Sudden Conjunctivitis, Lymphopenia, and Rash Combined With Hemodynamic Changes After Trimethoprim–Sulfamethoxazole Use

TAKE-HOME MESSAGE

• The authors of this retrospective case series propose an acronym, SCoRCH, for trimethoprim–sulfamethoxazole (TMP-SMX) severe hypersensitivity syndrome with clinical and mucocutaneous findings distinct from other drug reactions. They reviewed 7 cases in which patients treated with TMP-SMX developed the syndrome within 4 to 11 days in those with no prior TMP-SMX exposure and within 24 hours in those with prior exposure.
• Given the potential life-threatening presentation, clinicians should be aware of SCoRCH — sudden conjunctivitis, generalized erythema, lymphopenia, and hemodynamic instability — in a patient who used TMP-SMX in the preceding 2 weeks.

–  Ruth McTighe, MD

Abstract 

IMPORTANCE

Trimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity reaction, ranging from circulatory shock to aseptic meningitis and respiratory failure, is a potentially life-threatening condition with dermatologic relevance.

OBJECTIVE

To describe the mucocutaneous findings and clinical features of TMP-SMX hypersensitivity reaction.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective case series study of 7 patients who developed a characteristic rash, hemodynamic changes, and end-organ dysfunction after treatment with TMP-SMX at a large university hospital system during January 2013 to March 2022.

EXPOSURES

Treatment with TMP-SMX within 2 weeks of the reaction.

MAIN OUTCOME AND MEASURES

Descriptions of the condition, including the demographic information of the affected population, the reaction timeline, and mucocutaneous and clinical features.

RESULTS

The cohort comprised 7 patients (median [range] age, 20 [15-66] years; 4 female and 3 male). The most common mucocutaneous findings were generalized sunburn-like erythema without scale, conjunctivitis, and mild facial and acral edema. Three patients had previous exposure to TMP-SMX and developed symptoms in 1 day or less, while those without prior exposure presented from 4 to 11 days after drug initiation. Among the 7 patients, 6 had fever, 7 had hypotension, and 7 had tachycardia. All patients had lymphopenia and evidence of end-organ dysfunction with either kidney or liver involvement. Median (range) time to resolution was 72 (48-96) hours.

CONCLUSIONS AND RELEVANCE

This retrospective case series indicates that SCoRCH (sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes) should be considered in the differential diagnosis of patients presenting with acute generalized sunburn-like erythema, conjunctivitis, systemic symptoms, and hemodynamic changes in the setting of recent TMP-SMX use.

JAMA Dermatology

Sudden Conjunctivitis, Lymphopenia, and Rash Combined With Hemodynamic Changes (SCoRCH) After Trimethoprim-Sulfamethoxazole Use: A Case Series Study of a Hypersensitivity Reaction

JAMA Dermatol 2022 Nov 09;[EPub Ahead of Print], M O'Brian, EK Rose, MM Mauskar, AR Dominguez 

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Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
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Acute Graft-Versus-Host Disease Presenting as Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis

TAKE-HOME MESSAGE

• In this multicenter retrospective study involving 31 patients with acute graft-versus-host disease (aGVHD), 15 patients had Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN)–like presentation. Patients with SJS/TEN–like aGVHD had a higher body surface area involvement and a higher incidence of pancytopenia, liver dysfunction, renal dysfunction, and bacteremia. The mortality rate among patients with SJS/TEN–like aGVHD was 80% during the follow-up period compared with 25% among patients with non–SJS/TEN–like aGVHD. Sepsis was the most common cause of death.
• It is critical to differentiate drug-induced SJS/TEN from SJS/TEN–like aGVHD because of their similar clinical symptoms. SJS/TEN–like aGVHD is associated with a poor prognosis.

–  Katherine M. Stiff, MD

Abstract 

BACKGROUND

Cutaneous manifestations resembling Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported in patients with acute graft-versus-host disease (aGVHD); however, the clinicopathological characteristics of SJS/TEN-like aGVHD remain unexplored.

OBJECTIVE

To investigate the clinicopathology, complications, and outcomes of patients with SJS/TEN-like aGVHD.

