0.03). Joint and pulmonary involvement were more common in patients with MDA-5-positive DM (both P < 0.001) as was dysphagia (P < 0.01). Myopathy (P = 0.4) and malignancy (P = 0.34) were not statistically different between the cohorts. Vasculopathy was more common in MDA-5-positive DM (P < 0.01), while spongiosis was less common (P < 0.02).
CONCLUSION
This study not only confirms some known associations between disease manifestations and MDA-5 autoantibody status, as determined by commercially available tests, but also identifies new associations, including RP and dysphagia.
Clinical and Experimental Dermatology
Clinical and histopathological features of adult patients with dermatomyositis and melanoma differentiation associated-5 autoantibody seropositivity status, as determined by commercially available testing: a retrospective, single-institution comparative cohort study
Clin Exp Dermatol 2021 Aug 03;[EPub Ahead of Print], H Shakshouk, MA Deschaine, DA Wetter, LA Drage, FC Ernste, JS Lehman
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Infecciones en procedimientos dermatologicos menores
Risk Factors for Infection After Minor Dermatologic Procedures
Dermatologic Surgery
TAKE-HOME MESSAGE
Infection rates were low at 0.4% in 9031 minor dermatologic procedures including skin biopsies, shaves, conventional excisions, and destructions. The odds of infection were much higher for procedures on the arms and legs compared with the head/neck. Age, gender, or comorbid conditions were not associated with infection risk.
The incidence of infection after minor dermatologic procedures is low, with procedures on the extremities having the highest odds of infection.
There are limited published data regarding the incidence and risk factors for infection after minor dermatologic procedures, such as skin biopsy, shave, and curettage. Prior studies of infection risk after dermatologic procedures have often not specified the method of preparation of local anesthetic.
OBJECTIVE
To assess the incidence and risk factors for infection after minor procedures performed in a general dermatology clinic using buffered lidocaine prepared in office.
MATERIALS AND METHODS
In this retrospective case-control study, the medical record was searched for cases of infection after skin biopsies, shaves, conventional excisions, and destructions performed in a general dermatology clinic over a 4-year period. Patient and procedure characteristics were compared with uninfected controls.
RESULTS
Of 9,031 procedures performed during the study period, there were 34 infections (0.4%). The odds of infection for procedures on the arm and leg were 5.29 and 9.28 times higher, respectively, than those on the head/neck. There was no significant effect of age, sex, smoking, immunosuppression, diabetes, or anticoagulation.
CONCLUSION
The incidence of infection is low after minor dermatologic procedures performed with local anesthesia using buffered lidocaine prepared in office. There is a higher risk of infection on the arm and leg compared with the head and neck.
Dermatologic Surgery
Risk Factors for Infection After Minor Dermatologic Procedures: A Case-Control Study
Dermatol Surg 2021 Aug 18;[EPub Ahead of Print], S Matos, B Sturm, M Buhnerkempe, R Larson, M Wilson
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By Warren R. Heymann, MD, FAAD October 13, 2021 Vol. 3, No. 41
Being married to a geneticist has served me well as a dermatologist. Just as dermatologists can instantly diagnose many dermatoses based on pattern recognition, geneticists skilled in dysmorphology can identify many syndromes in a heartbeat. Physicians of all stripes need to recognize Down syndrome (DS, Trisomy 21) because of its vast multiorgan manifestations.
