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Adult atopic dermatitis brings increased osteoporosis risk
MADRID – – even if they’ve never taken systemic corticosteroids, according to a large observational Danish national registry study.
A key study finding was that these elevated risks were concentrated in the patients who used potent or superpotent topical corticosteroids. Adult AD patients who used mild- or moderate-potency topical steroids were not at significantly increased risk. Neither were patients on topical calcineurin inhibitors, Jacob P. Thyssen, MD, PhD, reported at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology.
“The absolute risk is low, but it’s real,” commented Dr. Thyssen, professor of dermatology at the University of Copenhagen.
His advice to colleagues: “Dermatologists should consider alternative treatments in the chronic excessive users of topical corticosteroids, or use them in combination with prophylactic treatment to preserve bone homeostasis in such patients.”
He presented the results of a retrospective case-control study of 10,636 Danish adults with AD and 87,989 matched controls. At baseline in this study, which featured a maximum of 20 years of follow-up starting in 1997, participants had no history of osteoporosis.
Dr. Thyssen expressed the absolute risk of being diagnosed with osteoporosis in the study as follows: If 10,000 adult AD patients were followed for 1 year, on average 23.5 of them would be diagnosed with osteoporosis, a rate more than double the 10.3 per 10,000 in the general population. Moreover, on average, 42.6 out of 10,000 adult AD patients would incur a major osteoporotic fracture during a year of follow-up, compared with 32.3 individuals in the general population.
In the subgroup of patients who never used systemic corticosteroids, the risk of being diagnosed with osteoporosis was 12.8 per 10,000 per year, significantly higher than the 7.4 per 10,000 rate in the general population. Similarly, the 1-year rate of major osteoporotic fractures was 33.1 per 10,000 among the AD group and 29.6 in matched controls.
In a Cox regression analysis adjusted for age, sex, socioeconomic status, body mass index, asthma, and the use of a variety of medications thought to potentially have a negative effect upon bone metabolism, the risk of osteoporosis in the entire group of 10,636 adult AD patients was 51% greater than in matched controls, and their risk of major osteoporotic fractures was 18% greater. In the subgroup of AD patients who never used systemic steroids, the risks of osteoporosis and major osteoporotic fractures were 82% and 14% greater than in controls. The medications adjusted for in the regression analysis included proton pump inhibitors, thiazide diuretics, H2 receptor blockers, statins, cyclosporine, hormone therapy, contraceptives, and psychotropic medications.
Scoring Atopic Dermatitis (SCORAD) ratings were available on roughly 4,000 of the adult AD patients. In an analysis of this large subgroup, disease severity as reflected in SCORAD scores did not explain the increased osteoporosis and fracture risks. However, the use of potent or superpotent topical corticosteroids did. Patients who used potent topical steroids had a statistically significant 16% increased risk of being diagnosed with osteoporosis than nonusers, as well as a 7% increased risk of major osteoporotic fractures. Patients who applied superpotent topical steroids had 42% and 18% increased risks of those two adverse outcomes.
In contrast, neither the use of topical calcineurin inhibitors nor mild- or mid-potency topical steroids was associated with increased risk of bone events in a Cox regression analysis adjusted for potential confounders.
A relationship between the use of high-potency topical corticosteroids and adverse bone events is biologically plausible, according to Dr. Thyssen. He and his coinvestigators have previously documented a 100%-400% increased rate of chemical penetration through atopic skin, which is notoriously barrier damaged.
“We find it very likely that, if you put topical steroids on atopic skin in high amounts and for a very long time, you may have systemic effects,” he said.
A great many adult AD patients do exactly that. When Dr. Thyssen and coworkers analyzed Danish national prescription drug registry data for their patient cohort, they found that roughly one-third of the elderly subgroup had filled prescriptions totaling greater than 2 kg of mometasone or other similar-potency steroids over the previous 10 years.
“So we know that a significant proportion of our atopic dermatitis patients are really high users of topical corticosteroids,” the dermatologist noted.
Dr. Thyssen’s national osteoporosis and fracture study was funded with a government research grant. He reported serving as an advisor to and/or recipient of research grants from AbbVie, Pfizer, Leo Pharma, Eli Lilly, Regeneron, Sanofi Genzyme, and Union Therapeutics.