METHODS

We analyzed a multicenter cohort of patients with aGVHD between 2000 and 2021.

RESULTS

We analyzed 31 patients with aGVHD, including SJS/TEN-like (n=15) and non-SJS/TEN-like (n=16). Patients with SJS/TEN-like aGVHD had significantly more extensive erythema and skin detachment/mucositis. SJS/TEN-like aGVHD was significantly associated with higher aGVHD grading and systemic complications, including pancytopenia, leukopenia, anemia, severe thrombocytopenia, coagulation abnormality, hepatitis, diarrhea, renal dysfunction, and bacteremia. A significantly lower hemoglobin/red cell distribution width ratio was identified in SJS/TEN-like aGVHD. Histopathology showed significant severe dyskeratosis and interface change. Patients with SJS/TEN-like aGVHD had lower 2-month survival rates and 5.35-fold higher 5-year mortality rates than those with non-SJS/TEN-like aGVHD. Total mortality rates of patients with SJS/TEN-like aGVHD reached 80% during follow-up; sepsis predominated the causes of death.

LIMITATIONS

Retrospective, nonrandomized study with a small sample size.

CONCLUSION

SJS/TEN-like aGVHD is associated with multiple systemic complications and high mortality. Early recognition, differential diagnosis from drug-induced-SJS/TEN, and appropriate treatment are critical.

Journal of the American Academy of Dermatology

Acute graft-versus-host disease presenting as Stevens-Johnson syndrome and toxic epidermal necrolysis: a retrospective cohort study

J Am Acad Dermatol 2022 Oct 21;[EPub Ahead of Print], YT Hung, YW Chen, YL Huang, YJ Lin, CB Chen, WH Chung 

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Lichen Simplex Chronicus Itch: An Update

An Update on Advancements in the Treatment of Lichen Simplex Chronicus Itch

Acta Dermato-Venereologica

TAKE-HOME MESSAGE

• The authors review the epidemiology, clinical characteristics, and pathophysiology, for lichen simplex chronicus (LSC), as well as therapeutic options. LSC affects an estimated 12% of the general population. In addition to topical corticosteroids, other topical treatment options for LSC include menthol, pramoxine, doxepin, aspirin with dichloromethane, a mixture of ketamine–amitriptyline–lidocaine in a lipoderm base, acetaminophen, and Janus kinase inhibitors. If topical agents fail, other treatments with reported success include gabapentin, narrowband ultraviolet B, and transcutaneous electrical nerve stimulation. Agents under investigation include dupilumab and the IL-31 inhibitors nemolizumab and vixarelimab.
• More treatments for pruritic conditions are becoming available with healthcare providers' growing understanding of the pathogenesis of itch.

–  Katherine M. Stiff, MD

Abstract 

Lichen simplex chronicus is a form of chronic localized pruritus with a secondary dermatitis, and one of the most common types of chronic itch conditions, estimated to affect more than 10% of the general population. However, despite its prevalence and burden, there has been limited research into the pathogenesis and aetiology of lichen simplex chronicus, which, historically, made it a challenging condition to treat. In recent years, our understanding of this condition, along with that of pruritus and the itch-scratch cycle, has increased greatly, enabling a substantial increase in treatment options. In addition, there are several new promising treatments currently in development and trials. This article discusses the definition, epidemiology, clinical characteristics, pathophysiology, and current therapeutic options for lichen simplex chronicus, in order to highlight recent advancements in this field.

Acta Dermato-Venereologica

Lichen Simplex Chronicus Itch: An Update

Acta Derm Venereol 2022 Oct 19;102(xx)adv00796, T Ju, A Vander Does, N Mohsin, G Yosipovitch

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

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NBUVB y Cancer de piel

Incidence of Skin Malignancies Among Patients With Vitiligo or Psoriasis Receiving Narrowband UVB Phototherapy

Abstract 

BACKGROUND

Previous studies regarding the risk of skin malignancy with NBUVB have been performed in Caucasian patients but few studies have been conducted in Asians.

AIMS

To determine the risk of skin cancer in Asian patients with psoriasis and vitiligo receiving NBUVB phototherapy.

