Search

Introduction: Dermal “micro-injections" of botulinum toxin A (BTX-A) treatment can improve facial flushing and erythema in patients with refractory rosacea. We present a case of a patient with longstanding papulo-pustular rosacea with flushing, refractory to laser, topical and systemic therapies, where intradermal microdroplet BTX-A injections successfully controlled erythema and flushing. Case Description: A 49-year-old White female with a 4-year history of refractory papulo-pustular rosacea presented with bright, central facial erythema and telangiectasias after failing multiple 595 nm pulsed dye laser, topical (azelaic acid 15% gel, 0.025% tretinoin cream, and metrocream 0.75%) and systemic (isotretinoin 20 mg daily, spironolactone 25 mg daily and doxycycline 100 mg twice daily for 14 days) treatments. At treatment 1, 20 U of BTX-A was injected intradermally (0.05 mL of 1.25 IU/0.1 mL per microdroplet) to erythematous lesion. Treatment 2 was performed at her 4 week follow-up were we administer 15 U of BTX-A intradermally (0.05 mL of 1.25 IU/0.1 mL per microdroplet) . The patient was seen 4, 8, and 16 weeks after her second treatment were no BTX-A was administered due to a significant reduction in erythema and lasting results. Discussion: Significant clinical improvement and patient satisfaction was achieved. No adverse events were reported after treatment aside from mild, localized injection site pain during the procedure. BTX-A administered as intradermal microdroplet injects can be a safe and efficacious option in the treatment of refractory rosacea erythema. Microbotox may be an effective adjunct, especially when topical and systemic therapies have failed.

BACKGROUND Although many generic dermatological quality-of-life (QoL) instruments exist, none have been specifically designed for patients with allergic contact dermatitis (ACD). In the preceding publication-Validating a Quality-of-Life Instrument for Allergic Contact Dermatitis-we developed and validated a QoL instrument specific to the ACD population. OBJECTIVE The aim of this study was to assess whether this ACD-specific QoL instrument appropriately captures change in QoL after patch testing in ACD patients. METHODS One hundred individuals completed the previously validated 17-item QoL survey plus 2 global questions and the Skindex-29 before patch testing. Two months after patch testing and allergen avoidance, the participants repeated the same questionnaires. We used statistical methods to evaluate the capacity of the ACD questionnaire to measure change in QoL in comparison with the Skindex-29. CONCLUSIONS The novel ACD-specific questionnaire was more sensitive to change in QoL than the generic Skindex-29. Eleven of the original 17 items were found to capture change in QoL, and of the 3 domains (emotions, symptoms, functioning), the emotional aspect of the disease was most burdensome and responsive to change 2 months after patch testing. Providers can reliably use this index to assess changes in QoL over time.

Background: Female dermatologists often face the challenges of balancing a rewarding medical career with duties of home life and childrearing. Excessive responsibility at home or work can introduce barriers to balance and prove detrimental to the health and wellness of the physician. Objective: We aim to perform a needs assessment through a series of survey questions with regard to home and work responsibilities and impacts on mental health. Methods: Survey participants were selected from the Women’s Dermatologic Society through an e-mail invitation with a link to an anonymous survey tool and a paper questionnaire at the Women’s Dermatologic Society Forum in February 2019 in Dallas, Texas. The survey included 20 questions with regard to household responsibilities, child care, clinical responsibilities, specialty education, and impacts on personal time, sleep, and overall sense of well-being. There were a total of 127 respondents. Results: Eighty-five percent of physicians in our cohort are currently married. A large percent of respondents utilized hired household help in the form of nannies to perform chores. Spousal contribution was emphasized in this cohort and often highlighted as an important factor in maintaining home life duties. Conclusion: The professional women in our cohort may be balancing work and life at the expense of personal physical and mental health with little time to exercise and fewer hours of sleep per night. Keywords: Work–life balance, female professionals, female dermatologists, Women’s Dermatologic Society, physician burnout