MADRID – – even if they’ve never taken systemic corticosteroids, according to a large observational Danish national registry study.
A key study finding was that these elevated risks were concentrated in the patients who used potent or superpotent topical corticosteroids. Adult AD patients who used mild- or moderate-potency topical steroids were not at significantly increased risk. Neither were patients on topical calcineurin inhibitors, Jacob P. Thyssen, MD, PhD, reported at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology.
“The absolute risk is low, but it’s real,” commented Dr. Thyssen, professor of dermatology at the University of Copenhagen.
His advice to colleagues: “Dermatologists should consider alternative treatments in the chronic excessive users of topical corticosteroids, or use them in combination with prophylactic treatment to preserve bone homeostasis in such patients.”
He presented the results of a retrospective case-control study of 10,636 Danish adults with AD and 87,989 matched controls. At baseline in this study, which featured a maximum of 20 years of follow-up starting in 1997, participants had no history of osteoporosis.
Dr. Thyssen expressed the absolute risk of being diagnosed with osteoporosis in the study as follows: If 10,000 adult AD patients were followed for 1 year, on average 23.5 of them would be diagnosed with osteoporosis, a rate more than double the 10.3 per 10,000 in the general population. Moreover, on average, 42.6 out of 10,000 adult AD patients would incur a major osteoporotic fracture during a year of follow-up, compared with 32.3 individuals in the general population.
In the subgroup of patients who never used systemic corticosteroids, the risk of being diagnosed with osteoporosis was 12.8 per 10,000 per year, significantly higher than the 7.4 per 10,000 rate in the general population. Similarly, the 1-year rate of major osteoporotic fractures was 33.1 per 10,000 among the AD group and 29.6 in matched controls.
In a Cox regression analysis adjusted for age, sex, socioeconomic status, body mass index, asthma, and the use of a variety of medications thought to potentially have a negative effect upon bone metabolism, the risk of osteoporosis in the entire group of 10,636 adult AD patients was 51% greater than in matched controls, and their risk of major osteoporotic fractures was 18% greater. In the subgroup of AD patients who never used systemic steroids, the risks of osteoporosis and major osteoporotic fractures were 82% and 14% greater than in controls. The medications adjusted for in the regression analysis included proton pump inhibitors, thiazide diuretics, H2 receptor blockers, statins, cyclosporine, hormone therapy, contraceptives, and psychotropic medications.
Scoring Atopic Dermatitis (SCORAD) ratings were available on roughly 4,000 of the adult AD patients. In an analysis of this large subgroup, disease severity as reflected in SCORAD scores did not explain the increased osteoporosis and fracture risks. However, the use of potent or superpotent topical corticosteroids did. Patients who used potent topical steroids had a statistically significant 16% increased risk of being diagnosed with osteoporosis than nonusers, as well as a 7% increased risk of major osteoporotic fractures. Patients who applied superpotent topical steroids had 42% and 18% increased risks of those two adverse outcomes.
In contrast, neither the use of topical calcineurin inhibitors nor mild- or mid-potency topical steroids was associated with increased risk of bone events in a Cox regression analysis adjusted for potential confounders.
A relationship between the use of high-potency topical corticosteroids and adverse bone events is biologically plausible, according to Dr. Thyssen. He and his coinvestigators have previously documented a 100%-400% increased rate of chemical penetration through atopic skin, which is notoriously barrier damaged.
“We find it very likely that, if you put topical steroids on atopic skin in high amounts and for a very long time, you may have systemic effects,” he said.
A great many adult AD patients do exactly that. When Dr. Thyssen and coworkers analyzed Danish national prescription drug registry data for their patient cohort, they found that roughly one-third of the elderly subgroup had filled prescriptions totaling greater than 2 kg of mometasone or other similar-potency steroids over the previous 10 years.
“So we know that a significant proportion of our atopic dermatitis patients are really high users of topical corticosteroids,” the dermatologist noted.
Dr. Thyssen’s national osteoporosis and fracture study was funded with a government research grant. He reported serving as an advisor to and/or recipient of research grants from AbbVie, Pfizer, Leo Pharma, Eli Lilly, Regeneron, Sanofi Genzyme, and Union Therapeutics.