METHODS

We performed a 9-year retrospective study including all patients with psoriasis and vitiligo receiving NBUVB (either 311nm wavelength through cabin phototherapy or 308nm through excimer lamp phototherapy) at the National Skin Centre. We matched the identification numbers of patients to the National Registry of Diseases Office database and collected data on all skin cancers diagnosed RESULTS: A total of 3730 patients were included. During the course of the study, 12 cases of skin cancer were diagnosed, of which 10 were basal cell carcinomas, and 2 were squamous cell carcinomas. No cases of melanoma were detected in the study. The age-standardized incidence of skin cancer in psoriasis and vitiligo patients who received phototherapy was 47.5 and 26.5 respectively, which is higher than the incidence of skin cancers in the general population. Risk of skin malignancy was positively correlated with the cumulative (p=0.008) and maximum dose of phototherapy (p=0.011) as well as previous systemic treatments (p=0.006).

LIMITATIONS

Limitations include a relatively short follow-up period as well as the lack of quantification of solar exposure.

CONCLUSIONS

NBUVB phototherapy in Asian skin increases the risk of skin malignancy. The risk of skin malignancy is higher with psoriasis patients, greater cumulative and maximal dose of phototherapy as well as use of systemic therapy. Despite the increased risk, the absolute number of skin malignancies remains low, especially for vitiligo patients, with no cases of melanoma diagnosed - a reassuring finding that phototherapy remains a safe alternative in the treatment of psoriasis and vitiligo.

TAKE-HOME MESSAGE

• In this retrospective study from Singapore involving 3730 patients with vitiligo or psoriasis who received narrowband ultraviolet B (NBUVB) phototherapy, fewer than 1% were diagnosed with non-melanoma skin cancer. There were zero cases of melanoma during the 12-year study period. The rate of incident skin cancer was higher among patients with psoriasis treated with NBUVB than among the general population. The risk of skin cancer increased with cumulative and maximum doses of phototherapy and prior systemic treatments.
• NBUVB phototherapy may marginally increase the risk of non-melanoma skin cancer in the Asian population.

–  Katherine M. Stiff, MD

Photodermatology, Photoimmunology & Photomedicine

Incidence of skin malignancies in patients with vitiligo or psoriasis who received narrowband ultraviolet B phototherapy (308nm/311nm): a retrospective review of 3730 patients

Photodermatol Photoimmunol Photomed 2022 Nov 07;[EPub Ahead of Print], BKY Chia, YW Yew, X Zhao, WS Chong, TGS Thng 

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Skin Care Physicians of Costa Rica

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A brain expert shares his 7 ‘hard rules’ for boosting memory and fighting off dementia

The average human brain shrinks by approximately 5% per decade after the age of 40. This can have a major impact on memory and focus.

What's more, brain disorders are on the rise. In 2020, 54 million people worldwide had Alzheimer's disease or other dementias, and that number is expected to grow. 

But serious mental decline doesn't have to be an inevitable part of aging. In fact, certain lifestyle factors have a greater impact than your genes do on whether you'll develop memory-related diseases.

As a neuroscience researcher, here are seven hard rules I live by to keep my brain sharp and fight off dementia.

1. Keep blood pressure and cholesterol levels in check

Your heart beats roughly 115,000 times a day, and with every beat, it sends about 20% of the oxygen in your body to your brain.

High blood pressure can weaken your heart muscle, and is one of the leading causes of strokes. Ideally, your blood pressure should be no higher than 120/80.

Cholesterol is critical to your brain and nervous system health, too. The American Heart Association recommends getting your cholesterol levels measured every four to six years.

2. Manage sugar levels

Blood sugar is the primary fuel of the brain. Not enough of it, and you have no energy; too much, and you can destroy blood vessels and tissue, leading to premature aging and cardiovascular disease.

Keep in mind that sugar isn't enemy, excess sugar is. It's easy for grams of sugar to add up, even if you think you're being careful — and usually, sugar will sneak in through packaged foods. 

Where is the sugar hidden? Look for these in the ingredients list:

• Dextrose
• Fructose
• Galactose
• Glucose
• Lactose
• Maltose
• Sucrose

And be wary of any product that includes syrup, such as agave nectar syrup or high-fructose corn syrup.