DS is the most common chromosomal abnormality accounting for 8% of all registered cases. The incidence of Down syndrome is every 1 in 700 live births in the United States. DS is caused by the presence of all, or part of a third copy of chromosome 21. This extra genetic material is responsible for the classical facial characteristics, multiple malformations, intellectual disability, immune and endocrine dysfunction associated with DS. Although DS has a variable phenotype there are many common physical manifestations such as hypotonia, epicanthic folds, flat nasal bridge, single palmar crease, and sandal toe gap. This commentary will focus on some newer dermatological literature about DS. For a review of the cardiac, neurologic, gastrointestinal, endocrinologic, growth, respiratory, otolaryngologic, sleep, hematologic, immunologic, renal, and ophthalmologic comorbidities of DS, the reader is referred to Lagan et al for an excellent summary. (1)
A self-limited leukemoid reaction (TMD) in a patient with DS — from JAAD 2006; 54; S62-64. Dermatology residents studying DS will naturally focus on its classical cutaneous manifestations (see below); however, as years pass, they will learn that "common diseases occur commonly." This is the thrust of the manuscript of Rork et al, an institutional retrospective analysis of 101 pediatric and adult patients with DS between 2008 and 2018. Folliculitis (especially of the thighs and buttocks) was the most common diagnosis overall (30.7%), followed by seborrheic dermatitis (26.7%) and hidradenitis suppurativa (22.8%). Eczematous dermatitis, alopecia areata, and xerosis were the most common diagnoses observed in children aged 0-12 years; hidradenitis suppurativa, folliculitis, and seborrheic dermatitis in adolescents aged 13-17 years; and folliculitis, seborrheic dermatitis, and xerosis in adults 18 years and older. Other notable diagnoses present overall included onychomycosis (9.9%) and psoriasis (8.9%). Malignant cutaneous tumors were present in two patients, specifically basal cell carcinoma and malignant melanoma in situ (both in Caucasian men in their 50s). The authors concluded that dermatologic disorders in patients with Down syndrome vary by age but are most often adnexal and eczematous disorders. Trisomy 21 and the resulting downstream effects, specifically on the immune system, may contribute to these findings. (2)
Immunodysregulation in DS is complex, involving interferon-gamma (IFN-γ) hyperactivity and trisomy of the AIRE (autoimmune regulator) gene located on chromosome 21, reflected in the well-recognized association with autoimmune diseases such as alopecia areata, vitiligo, celiac disease, propensity to crusted scabies, multiple eruptive dermatofibromas, and type I diabetes. The interferon (IFN) response involves multiple cell types, causing hypersensitivity to IFN ligands, hyperactivation of downstream Janus kinase/signal transducer activator of transcription (JAK/STAT) signaling, and significant overexpression of IFN-stimulated genes. (2,3,4)
Rarer, but well-known associated dermatoses with DS include: Transient myeloproliferative disorder (TMD), elastosis perforans serpiginosa, syringomas, and milia-like calcinosis cutis. (4)
According to Brazzelli, "TMD is a spontaneously resolving clonal myeloid proliferation characterized by circulating megakaryoblasts in the peripheral blood that is restricted to neonates with Down syndrome (DS) or those with trisomy 21 mosaicism. Cutaneous manifestations of TMD are observed in only 5% of affected neonates and present as a diffuse eruption of erythematous, crusted papules, papulovesicles, and pustules, often with prominent and initial facial involvement." The dermatologic manifestations usually appear within the first 3 weeks of life, often starting on the face (cheeks), but may be distributed anywhere. Lesions last a few days and resolve without scarring. The leukemogenic source TMD is a somatic mutation of the X-linked GATA1 gene. Importantly, 20% of affected neonates ultimately develop acute leukemia later in life, typically with features of megakaryoblastic leukemia. (5) Patients with DS also have a twenty-fold increased risk of developing acute lymphoblastic leukemia (ALL). (1)
Regarding newer literature in DS, I found the following topics of interest.
Lam et al performed a meta-analysis to study the association of hidradenitis suppurativa (HS) and DS. Twelve studies were included in this systematic review, with a total of 358 patients presenting with both HS and DS. Pooled analysis of mean differences between DS and non-DS participants presenting with HS found a significantly younger age of HS symptom onset for DS patients and a significantly increased likelihood of HS in DS patients. The authors suggest an association between HS and DS; this occurrence may be due to a combination of factors related to a propensity of follicular disorders in DS, immunodysregulation, and a trend toward obesity. (6)
The precise relationship of psoriasis with DS remains to be defined, although with the similarities in the Th1 pathway leading to production of interferon-gamma and tumor necrosis factor-alpha in both disorders, one would expect to see the two concurrently. Hedayati et al reported the case of annular psoriasis in a 17-year-old girl with DS. (7) Morita et al detail annular pustular psoriasis in an 8-year-old boy with DS following growth hormone therapy. (8) Senterre et al remind us to be careful with administration of biologics in patients with DS with presumed psoriasis. A 26-year-old woman was thought to have psoriasiform lesions for which the IL-23 inhibitor risankizumab was prescribed; unfortunately, the patient had crusted scabies which flared dramatically. She ultimately responded to topical permethrin and systemic ivermectin. (9)
Finally, Riga-Fede disease (traumatic granuloma of the tongue) which may have an alarming appearance mimicking malignancy, maybe due to the early onset and persistence of neonatal teeth, combined with uncontrolled [macroglossic, fissured] tongue movements in patients with DS. (10)
Point to Remember: Both common and rare disorders may be observed in patients with DS, but particular attention should be made on follicular, eczematous, immunologic disorders. Hidradenitis suppurativa is increasingly recognized in patients with DS. Multiorgan involvement mandates a multidisciplinary management approach.