MADRID – – even if they’ve never taken systemic corticosteroids, according to a large observational Danish national registry study.
A key study finding was that these elevated risks were concentrated in the patients who used potent or superpotent topical corticosteroids. Adult AD patients who used mild- or moderate-potency topical steroids were not at significantly increased risk. Neither were patients on topical calcineurin inhibitors, Jacob P. Thyssen, MD, PhD, reported at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology.
“The absolute risk is low, but it’s real,” commented Dr. Thyssen, professor of dermatology at the University of Copenhagen.
His advice to colleagues: “Dermatologists should consider alternative treatments in the chronic excessive users of topical corticosteroids, or use them in combination with prophylactic treatment to preserve bone homeostasis in such patients.”
He presented the results of a retrospective case-control study of 10,636 Danish adults with AD and 87,989 matched controls. At baseline in this study, which featured a maximum of 20 years of follow-up starting in 1997, participants had no history of osteoporosis.
Dr. Thyssen expressed the absolute risk of being diagnosed with osteoporosis in the study as follows: If 10,000 adult AD patients were followed for 1 year, on average 23.5 of them would be diagnosed with osteoporosis, a rate more than double the 10.3 per 10,000 in the general population. Moreover, on average, 42.6 out of 10,000 adult AD patients would incur a major osteoporotic fracture during a year of follow-up, compared with 32.3 individuals in the general population.
In the subgroup of patients who never used systemic corticosteroids, the risk of being diagnosed with osteoporosis was 12.8 per 10,000 per year, significantly higher than the 7.4 per 10,000 rate in the general population. Similarly, the 1-year rate of major osteoporotic fractures was 33.1 per 10,000 among the AD group and 29.6 in matched controls.
In a Cox regression analysis adjusted for age, sex, socioeconomic status, body mass index, asthma, and the use of a variety of medications thought to potentially have a negative effect upon bone metabolism, the risk of osteoporosis in the entire group of 10,636 adult AD patients was 51% greater than in matched controls, and their risk of major osteoporotic fractures was 18% greater. In the subgroup of AD patients who never used systemic steroids, the risks of osteoporosis and major osteoporotic fractures were 82% and 14% greater than in controls. The medications adjusted for in the regression analysis included proton pump inhibitors, thiazide diuretics, H2 receptor blockers, statins, cyclosporine, hormone therapy, contraceptives, and psychotropic medications.
Scoring Atopic Dermatitis (SCORAD) ratings were available on roughly 4,000 of the adult AD patients. In an analysis of this large subgroup, disease severity as reflected in SCORAD scores did not explain the increased osteoporosis and fracture risks. However, the use of potent or superpotent topical corticosteroids did. Patients who used potent topical steroids had a statistically significant 16% increased risk of being diagnosed with osteoporosis than nonusers, as well as a 7% increased risk of major osteoporotic fractures. Patients who applied superpotent topical steroids had 42% and 18% increased risks of those two adverse outcomes.
In contrast, neither the use of topical calcineurin inhibitors nor mild- or mid-potency topical steroids was associated with increased risk of bone events in a Cox regression analysis adjusted for potential confounders.
A relationship between the use of high-potency topical corticosteroids and adverse bone events is biologically plausible, according to Dr. Thyssen. He and his coinvestigators have previously documented a 100%-400% increased rate of chemical penetration through atopic skin, which is notoriously barrier damaged.
“We find it very likely that, if you put topical steroids on atopic skin in high amounts and for a very long time, you may have systemic effects,” he said.
A great many adult AD patients do exactly that. When Dr. Thyssen and coworkers analyzed Danish national prescription drug registry data for their patient cohort, they found that roughly one-third of the elderly subgroup had filled prescriptions totaling greater than 2 kg of mometasone or other similar-potency steroids over the previous 10 years.
“So we know that a significant proportion of our atopic dermatitis patients are really high users of topical corticosteroids,” the dermatologist noted.