3. Get quality sleep

Studies show that people with untreated sleep apnea raise their risk of memory loss by an average of 10 years before the general population.

For most people, a healthy brain needs somewhere between seven and nine hours of sleep a night. 

My tips for memory-boosting, immune-enhancing sleep:

• Keep a consistent bedtime and wake-up schedule. 
• Turn off devices one hour before bedtime.
• Do something relaxing before bedtime, like listening to soft music or doing mindful breathing exercises.
• Go outside and get in natural sunlight as soon as you can after waking up.

4. Eat a nutritious diet

One way I keep things simple is to have most, if not all, of these items in my grocery cart:

• Fatty fish like salmon
• Avocados
• Nuts
• Blueberries
• Cruciferous veggies like arugula, broccoli, Brussels sprouts and collard greens

When food shopping, I ask myself three questions to help determine whether something is good for my brain:

1. Will it spoil? In many cases, perishable is a good thing. The additives and preservatives that keep food from spoiling wreak havoc on your gut bacteria.

2. Are there tons of ingredients in that packaged food? And for that matter, can you pronounce the ingredients? Or does it look like the makings of a chemical experiment? Also avoid anything where sugar is one of the first few ingredients.

3. Do you see a rainbow on your plate? The chemicals that give fruits and vegetables their vibrant colors help boost brain health. 

5. Don't smoke (and avoid secondhand and thirdhand smoke)

Smokers have a 30% higher risk of developing dementia than non-smokers. They also put those around them at risk: Secondhand smoke contains 7,000 chemicals — and at least 70 of them can cause cancer. 

Then there's thirdhand smoke, which is not actually smoke. It's the residue of cigarette smoke that creates the telltale smell on clothing or in a room. That residue alone can emit chemicals that are toxic to the brain.

6. Make social connections

In a recent study, people over the age of 55 who regularly participated in dinner parties or other social events had a lower risk of losing their memory. But it wasn't because of what they ate, it was the effect of the repeated social connection.

To lessen isolation and loneliness, you can also boost brain chemicals like serotonin and endorphins by performing small acts of kindness:

• Wish others well or check in with somebody.
• Give a compliment without expecting anything in return.
• Make a phone call to somebody you don't usually reach out to.

7. Continuously learn new skills

Maintaining a strong memory is not all about brain games like Sudoku, Wordle and crossword puzzles. 

Learning skills and acquiring information are much more effective ways to make new connections in the brain. The more connections you make, the more likely you are to retain and even enhance your memory.

When you think about learning something new, approach it the way you would with fitness training. You want to work out different muscles on different days. The same goes for the brain. 

Over the course of this week, try cross-training your brain by mixing mental activities (learning a new language or reading a book) and physical learning activities (playing tennis or soccer) .

Marc Milstein, PhD, is a brain health expert and author of "The Age-Proof Brain: New Strategies to Improve Memory, Protect Immunity, and Fight Off Dementia." He earned both his PhD in Biological Chemistry and his Bachelor of Science in Molecular, Cellular, and Developmental Biology from UCLA, and has conducted research on genetics, cancer biology and neuroscience. Follow him on Twitter and Instagram.

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

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Journal Scan / Research · October 26, 2022 Risk of Nonkeratinocyte Skin Cancers in People Living With HIV During the Era of Antiretroviral Therapy Journal of Investigative Dermatology

TAKE-HOME MESSAGE

• This study of 585,706 people living with HIV in the age of antiretroviral therapy (ART) found a total of 2743 nonkeratinocyte skin cancers (0.5% of patients). The most common skin cancer was Kaposi sarcoma (82.0%), followed by melanoma (12.0%) and cutaneous lymphoma (2.6%). There was an elevated risk of diffuse large B-cell lymphoma (DLBCL) and Merkel cell carcinoma (MCC) among those with a prior diagnosis of AIDS.

• Kaposi sarcoma remains the most common nonkeratinocyte skin cancer among patients living with HIV during the era of ART, and patients with prior history of AIDS are at risk of other virus-associated cancers such as MCC and DLBCL.