We sought to determine the incidence of RFDD in patients receiving dupilumab and the rate of resolution of RFDD after expanded series patch testing (ESPT) and allergen avoidance.This is a retrospective chart review of 80 patients with atopic dermatitis who were evaluated for RFDD after treatment with dupilumab. Expanded series patch testing findings and response to allergen avoidance were assessed in the subset of patients with RFDD who subsequently underwent ESPT while continuing to receive dupilumab.Forty-nine patients (61.3%) experienced facial dermatitis before initiating dupilumab. Thirty-five patients (43.8%) experienced RFDD after starting dupilumab. Of the 14 patients with RFDD who received ESPT, 92.9% had 1 or more relevant positive patch test results, with 50% of such patients being mostly to completely clear of facial dermatitis after allergen avoidance. Importantly, 50.6% of the positive reactions to allergens were not included on the North American Contact Dermatitis Group Core 80.Many patients with RFDD benefit from patch testing and subsequent allergen avoidance. Expanded series patch testing should be offered to patients who experience RFDD after beginning dupilumab therapy to ensure that such patients have eliminated any exogenous component of their dermatitis, such as concomitant allergic contact dermatitis.

Certain types of alopecia, such as traction alopecia, discoid lupus erythematosus, and central centrifugal cicatricial alopecia, occur more commonly in African-American individuals than in those of other ethnicities. Both intrinsic hair qualities and hair care practices play a role. Lower baseline tensile strength, hair density, and growth rates, as well as the use of high-tension hairstyles and chemical relaxers may contribute to alopecia in this group. Alopecia can also occur as a result of discoid lupus erythematosus, which involves chronic lymphocytic infiltration and eventual scarring of the hair follicle. Lichen planopilaris is a less common cause of scarring alopecia that can appear clinically similar to other forms of cicatricial alopecia. Lastly, although not classically associated with hair loss, recent evidence indicates that seborrheic dermatitis may play a role in shedding and alopecia. Recognizing and differentiating these alopecic subtypes clinically and histopathologically is important for prompt diagnosis and treatment. This article is based on a chapter in Ethnic Skin and Hair, and intended as a supplemental article to “Current and Emerging Treatment Strategies for Hair Loss in Women of Color.” Keywords: Alopecia, Traction alopecia, Seborrheic dermatitis, Lichen planopilaris, Discoid lupus erythematosus

Background: The mechanisms underlying eye-related complications with dupilumab are poorly understood. Objective: This study aimed to determine the incidence and characteristics of ocular complications with dupilumab and the prevalence of comorbid allergic contact dermatitis in the same subpopulation. Methods: This is a retrospective chart review of 48 patients with atopic dermatitis who received dupilumab. For patients with eye involvement at first follow-up, we discuss the presence of eyelid dermatitis, blepharitis, or conjunctivitis and analyze available patch test findings in patients with ocular complications while treated with dupilumab. Results: A total of 14 patients (29.2%) showed eye involvement while on dupilumab, all of whom experienced eye involvement prior to dupilumab. The results of the patch test were most commonly positive for emulsifier/surfactants (42.5%) and fragrances (30.4%). Nine patients experienced improvement with allergen avoidance subsequent to patch testing, and four of nine patients’ conditions cleared almost entirely. This is a non-randomized study in a small cohort of patients. Only 18 patients had their disease confirmed by an ophthalmologist. Conclusion: All patients with eye involvement while on dupilumab had a history of eye involvement prior to dupilumab, suggest that dupilumab may encourage rather than cause ocular surface inflammation. Significant improvement after patch testing in nearly half of patients suggests that allergic contact dermatitis contributes to some cases of dupilumab-associated eye complications. Keywords: Atopic dermatitis, Allergic contact dermatitis, Dupilumab, Patch testing, Conjunctivitis, Blepharitis

Vulvar disease is common, and urologists are often the first providers to see patients with a vulvar skin condition. Primary vulvar dermatoses can be localized to the anogenital area or a manifestation of more diffuse cutaneous disease. Additionally, secondary dermatoses can develop from exogenous agents and inflammatory vaginitis. Vulvar conditions are challenging to diagnose due to location and different types of skin and mucosal epithelium involved. Herein, we provide an overview of noninfectious inflammatory vulvar dermatoses (Part I) and benign and malignant vulvar neoplasms (Part II), grouped by morphologic findings. We include diagnostic evaluation, workup, and management of these conditions.