Dr. Thyssen’s national osteoporosis and fracture study was funded with a government research grant. He reported serving as an advisor to and/or recipient of research grants from AbbVie, Pfizer, Leo Pharma, Eli Lilly, Regeneron, Sanofi Genzyme, and Union Therapeutics.
REPORTING FROM EADV 2019
Calif. woman poisoned by methylmercury-containing skin cream
The first known case of contamination of skin-lightening cream with methylmercury was identified in July 2019 in a Mexican American woman in Sacramento, Calif., according to Anita Mudan, MD, of the department of emergency medicine at the University of California, San Francisco, and associates.
The woman, aged 47 years, sought medical care for dysesthesias and weakness in the upper extremities, the investigators wrote in a report published in Morbidity and Mortality Weekly Report.
This progressed to dysarthria, blurry vision, and unsteady gait over a 2-week period, leading to her hospitalization. Over the next 2 weeks, she declined into an agitated delirium; screening blood and urine tests detected levels of mercury exceeding the upper limit of quantification.
Oral dimercaptosuccinic acid at 10 mg/kg every 8 hours was administered via feeding tube. The California Department of Public Health (CDPH) conducted interviews with the patient’s family, discovering that the patient had used a skin-lightening cream obtained from Mexico for the past 7 years. The cream was analyzed and found to contain mercury at a concentration of 12,000 ppm. A Raman spectral analysis showed that the sample contained the organic compound methylmercury iodide.
Typically, contaminated skin-lightening creams contain inorganic mercury at levels up to 200,000 ppm; the significantly lower mercury content of the cream in this case “underscores the far higher toxicity of organic mercury compounds,” the investigators wrote.
The patient has undergone extensive chelation therapy, but remains unable to verbalize or care for herself, requiring continued tube feeding for nutritional support, Dr. Mudan and associates noted.
“CDPH is actively working to warn the public of this health risk, actively screening other skin lightening cream samples for mercury, and is investigating the case of a family member with likely exposure but less severe illness,” the investigators concluded.
The study authors reported that they had no conflicts of interest.
SOURCE: Mudan A et al. MMWR Morb Mortal Wkly Rep. 2019 Dec 20. doi: 10.15585/mmwr.mm6850a4.
The first known case of contamination of skin-lightening cream with methylmercury was identified in July 2019 in a Mexican American woman in Sacramento, Calif., according to Anita Mudan, MD, of the department of emergency medicine at the University of California, San Francisco, and associates.
The woman, aged 47 years, sought medical care for dysesthesias and weakness in the upper extremities, the investigators wrote in a report published in Morbidity and Mortality Weekly Report.
This progressed to dysarthria, blurry vision, and unsteady gait over a 2-week period, leading to her hospitalization. Over the next 2 weeks, she declined into an agitated delirium; screening blood and urine tests detected levels of mercury exceeding the upper limit of quantification.
Oral dimercaptosuccinic acid at 10 mg/kg every 8 hours was administered via feeding tube. The California Department of Public Health (CDPH) conducted interviews with the patient’s family, discovering that the patient had used a skin-lightening cream obtained from Mexico for the past 7 years. The cream was analyzed and found to contain mercury at a concentration of 12,000 ppm. A Raman spectral analysis showed that the sample contained the organic compound methylmercury iodide.
Typically, contaminated skin-lightening creams contain inorganic mercury at levels up to 200,000 ppm; the significantly lower mercury content of the cream in this case “underscores the far higher toxicity of organic mercury compounds,” the investigators wrote.
The patient has undergone extensive chelation therapy, but remains unable to verbalize or care for herself, requiring continued tube feeding for nutritional support, Dr. Mudan and associates noted.
“CDPH is actively working to warn the public of this health risk, actively screening other skin lightening cream samples for mercury, and is investigating the case of a family member with likely exposure but less severe illness,” the investigators concluded.
The study authors reported that they had no conflicts of interest.
SOURCE: Mudan A et al. MMWR Morb Mortal Wkly Rep. 2019 Dec 20. doi: 10.15585/mmwr.mm6850a4.
The first known case of contamination of skin-lightening cream with methylmercury was identified in July 2019 in a Mexican American woman in Sacramento, Calif., according to Anita Mudan, MD, of the department of emergency medicine at the University of California, San Francisco, and associates.