Our expert's viewpoint
Jillian F. Rork, MD, FAAD Assistant Professor of Dermatology Dartmouth-Hitchcock Medical Center at Manchester and The Geisel School of Medicine
I have a phrase I like to teach about Down syndrome and skin: "Don't forget the hidden spots!" It is simplistic, but if you can recall this when examining a patient with Down syndrome, you will remember many of the common skin conditions that can be overlooked.
Courtesy of Dr. Rork.Perform a thorough scalp examination for alopecia areata and make sure thyroid screening is up-to-date. In general, thyroid blood work should be performed at ages 6 months and 12 months, annually beginning at age 1 year, and every 1-2 years beginning at age 21 years. (11-12) As Dr. Heymann just summarized, immune and endocrine dysfunction is common in Down syndrome; we should be part of the multidisciplinary approach and be aware of these guidelines. Seborrheic dermatitis is often a common finding too. I like to spend extra time with patients and families to ask about bathing routines. For some individuals with DS, this is an easy part of the day, but for others it is challenging. It can be stressful to add in multiple treatments, so take time to listen and come up with a feasible plan.
Make sure to look at the armpits, groin, and buttocks. Even in my young career, I have had numerous Down syndrome patients come in for different skin complaints only to find they have hidradenitis suppurativa (HS) or severe folliculitis on their buttocks. We, as dermatologists, know these can be painful, scarring skin conditions if untreated. While the literature is limited, it would appear that HS starts at a younger age in Down syndrome. We should be thinking about this diagnosis in school-aged and early adolescent patients.
Lastly, look at those feet! You could find hyperkeratosis that can impact how shoes fit and also dermatophyte infections. Onychomycosis can be found in younger patients with Down syndrome and should not just be considered in adults.
So, when seeing a Down syndrome patient, I would advocate for a complete skin examination. A cursory or focused examination may overlook skin conditions that could use our expertise.
Lagan N, Huggard D, Mc Grane F, Leahy TR, Franklin O, Roche E, Webb D, O' Marcaigh A, Cox D, El-Khuffash A, Greally P, Balfe J, Molloy EJ. Multiorgan involvement and management in children with Down syndrome. Acta Paediatr. 2020 Jun;109(6):1096-1111.
Rork JF, McCormack L, Lal K, Wiss K, Belazarian L. Dermatologic conditions in Down syndrome: A single-center retrospective chart review. Pediatr Dermatol. 2020 Sep;37(5):811-816.
Rachubinski AL, Estrada BE, Norris D, Dunnick CA, Boldrick JC, Espinosa JM. Janus kinase inhibition in Down syndrome: 2 cases of therapeutic benefit for alopecia areata. JAAD Case Rep. 2019 Apr 5;5(4):365-367.
Fölster-Holst R, Rohrer T, Jung AM. Dermatological aspects of the S2k guidelines on Down syndrome in childhood and adolescence. J Dtsch Dermatol Ges. 2018 Oct;16(10):1289-1295.
Brazzelli V, Segal A, Bernacca C, Tchich A, Bolcato V, Croci G, Mina T, Zecca M, Zanette S, Stronati M. Neonatal vesiculopustular eruption in Down syndrome and transient myeloproliferative disorder: A case report and review of the literature. Pediatr Dermatol. 2019 Sep;36(5):702-706.
Lam M, Lai C, Almuhanna N, Alhusayen R. Hidradenitis suppurativa and Down syndrome: A systematic review and meta-analysis. Pediatr Dermatol. 2020 Sep 6. doi: 10.1111/pde.14326. Epub ahead of print.
Hedayati B, Carley SK, Kraus CN, Smith J. Arcuate pink plaques in a female with Down syndrome. Int J Dermatol. 2020 Apr;59(4):e127-e128.
Morita A, Kawakami Y, Kaji T, Hirai Y, Miyake T, Takahashi M, Yamasaki O, Sugiura K, Morizane S. Pediatric-onset annular pustular psoriasis in a patient with Down syndrome. J Dermatol. 2019 Oct;46(10):e367-e368.