Idiopathic pure sudomotor failure (IPSF) is a rare disease characterized by acquired impairment in total body sweating despite exposure to heat or exercise. Its etiology is unknown but thought to involve defective cholinergic receptors on eccrine sweat glands. This article reviews the epidemiology, pathophysiology, presentation, and management of IPSF. Additionally, we report two cases of IPSF treated with multimodal therapy, including stacked antihistamine regimens and omalizumab, resulting in symptom improvement. This is the first report of treatment of IPSF with omalizumab, although its benefit is uncertain and requires further study.

Author(s): Abel, Mary Kathryn; Suresh, Raagini; Raffi, Jodie; McCalmont, Timothy H; Murase, Jenny E

Introduction: Atopic dermatitis (AD) is a chronic, inflammatory skin disease. Conventional treatments include topical emollients, corticosteroids, calcineurin inhibitors, phototherapy, and systemic immunomodulatory agents, however, these medications have limitations in the treatment of moderate to severe AD. Current literature demonstrates that oral small molecules may be an effective modality to treat AD. Method: Using PubMed/MEDLINE, Embase, Cochrane Skin databases and clinicaltrials.gov a search with terms 'atopic dermatitis or atopic eczema' and 'name of the oral small molecule' was conducted resulting in 1197 articles. Inclusion criteria were studies involving human subjects treated with oral small molecule medication for AD and written in English. Randomized clinical trials, open-label prospective trials, and case reports/series were reviewed. Results: Seven articles, with a total of 250 patients, were included for review. Oral small molecules studied include: apremilast, baricitinib, JNJ-39758979, and tofacitinib. Small molecules demonstrate improvement in AD disease scores, patient-reported outcomes, and quality of life. Conclusion: Preliminary results demonstrate that oral small molecules are an effective treatment option in AD with minimal side effects. Additional randomized studies with larger sample sizes are needed to determine the efficacy and long-term side effects of these novel therapies.

Alopecia occurs at a higher rate in women of color (WOC) and has a negative psychosocial impact on the patient; thus it is imperative that all dermatologists are up to date on how to address hair loss-related concerns effectively in this population. Basic structural features of hair differ between ethnic groups and may contribute to hair loss later in life. Unique hair care practices in this group, which can play a role in hair loss in WOC, will be discussed in detail. Alopecia has a wide range of etiologic subtypes, certain forms of which are more common in WOC. Non-scarring alopecias of special focus to the WOC population include traction alopecia, trichorrhexis nodosa, and seborrheic dermatitis, the latter of which can be associated with alopecia. It is important to be familiar with non-scarring forms of alopecia, as prompt diagnosis can have a profound impact on the clinical course and total eventual hair loss associated with these diseases. Examples of scarring or cicatricial alopecias include central centrifugal cicatricial alopecia, discoid lupus erythematosus, lichen planopilaris, and frontal fibrosing alopecia. While some alopecias are potentially reversible, management of cicatricial alopecias focuses on symptom relief and halting the progression of hair loss.