–  Kelly B. Scarberry, MD

Written by

 

 

Klint Peebles MD

This is a large population-based study of non-keratinocyte skin cancers (NKSC) in people living with HIV infection (PLWH) during the antiretroviral therapy era. It is important to remember that PLWH face the complete spectrum of dermatologic conditions, including cutaneous malignancies. And, while entities such as Kaposi sarcoma and other AIDS-defining conditions may be perceived as most classically associated with HIV infection, PLWH may present with any type of skin cancer. That written, this study found that, for most NKSCs, risk was not elevated for PLWH compared with the general population, suggesting that PLWH may not require routine skin cancer screening in the absence of other meaningful risk factors.

Importantly, comments made in this paper regarding screening are made in the context of the cancers specifically investigated in the study, namely NKSCs. The jury is still out regarding risk of keratinocyte skin cancer in PLWH. Prior studies, including meta-analyses, have suggested that HIV infection may be independently associated with a higher incidence of both keratinocyte carcinoma and melanoma, although these studies come with limitations.1-4 A more recent systematic review included four studies, the majority of which did not show any such associations in patients older than 50 years compared with age-matched, HIV-uninfected persons.5 However, it was found that HIV infection might be associated with higher risks of subsequent squamous cell carcinoma in PLWH who already had a history of keratinocyte carcinoma.

Of course, the USPSTF currently does not recommend routine skin cancer screening, and existing care guidelines for PLWH have also yet to offer specific recommendations on skin cancer screening and risk reduction. That written, it is important that a personalized, patient-centered approach be utilized in the care of PWLH given the intersection of multiple factors germane to skin cancer outcomes, including HIV infection itself, degree of immunosuppression, medications, aging, and behavioral risk factors, just to name a few. Regarding the latter, disproportionately high rates of some skin cancers and indoor tanning have been identified in some populations of gay and bisexual men,6 and, given the higher risk of HIV infection in these populations, these intersections further amplify the need for focused research into these risks and how they can be mitigated in a manner that does not unduly conflate distinct populations and risk factors.

Intuitively, PLWH may be at a higher risk for tumors caused by oncogenic viruses, including Merkel cell carcinoma, associated with the Merkel cell polyomavirus, and diffuse large B-cell lymphoma, associated with the Epstein-Barr virus. Conceptually, this mirrors observations in other organ systems in PLWH, specifically the rising incidence of anal dysplasia and anal cancer (caused by the human papillomavirus). In the case of anal cancer, the ongoing increase in incidence despite antiretroviral therapy may be related to the qualitative impacts of HIV infection on the immune system, immunologic dysregulation, and/or decreased efficiency of oncogenic viral surveillance. Further, antiretroviral therapy has allowed for PLWH to live longer and healthier lives, but this also arguably allows for greater opportunities for oncogenic viral replication and transformation.

Ultimately, we must be aware that neither all people within a group nor all skin cancers are homogeneous. PLWH encompass innumerable characteristics from all walks of life, representing all gender identities, sexual orientations, races/ethnicities, countries of origin, and ages. As such, care must be individualized and patient-centered to understand the unique risk factors of the patient in front of you and to most effectively and humbly meet them where they are. 

References

1. Olsen CM, Knight LL, Green AC. Risk of melanoma in people with HIV/AIDS in the pre-and post-HAART eras: a systematic review and meta-analysis of cohort studies. PloS One. 2014;9(4):e95096. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0095096 
2. Zhao H, Shu G, Wang S. The risk of non-melanoma skin cancer in HIV-infected patients: new data and meta-analysis. Int J STD AIDS. 2016;27(7):568-575. https://journals.sagepub.com/doi/10.1177/0956462415586316 
3. Omland SH, Ahlström MG, Gerstoft J, et al. Risk of skin cancer in patients with HIV: A Danish nationwide cohort study. J Am Acad Dermatol. 2018;79(4):689-695. https://www.jaad.org/article/S0190-9622(18)30475-4/fulltext 
4. Venanzi Rullo E, Maimone MG, Fiorica F, et al. Non-Melanoma Skin Cancer in People Living With HIV: From Epidemiology to Clinical Management. Front Oncol. 2021;11:689789. https://www.frontiersin.org/articles/10.3389/fonc.2021.689789/full 
5. Yeung H, Balakrishnan V, Luk KMH, et al. Risk of skin cancers in older persons living with HIV: a systematic review. J Assoc Nurses AIDS Care. 2019;30(1):80-86. https://journals.lww.com/janac/Abstract/2019/02000/Risk of Skin Cancers in Older Persons Living With.10.aspx 
6. Mansh M, Katz KA, Linos E, et al. Association of skin cancer and indoor tanning in sexual minority men and women. JAMA Dermatol. 2015;151(12):1308-1316. https://jamanetwork.com/journals/jamadermatology/fullarticle/2453327 