The woman, aged 47 years, sought medical care for dysesthesias and weakness in the upper extremities, the investigators wrote in a report published in Morbidity and Mortality Weekly Report.
This progressed to dysarthria, blurry vision, and unsteady gait over a 2-week period, leading to her hospitalization. Over the next 2 weeks, she declined into an agitated delirium; screening blood and urine tests detected levels of mercury exceeding the upper limit of quantification.
Oral dimercaptosuccinic acid at 10 mg/kg every 8 hours was administered via feeding tube. The California Department of Public Health (CDPH) conducted interviews with the patient’s family, discovering that the patient had used a skin-lightening cream obtained from Mexico for the past 7 years. The cream was analyzed and found to contain mercury at a concentration of 12,000 ppm. A Raman spectral analysis showed that the sample contained the organic compound methylmercury iodide.
Typically, contaminated skin-lightening creams contain inorganic mercury at levels up to 200,000 ppm; the significantly lower mercury content of the cream in this case “underscores the far higher toxicity of organic mercury compounds,” the investigators wrote.
The patient has undergone extensive chelation therapy, but remains unable to verbalize or care for herself, requiring continued tube feeding for nutritional support, Dr. Mudan and associates noted.
“CDPH is actively working to warn the public of this health risk, actively screening other skin lightening cream samples for mercury, and is investigating the case of a family member with likely exposure but less severe illness,” the investigators concluded.
The study authors reported that they had no conflicts of interest.
SOURCE: Mudan A et al. MMWR Morb Mortal Wkly Rep. 2019 Dec 20. doi: 10.15585/mmwr.mm6850a4.
FROM MMWR
Fingernail deformity
The groove in the patient’s nail, and associated splitting, was due to a digital mucous cyst seen in the photo proximal to the cuticle.
In spite of the name, these cysts do not contain mucus. Instead, they contain synovial fluid and represent an outpouching of the distal interphalangeal joint of the index finger. This same process is called a ganglion cyst when it is seen at the wrist and a Baker’s cyst when it is behind the knee. These cysts typically form from an increase in synovial fluid, often due to underlying osteoarthritis, injury, or degenerative changes of the joint capsule. If the patient is asymptomatic, no treatment is required. Half of the lesions spontaneously resolve. If the patient is symptomatic, treatment options include a steroid injection; aspirating the cyst and then using a compressive cryosurgery tip to freeze the superficial and deep aspects of the cyst to scar it down; and surgical resection of the cyst.
In this case, the patient was in pain because the abnormally shaped nail was breaking. She elected to have a steroid injection into the cyst—0.25 ml of triamcinolone 20 mg/ml. The family physician (FP) advised her that this would reduce the inflammation in the distal interphalangeal joint, hopefully reducing the size of the digital mucous cyst. The FP also indicated that she might require several injections to achieve a positive outcome and that it would take 6 months for her fingernail to return to normal.
Images and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
The groove in the patient’s nail, and associated splitting, was due to a digital mucous cyst seen in the photo proximal to the cuticle.
In spite of the name, these cysts do not contain mucus. Instead, they contain synovial fluid and represent an outpouching of the distal interphalangeal joint of the index finger. This same process is called a ganglion cyst when it is seen at the wrist and a Baker’s cyst when it is behind the knee. These cysts typically form from an increase in synovial fluid, often due to underlying osteoarthritis, injury, or degenerative changes of the joint capsule. If the patient is asymptomatic, no treatment is required. Half of the lesions spontaneously resolve. If the patient is symptomatic, treatment options include a steroid injection; aspirating the cyst and then using a compressive cryosurgery tip to freeze the superficial and deep aspects of the cyst to scar it down; and surgical resection of the cyst.
In this case, the patient was in pain because the abnormally shaped nail was breaking. She elected to have a steroid injection into the cyst—0.25 ml of triamcinolone 20 mg/ml. The family physician (FP) advised her that this would reduce the inflammation in the distal interphalangeal joint, hopefully reducing the size of the digital mucous cyst. The FP also indicated that she might require several injections to achieve a positive outcome and that it would take 6 months for her fingernail to return to normal.