Senterre Y, Jouret G, Collins P, Nikkels AF. Risankizumab-Aggravated Crusted Scabies in a Patient with Down Syndrome. Dermatol Ther (Heidelb). 2020 Aug;10(4):829-834.
Polat Ekinci A, Kılıç S, Babuna Kobaner G. Early-onset and persistent traumatic granuloma of the tongue (Riga-Fede disease) associated with neonatal teeth and Down syndrome. J Eur Acad Dermatol Venereol. 2019 Mar;33(3):e131-e132.
Bull MJ; Committee on Genetics. Pediatrics. 2011;128(2):393-406
Tsou AY, Bulova P, Capone G, et al. Medical Care of Adults With Down Syndrome: A Clinical Guideline. JAMA.2020; 324(15):1543–1556.
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COVID-19 Infection Plus Vaccination May Provide Strongest Protection, Research Suggests
USA Today (10/19, Weintraub) reports "a growing body of research suggests" COVID-19 infection "plus vaccination provides the strongest protection against a wide range of variants." One study published in Science found that "this combined protection seems to last a long time." USA Today then quotes health officials on research into the protection potentially offered by infection plus vaccination.
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By Warren R. Heymann, MD, FAAD October 6, 2021 Vol. 3, No. 40
After attending a clinic at the University of Pennsylvania 30 years ago, I recall relaxing in the cafeteria, coffee in one hand and JAAD in the other, being impressed with an article by Northcutt et al (1), describing cases of a new entity they called axillary granular parakeratosis. I thought this would be worth remembering. Time would prove me right. The following is the abstract from the article:
The term axillary granular parakeratosis is proposed for a unique axillary eruption with distinct histopathologic features. Four middle-aged to elderly patients (three women, one man) had unilateral or bilateral, usually pruritic, hyperpigmented to bright red patches in the axillae. Biopsy specimens revealed severe compact parakeratosis with the stratum corneum measuring 80 to 250 microns in maximal thickness, maintenance of the stratum granulosum, remarkable retention of keratohyaline granules throughout the stratum corneum, and vascular proliferation and ectasia. A contact reaction to an antiperspirant/deodorant is suspected as the cause. We speculate that the offending agent alters the maturation sequence of the stratum granulosum and stratum corneum, possibly by interfering with the degradation of filaggrin precursor to filaggrin units.
The disorder is now referred to as granular parakeratosis (GP) because of its presence at other (mostly flexural) sites. GP occurs in all ages but is most commonly seen in adults. Patients with GP characteristically present with asymptomatic to pruritic papules or plaques in intertriginous areas. Lesions are typically reddish to brown and present as scaly-to-keratotic papules that may coalesce into plaques in intertriginous areas such as the axillae, submammary folds, abdominal folds, or inguinal folds. In children GP presents as linear plaques in the bilateral inguinal folds or as geometric plaques in areas of increased pressure during diaper-wearing. Granular parakeratosis has not been associated with any systemic diseases. (2)
The clinical differential diagnosis includes intertrigo, Hailey-Hailey disease, Darier disease, pemphigus vegetans, confluent and reticulated papillomatosis, acanthosis nigricans, seborrheic keratoses, and irritant or allergic contact dermatitis. The diagnosis of GP is confirmed histologically marked compact parakeratotic horn with retention of keratohyalin granules. (3)
Image from JAAD 1997; 37: 789-790.As stated by Lucero and Horowitz, "The condition was originally thought to be a contact dermatitis to personal hygiene products such as deodorants and antiperspirants; however, cases have been reported in the absence of personal hygiene products in the affected areas, which discredited contact dermatitis as the etiology. The possibility of the condition being an unusual reaction to other topical preparations has not been entirely ruled out as a contributing etiology." (2) For example, Shen et al reported the case of a 75-year-old woman with extensive flexural GP due to a benzalkonium-based laundry rinse. (4) Occlusion appears to be a factor in the etiology of GP, given the predilection for intertriginous areas, however, case reports of GP in non-intertriginous body areas such as the face suggest that occlusion does not appear to be the only etiologic factor. (2)
In a letter to the editor regarding the article by Shen et al, Kumarasinghe et al report that in their experience similar cases were observed in patients who have not used any benzalkonium chloride-containing laundry detergents. They also propose the term hyperkeratotic flexural erythema (HKFE) to encompass all cases of this clinical entity based on the observation that GP may or may not be present on all biopsies. The authors suggest that disordered keratinization of HKFE may be due to a change in the flexural microbiome due to irritants or other causes. (5)
Therapeutically, most cases will respond to removal of the trigger (usually an antiperspirant) with concurrent use of topical steroids. Therapeutic success has also been reported with vitamin D analogues, topical or oral retinoids, ammonium lactate, calcineurin inhibitors, topical or oral antifungals, cryotherapy, and botulinum toxin injections. (3,6)
Image from JAAD 1997; 37: 789-790.