Abstract

Antiretroviral therapy (ART) may alter susceptibility to nonkeratinocyte skin cancers (NKSCs) by improving immunity in people living with HIV (PLWH). Using linked data from HIV and cancer registries in 12 US states/regions during the ART era (1996-2018), we calculated standardized incidence ratios (SIRs) for 27 NKSCs comparing incidence to the general population. Risk factors for NKSCs were evaluated using Poisson regression. There were 2,743 NKSCs diagnosed in 585,706 PLWH followed for 4,575,794 person-years. Kaposi sarcoma (KS) was the most common cancer (82%) followed by melanoma (12%) and cutaneous lymphoma (2.6%). Incidence was elevated for virus-related NKSCs: KS (SIR 147, 95%CI 141-153), diffuse large B-cell lymphoma (DLBCL, 5.19, 3.13-8.11), and Merkel cell carcinoma (MCC, 3.15, 1.93-4.87); elevated incidence for DLBCL and MCC was observed only among PLWH with a prior AIDS diagnosis. KS risk was highest among men who have sex with men. Incidence was not increased for melanoma, adnexal carcinomas, and sarcomas. Melanoma and MCC arose disproportionately on sun-exposed skin, supporting a role for ultraviolet radiation in their development. In conclusion, risk for most NKSCs was similar to the general population during the ART era, suggesting that PLWH without NKSC risk factors may not require intensive skin surveillance.

Journal of Investigative Dermatology

Risk of nonkeratinocyte skin cancers in people living with HIV during the era of antiretroviral therapy

J Invest Dermatol 2022 Oct 07;[EPub Ahead of Print], YT Luu, Q Luo, MJ Horner, M Shiels, EA Engels, MR Sargen 

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March 17, 2016

Does Childhood Vitiligo Differ When Halo Nevi Are Present?

Mary Wu Chang, MD, reviewing Cohen BE et al. Pediatr Dermatol 2016 Jan/Feb

HN are much more common in vitiligo patients, especially children, but they do not significantly alter treatment response or risk for disease progression.

Vitiligo, characterized by depigmented patches due to loss of melanocytes, affects up to 4% of individuals worldwide. Childhood vitiligo differs from adult vitiligo regarding higher prevalence of segmental disease, history of atopy, and family history of autoimmune disease. Halo nevi (HN) — nevi with an acquired depigmented peripheral zone (see NEJM JW Dermatol Nov 2012 and Am Acad Dermatol 2012; 67:582) that occur in 1% of the general population, usually on the trunk — are more common in vitiligo patients than in the general population and are considerably more common in children with vitiligo than in adults.

These authors retrospectively reviewed charts at an academic pediatric dermatology unit to characterize childhood vitiligo with and without associated HN. Over a 24-year period, 208 children presented with vitiligo, 55 (26%) of whom had HN. Children with vitiligo-associated HN were more likely to be male (62%; P = 0.03) and older at presentation than those with vitiligo alone (5.8 vs. 7.3 years; P = 0.01).

Children with vitiligo-associated HN were more likely to have the generalized vitiligo subtype. No between-group differences were observed in body surface area affected or family history of vitiligo or autoimmune diseases. Patients with HN were no more likely to develop new vitiligo over a mean of 1.9 years, and there were no significant differences in repigmentation.

Comment

HN are up to 10 times more common in vitiligo patients than in the general population, and even more common in children versus adult vitiligo patients. These findings reassure us that HN do not significantly alter treatment response or risk for disease progression.