Images and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
The groove in the patient’s nail, and associated splitting, was due to a digital mucous cyst seen in the photo proximal to the cuticle.
In spite of the name, these cysts do not contain mucus. Instead, they contain synovial fluid and represent an outpouching of the distal interphalangeal joint of the index finger. This same process is called a ganglion cyst when it is seen at the wrist and a Baker’s cyst when it is behind the knee. These cysts typically form from an increase in synovial fluid, often due to underlying osteoarthritis, injury, or degenerative changes of the joint capsule. If the patient is asymptomatic, no treatment is required. Half of the lesions spontaneously resolve. If the patient is symptomatic, treatment options include a steroid injection; aspirating the cyst and then using a compressive cryosurgery tip to freeze the superficial and deep aspects of the cyst to scar it down; and surgical resection of the cyst.
In this case, the patient was in pain because the abnormally shaped nail was breaking. She elected to have a steroid injection into the cyst—0.25 ml of triamcinolone 20 mg/ml. The family physician (FP) advised her that this would reduce the inflammation in the distal interphalangeal joint, hopefully reducing the size of the digital mucous cyst. The FP also indicated that she might require several injections to achieve a positive outcome and that it would take 6 months for her fingernail to return to normal.
Images and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
Which children are at greatest risk for atopic dermatitis?
MADRID – A parental history of asthma or allergic rhinitis significantly increases the risk that a child will develop atopic dermatitis, and that risk doubles if a parent has a history of atopic dermatitis rather than another atopic disease, Nina H. Ravn reported at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology.
She presented a comprehensive meta-analysis of 149 published studies addressing the risk of developing atopic dermatitis according to parental history of atopic disease. The studies included more than 656,000 participants. The picture that emerged from the meta-analysis was one of a stepwise increase in the risk of pediatric atopic dermatitis according to the type and number of parental atopic diseases present.
“This is something that hopefully can be useful when you talk with parents or parents-to-be with atopic diseases and they want to know how their disease might affect their child,” explained Ms. Ravn of the University of Copenhagen.
It’s also information that clinicians will find helpful in appropriately targeting primary prevention interventions if and when methods of proven efficacy become available. That’s a likely prospect, as this is now an extremely active field of research, she noted.
The meta-analysis showed that a parental history of atopic dermatitis was associated with a 3.3-fold greater risk of atopic dermatitis in the offspring than in families without a parental history of atopy. A parental history of asthma was associated with a 1.56-fold increased risk, while allergic rhinitis in a parent was linked to a 1.68-fold increased risk.
“It does matter what type of atopic disease the parents have,” she observed. “Those with a parental history of asthma or allergic rhinitis can be considered as being at more of an intermediate risk level, while those with a parental history of atopic dermatitis are a particularly high risk group.”
Of note, the risk of pediatric atopic dermatitis was the same regardless of whether the father or mother was the one with a history of atopic disease. If one parent had a history of an atopic disease, the pediatric risk was increased 1.3-fold compared to when the parental history was negative. If both parents had a history of atopic illness, the risk jumped to 2.08-fold. And if one parent had a history of more than one form of atopic disease, the pediatric risk of atopic dermatitis was increased 2.32-fold.
“An interesting result that was new to me what that fathers’ and mothers’ contribution to risk is equal,” said session cochair Andreas Wollenberg, MD, professor of dermatology at Ludwig Maximilian University of Munich. “For the past 2 decades we were always taught that the mother would have a greater impact on that risk.”
“I was also surprised by our findings,” Ms. Ravn replied. “But when we pooled all the data there really was no difference, nor in any of our subanalyses.”
She reported having no financial conflicts regarding her study.
SOURCE: Ravn NH. THE EADV CONGRESS.
MADRID – A parental history of asthma or allergic rhinitis significantly increases the risk that a child will develop atopic dermatitis, and that risk doubles if a parent has a history of atopic dermatitis rather than another atopic disease, Nina H. Ravn reported at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology.
She presented a comprehensive meta-analysis of 149 published studies addressing the risk of developing atopic dermatitis according to parental history of atopic disease. The studies included more than 656,000 participants. The picture that emerged from the meta-analysis was one of a stepwise increase in the risk of pediatric atopic dermatitis according to the type and number of parental atopic diseases present.