My interest in GP was rekindled after reading the article by Fujii et al detailing their mouse model where topical aluminum chloride caused apoptosis, maturation arrest, and GP. (7). The following is the abstract of the article.
Aluminum chloride (AlCl3) is the main active ingredient in commonly used antiperspirant. Antiperspirant use may cause a rare keratinization disease, granular parakeratosis (GP), then AlCl3 may be associated with the etiology of GP. The objective of this study is to elucidate the skin effect of topical aluminum application using a mouse model. We sprayed 20% aluminum chloride every day on the depilated mice skin and analyzed the skin clinically, histopathologically, and immunohistologically. We have succeeded in the histological replication of GP on mouse skin. The basophilic granules in the stratum corneum contained filaggrin, and processing of profilaggrin to filaggrin was disrupted in aluminum-treated mouse skin (Al-mouse). In Al-mouse, cytochrome c and cleaved-caspase 3 were upregulated mainly in the granular layer, and caspase 3 p20 subunit was upregulated. TUNEL-positive cells increased significantly in the Al-mouse from the granular to the horny layer. Caspase 3 inhibitor inhibited granular parakeratotic change of Al-mouse. Our results indicated that aluminum-induced apoptosis leads to keratinization arrest and acceleration of nuclear degradation before completion of profilaggrin processing. This could lead to retention of the basophilic granules composed of underprocessed profilaggrin in the horny layer of Al-mouse skin, the hallmark of GP.
It is fascinating to ponder how topical caspase inhibitors may affect other disorders of keratinization. Most importantly, I encourage you to reread the abstract by Northcutt et al — I was awestruck by their prescience and brilliance. It serves as a reminder that every dermatologist has the opportunity to carefully examine patients making novel observations which may open new vistas of diagnosis and therapy.
Point to Remember: Granular parakeratosis may affect all age groups and usually responds to removal of the potential irritant with straightforward topical therapy. A mouse model of GP raises intriguing possibilities about pathogenesis and potential new therapies for disorders of keratinization.
Our expert's viewpoint
Christen Mowad, MD, FAAD Chair of Dermatology, Geisinger Medical Center
This was a very timely commentary as I had just seen a 54-year-old Caucasian women with a several month history of an itchy rash in both axilla. She denied a new deodorant but had just purchased a new container of it. The eruption was a characteristic brownish keratotic set of papules coalescing into plaques with some maceration involving both axillae. This eruption known as granular parakeratosis has these characteristic clinical features and occurs most commonly in women and typically in adults. It is usually localized to intertriginous sites. There is an infantile presentation associated with diapers involving the inguinal folds. The pathology is characteristic and demonstrates retention of basophilic keratohyaline granules and parakeratosis. The pathophysiology of this eruption has been linked to an allergic contact dermatitis as well as occlusion, maceration, and friction. It appears that an abnormality in keratinization occurs either from an underlying defect in filaggrin or a change in the microbiome or a change in the keratinization process due to irritants. The recent article demonstrating aluminum chloride as a cause of apoptosis and keratinization arrest and granular parakeratosis is intriguing. The awareness of this condition when considering the differential diagnosis of the clinical picture is important. Treatment typically involves removal of the antiperspirant and topical agents. The effect of aluminum chloride and other topical agents on keratinization is fascinating and may be a key to treating keratinization disorders. Though not yet crystal clear the granules of this disorder are being put together and may go far beyond the understanding of just this entity.
Northcutt AD, Nelson DM, Tschen JA. Axillary granular parakeratosis. J Am Acad Dermatol. 1991 Apr;24(4):541-4.
Gaul M, Bass J, Wikas S. Granular parakeratosis. Cutis. 2020 Jun;105(6):E42-E43.
Shen S, Pham CT, Ryan A, Bruce F. Granular parakeratosis in an adult female secondary to exposure to benzalkonium chloride laundry rinse. Australas J Dermatol. 2019 Aug;60(3):254-256.