Citations

Cohen BE et al. Comparison of childhood vitiligo presenting with or without associated halo nevi. Pediatr Dermatol 2016 Jan/Feb; 33:44. (http://dx.doi.org/10.1111/pde.12717. opens in new tab)

Quemaduras temprano en la vida.

Original Investigation 

October 5, 2022

Lifetime Sunburn Trajectories and Associated Risks of Cutaneous Melanoma and Squamous Cell Carcinoma Among a Cohort of Norwegian Women

Simon Lergenmuller, PhD^1,2; Corina S. Rueegg, PhD³; Flavie Perrier, PhD¹; et alTrude E. Robsahm, PhD⁴; Adele C. Green, PhD^5,6; Eiliv Lund, PhD^4,7; Reza Ghiasvand, PhD^3,4; Marit B. Veierød, PhD¹

Author Affiliations

JAMA Dermatol. Published online October 5, 2022. doi:10.1001/jamadermatol.2022.4053

Key Points

Question  What are the lifetime trajectories of sunburns among Norwegian women, and how are these associated with subsequent risk of cutaneous melanoma and squamous cell carcinoma?

Findings  In this cohort study of 168 553 participants from the Norwegian Women and Cancer Study, 5 classes of lifetime sunburn trajectories were identified, in line with health behaviors generally observed in people. Trajectories with high sunburn frequencies in childhood and throughout life were associated with both increased melanoma and cSCC risks.

Meaning  Lifetime trajectories of sunburns were identified, and the findings provide supporting evidence that avoiding sunburns throughout life, in particular in childhood, is crucial.

Abstract

Importance  To our knowledge, no study has prospectively investigated sunburn patterns over age periods from childhood to adulthood and their associations with skin cancer risk.

Objective  To identify lifetime trajectories of sunburns and compare the association between these trajectories and subsequent risk of cutaneous melanoma and squamous cell carcinoma (cSCC).

Design, Setting, and Participants  This population-based cohort study included participants from the Norwegian Women and Cancer Study, established in 1991, with follow-up through 2018. Baseline questionnaires were issued from 1991 to 2007, with follow-up questionnaires every 5 to 7 years. Data analysis was performed from March 16, 2021, to December 4, 2021.

Exposures  Participants reported pigmentation factors, sunbathing vacations, and indoor tanning. Annual frequencies of sunburns were reported for childhood, adolescence, and adulthood.

Main Outcomes and Measures  Information on cancer diagnoses, emigration, and death were obtained through linkage to the Cancer Registry of Norway using the unique personal identification number of Norwegian citizens.

Results  Of the 172 472 women (age range, 31-70 years) who returned questionnaires, 169 768 received questions about sunburns at study inclusion. Five classes (stable low, low-moderate-low, low to high, high to low, and stable high) of individual lifetime sunburn trajectories with similar shapes were estimated in 3 samples up to 39 years (n = 159 773), up to 49 years (n = 153 297), and up to 59 years (n = 119 170). Mean follow-up ranged from 14.3 to 19.5 years in the 3 samples, during which 1252 to 1774 women were diagnosed with incident primary melanoma and 739 to 871 women with incident primary cSCC. With hazard ratios (HRs) and 95% CIs estimated using a Cox proportional hazards model, the stable high and high to low trajectories showed statistically significant increased melanoma and cSCC risks compared with the stable low trajectory across all samples (≤39 years for stable high and high to low trajectories: melanoma: HR, 1.50 [95% CI, 1.28-1.75] and HR, 1.44 [95% CI, 1.20-1.73]; cSCC: HR, 1.51 [95% CI, 1.22-1.87] and HR, 1.47 [95% CI, 1.14-1.91]). Other trajectories showed increased risk, though generally weaker and mainly estimates that were not statistically significant. There was no statistically significant heterogeneity between melanoma and cSCC estimates.

Conclusion and Relevance  This cohort study showed that high sunburn frequency throughout life was associated with increased melanoma and cSCC risk. Furthermore, sunburns in childhood are especially important for subsequent risk of these skin cancers. Avoiding sunburns throughout life, in particular in childhood, is therefore crucial.

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Skin Care Physicians of Costa Rica

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