BACKGROUND: Changes in skin pigmentation patterns related to the fluctuation of estrogen receptors and progesterone receptors during menstruation, also known as catamenial hyperpigmentation, have been reported in several studies. OBJECTIVE: We sought to summarize the literature on catamenial skin hyperpigmentation and menses-induced exacerbations of skin pigmentation disorders. METHODS: We searched PubMed/MEDLINE and the Cochrane Skin database with the search terms menses and pigment, estrogen and pigment, progesterone and pigment, and hyperpigmentation and menses, then assessed the relevant literature on skin diseases related to nonpathological menstruation. RESULTS: The most commonly reported primary catamenial hyperpigmentation disorders are postinflammatory hyperpigmentation (PIH) after laser therapy and ultraviolet sensitivity (UV). The most reported chronic skin pigmentation exacerbated by menses is melasma. The literature detailing catamenial hyperpigmentation is limited to cross-sectional studies, experimental studies, surveys, review articles, case reports, and small trials, leading to a lower level of evidence. CONCLUSION: Our review of the literature revealed that the most common catamenial hyperpigmentation is melasma. We also found a reported higher risk of PIH after laser therapies and UV sensitivity. Estrogen and progesterone are two of the major factors responsible for catamenial hyperpigmentation of the skin. Generally, the changes happen in the luteal phase of the menstrual cycle when the serum levels of sex hormones are at their peak. Although the exact balance of influence is controversial, most recent studies indicate that estrogen has a more prominent role than progesterone in inducing hyperpigmentation.

The year 2019 marks the 30th anniversary of the American Contact Dermatitis Society (ACDS). The work of inaugural ACDS members and the 3 decades of camaraderie, collaboration, education, and investigation of contact dermatitis that followed the inception of the ACDS are celebrated in this historical account.

The degree of neonatal exposure to potentially sensitizing agents on neonatal intensive care units (NICUs) and the process by which personal care products are selected for use in the NICU are poorly documented. We evaluated personal care products used in three NICUs for potentially sensitizing agents. We interviewed NICU staff to analyze how products are selected and approved for use. Twenty-four personal care products were evaluated. 75% contained one or more potential contact allergen, with fragrances being most common. Staff preference, brand loyalty, cost, and small product size were often considered when approving NICU products. The prevalence of potentially sensitizing agents in the products indicates a need for improvement in the evaluation and acquisition process of over-the-counter products used for neonatal skin care. The involvement of dermatology in this process may be beneficial.

BACKGROUND Contact dermatitis is a prevalent condition that has a significant impact on quality of life (QoL). Although many generic dermatological QoL instruments exist, none were developed by and for patients with allergic contact dermatitis (ACD). OBJECTIVE The aim of the study was to create and validate a reliable QoL instrument specific for the ACD population. METHODS We identified QoL items specific to ACD through a series of qualitative interviews with ACD patients and experts. We created a 17-question survey that queries the patient across the following 3 major domains: symptoms, functioning, and emotions. We used statistical methods to evaluate the reliability and validity of this tool. RESULTS Ninety patients with relevant positive results on patch testing completed the novel ACD instrument and the Skindex-29. This instrument exhibited reliability and validity in individuals with ACD and was more sensitive than the generic tool Skindex-29. CONCLUSIONS This novel instrument is the first tool developed specifically to assess the unique impacts of ACD on QoL. Providers can reliably use this index to assess the specific aspects of the disease most problematic for the ACD patient and use this information to more properly inform counseling and management.

Background It is unclear whether the type 2 T helper cell–specific immunosuppressive action of dupilumab interferes with patch testing. Objectives We sought to evaluate the reliability of patch testing on dupilumab and the contribution of allergic contact dermatitis (ACD) to complex dermatitis in patients with residual dermatitis on dupilumab. Methods This is a retrospective chart review of 48 patients with atopic dermatitis (AD) who were treated with dupilumab. We compare the results of patch tests performed before and after the initiation of dupilumab and the prevalence of comorbid ACD in patch-tested individuals. Results A minority of patch test reactions were “lost” on dupilumab (13/125; 10.4%). Five of 13 lost reactions occurred in individuals with documented immunodeficiency. Thirty-two of 35 patch-tested patients (91.4%) had comorbid ACD; 92.3% of individuals patch tested on dupilumab experienced further clinical improvement with allergen avoidance. Limitations This is a nonrandomized study in a small cohort of patients. The clearance of dupilumab was assessed by subjective patient reports. Conclusions Dupilumab does not appear to exert a dampening effect on patch test results. AD with comorbid ACD was highly prevalent and allergen avoidance resulted in significant improvement in residual dermatitis that had not resolved without dupilumab therapy.