Kumarasinghe SP, Chandran V, Raby E, Wood B. Granular parakeratosis is a reaction pattern in hyperkeratotic flexural erythema. Australas J Dermatol. 2020 May;61(2):159-160.
Fujii M, Kishibe M, Honma M, Anan T, Ishida-Yamamoto A. Aluminum Chloride-Induced Apoptosis Leads to Keratinization Arrest and Granular Parakeratosis. Am J Dermatopathol. 2020 Oct;42(10):756-761.
All content found on Dermatology World Insights and Inquiries, including: text, images, video, audio, or other formats, were created for informational purposes only. The content represents the opinions of the authors and should not be interpreted as the official AAD position on any topic addressed. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
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The use of intralesional corticosteroid combined with narrowband ultraviolet B in vitiligo treatment: clinical, histopathologic, and histometric evaluation
Abstract
Background
Treatment of vitiligo with intralesional steroid (ILS) injections has shown to be successful in quite a few studies. It is a simple and safe treatment when used with caution with a better response in localized lesions.
Objectives
The aim of the present study is to explore the efficacy and safety of using different concentrations of intralesional corticosteroid combined with NB-UVB phototherapy in the treatment of non-segmental vitiligo (NSV) patients.
Methodology
Twenty patients with non-segmental vitiligo were subjected to different concentrations of ILS injections (triamcinolone acetonide); that was carried out monthly for six sessions. All patients were also subjected to twice-weekly sessions of NB-UVB for 6 months. Punch biopsy was taken from each patch before and at the end of treatment sessions. Each biopsy was stained with hematoxylin and eosin (H&E), Orcein, and Masson's trichrome stains.
Results
There was a significant difference between all groups in their repigmentation response (P = 0.017). After treatment, the epidermal thickness (histometry) was decreased (epidermal atrophy), especially with concentrations of 2.5 and 5 mg/ml of intralesional triamcinolone acetonide injection with decreased and disorganized collagen fibers.
Conclusion
Intralesional corticosteroid injections combined with NB-UVB showed a good and well-tolerated therapeutic option for vitiligo. The concentrations of 0.625 and 1.25 mg/ml of triamcinolone acetonide were the safest with fewer side effects and complications. However, higher concentrations of 2.5 and 5 mg/ml were more effective but with more side effects.
Facial Contact Dermatitis From Cosmetic-Relevant Allergens
Abstract
BACKGROUND
Facial allergic contact dermatitis caused by cosmetic products is common. New allergens in cosmetics continuously emerge.
OBJECTIVES
To investigate characteristics of patients with facial dermatitis (FD) between 2010 and 2019 including patch test results from cosmetic-related allergens and a new test series with cosmetic-relevant natural ingredients (CRNIs).
METHODS
This is a retrospective study analysing demographics, clinical characteristics according to MOAHLFA index (male; occupation; atopic dermatitis; hand; leg; face; age ≥ 40 years), and patch test results to 27 cosmetic-relevant allergens in FD patients. A prospective study evaluating a screening test series with CRNIs in consecutive FD patients for 1 year was also conducted. These patients received a questionnaire for collecting extra characteristics (eg, concerning quality of life).
RESULTS
Of 8740 tested patients, 2292 (26.2%) had FD. Of these, 30.6% had cosmetic-induced FD. The most common cosmetic-related allergens were fragrances and preservatives. The most common patch test-positive CRNIs were hydroperoxides of limonene and linalool, and propolis. Potato and peanut were rare, but the most common prick test-positive CRNIs, however, without any relation to the use of cosmetic products. FD affected nearly all patients' quality of life and caused limitations to their daily life.
CONCLUSIONS
Updated management and quick diagnosis of FD is important to avoid negative impact on patients' quality of life.
TAKE-HOME MESSAGE
In this registry-based study, almost a third of patients with facial dermatitis undergoing patch testing had a rash induced partly or fully by cosmetics. Allergic contact dermatitis was seen in 90% of cases while 8% had irritant dermatitis. Female gender and age >40 years were associated with facial dermatitis due to cosmetics. Patch test reactions to cosmetics-related allergens were most commonly caused by fragrance and preservatives. Limonene, linalool, and propolis were the most common cause of reactions among cosmetic-related natural ingredients. Most patients reported an impact on their quality of life.
The management of facial dermatitis secondary to cosmetic use is important to preserve the quality of life of patients.
Dermatology Patients on Biologics and Certain Other Systemic Therapies Should Receive a 'Booster' mRNA COVID-19 Vaccine Dose
TAKE-HOME MESSAGE
The Advisory Committee on Immunization Practices recommends a 3rd dose of the mRNA COVID-19 vaccine for certain immunocompromised individuals ≥28 days after completion of their 2-dose vaccine series. The authors review the current literature and evaluated its application to dermatology patients. Patients with psoriasis and psoriatic arthritis treated with glucocorticoids, mycophenolate mofetil, methotrexate, and anti-CD20 monoclonal antibodies, have reduced rates of seroconversion. A reduction in seroconversion was not seen in patients taking IL-17 and TNF inhibitors. A third dose lead to seroconversion in 33% to 50% of patients who had no detectable antibody response to the initial vaccine series.
Patients taking high-dose systemic glucocorticoids, oral immunosuppressants, or B-cell depletion therapies require an additional dose of the mRNA COVID-19 vaccine. This is not necessary for patients taking IL-17, TNF, IL-12/23, IL-23, and IL-4/13 inhibitors.
On August 12th, 2021, the FDA expanded the emergency use authorization of both mRNA COVID-19 vaccines "to allow for the use of an additional dose in certain immunocompromised individuals.1" This announcement may leave dermatologists wondering whether certain patients should receive a 3rd dose of the mRNA COVID-19 vaccine. Herein, we will summarize the data supporting the FDA/ACIP expansion of vaccine authorization and then apply this data to dermatology practice.
Journal of the American Academy of Dermatology
Dermatology Patients on Biologics and Certain Other Systemic Therapies Should Receive a 'Booster' mRNA COVID-19 Vaccine Dose: A Critical Appraisal of Recent FDA and ACIP Recommendations
J Am Acad Dermatol 2021 Aug 23;[EPub Ahead of Print], RA Waldman, JM Grant-Kels
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Surgical Delays in Mohs Micrographic Surgery Are Associated With Tumor Growth in Moderate- and Poorly-Differentiated SCCs
TAKE-HOME MESSAGE
The mean time from biopsy to surgery was 55 days among patients with squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) treated with Mohs surgery. The mean change in major diameter for all lesions was 0.9 cm. SCCs showed a larger change in diameter than BCCs. For SCCs, a histologic subtype of poor or moderate differentiation were independent predictors of change in mean diameter, with growth of 0.28 cm and 0.24 cm per month of delay, respectively. BCC histologic subtypes did not demonstrate a relationship between change in diameter and surgical delay.
Prompt treatment is most important for moderate and poorly differentiated SCCs.
Evidence is controversial and limited surrounding whether surgical delays are associated with tumor growth for cutaneous squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs).
OBJECTIVE
Identify tumor subpopulations that may demonstrate an association between tumor growth and surgical delay.
METHODS
We retrospectively analyzed 299 SCCs and 802 BCCs treated with Mohs surgery at a single institution. Time interval from biopsy to surgery represented surgical delay. Change in major diameter (ΔMD) from size at biopsy to postoperative defect represented tumor growth. Independent predictors of ΔMD were identified by multivariate analysis. Linear regression was then utilized to assess for whether the ΔMD from these independent predictors trended with surgical delay.
RESULTS
Surgical delays ranged 0-331 days. Among SCCs, histologic subtype and prior treatment were identified as independent predictors of ΔMD. Significant associations between ΔMD and surgical delay were found for poorly- and moderately differentiated SCCs, demonstrating growth rates of 0.28cm and 0.24cm per month of delay, respectively. The ΔMD for SCCs with prior treatment and BCC subgroups did not vary with surgical delay.
LIMITATIONS
Retrospective design, single center.
CONCLUSION
Surgical delays under a year were associated with tumor growth for higher-grade SCCs, with effect sizes bearing potential for clinical significance.
ournal of the American Academy of Dermatology
Surgical delays less than 1 year in Mohs micrographic surgery associated with tumor growth in moderate- and poorly-differentiated squamous cell carcinomas but not lower-grade squamous cell carcinomas or basal cell carcinomas, a retrospective analysis
J Am Acad Dermatol 2021 Sep 06;[EPub Ahead of Print], J Lee, VJ Forrester, WM Novicoff, DJ Guffey, MA Russell
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Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
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