“This is something that hopefully can be useful when you talk with parents or parents-to-be with atopic diseases and they want to know how their disease might affect their child,” explained Ms. Ravn of the University of Copenhagen.
It’s also information that clinicians will find helpful in appropriately targeting primary prevention interventions if and when methods of proven efficacy become available. That’s a likely prospect, as this is now an extremely active field of research, she noted.
The meta-analysis showed that a parental history of atopic dermatitis was associated with a 3.3-fold greater risk of atopic dermatitis in the offspring than in families without a parental history of atopy. A parental history of asthma was associated with a 1.56-fold increased risk, while allergic rhinitis in a parent was linked to a 1.68-fold increased risk.
“It does matter what type of atopic disease the parents have,” she observed. “Those with a parental history of asthma or allergic rhinitis can be considered as being at more of an intermediate risk level, while those with a parental history of atopic dermatitis are a particularly high risk group.”
Of note, the risk of pediatric atopic dermatitis was the same regardless of whether the father or mother was the one with a history of atopic disease. If one parent had a history of an atopic disease, the pediatric risk was increased 1.3-fold compared to when the parental history was negative. If both parents had a history of atopic illness, the risk jumped to 2.08-fold. And if one parent had a history of more than one form of atopic disease, the pediatric risk of atopic dermatitis was increased 2.32-fold.
“An interesting result that was new to me what that fathers’ and mothers’ contribution to risk is equal,” said session cochair Andreas Wollenberg, MD, professor of dermatology at Ludwig Maximilian University of Munich. “For the past 2 decades we were always taught that the mother would have a greater impact on that risk.”
“I was also surprised by our findings,” Ms. Ravn replied. “But when we pooled all the data there really was no difference, nor in any of our subanalyses.”
She reported having no financial conflicts regarding her study.
SOURCE: Ravn NH. THE EADV CONGRESS.
MADRID – A parental history of asthma or allergic rhinitis significantly increases the risk that a child will develop atopic dermatitis, and that risk doubles if a parent has a history of atopic dermatitis rather than another atopic disease, Nina H. Ravn reported at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology.
She presented a comprehensive meta-analysis of 149 published studies addressing the risk of developing atopic dermatitis according to parental history of atopic disease. The studies included more than 656,000 participants. The picture that emerged from the meta-analysis was one of a stepwise increase in the risk of pediatric atopic dermatitis according to the type and number of parental atopic diseases present.
“This is something that hopefully can be useful when you talk with parents or parents-to-be with atopic diseases and they want to know how their disease might affect their child,” explained Ms. Ravn of the University of Copenhagen.
It’s also information that clinicians will find helpful in appropriately targeting primary prevention interventions if and when methods of proven efficacy become available. That’s a likely prospect, as this is now an extremely active field of research, she noted.
The meta-analysis showed that a parental history of atopic dermatitis was associated with a 3.3-fold greater risk of atopic dermatitis in the offspring than in families without a parental history of atopy. A parental history of asthma was associated with a 1.56-fold increased risk, while allergic rhinitis in a parent was linked to a 1.68-fold increased risk.
“It does matter what type of atopic disease the parents have,” she observed. “Those with a parental history of asthma or allergic rhinitis can be considered as being at more of an intermediate risk level, while those with a parental history of atopic dermatitis are a particularly high risk group.”
Of note, the risk of pediatric atopic dermatitis was the same regardless of whether the father or mother was the one with a history of atopic disease. If one parent had a history of an atopic disease, the pediatric risk was increased 1.3-fold compared to when the parental history was negative. If both parents had a history of atopic illness, the risk jumped to 2.08-fold. And if one parent had a history of more than one form of atopic disease, the pediatric risk of atopic dermatitis was increased 2.32-fold.
“An interesting result that was new to me what that fathers’ and mothers’ contribution to risk is equal,” said session cochair Andreas Wollenberg, MD, professor of dermatology at Ludwig Maximilian University of Munich. “For the past 2 decades we were always taught that the mother would have a greater impact on that risk.”
“I was also surprised by our findings,” Ms. Ravn replied. “But when we pooled all the data there really was no difference, nor in any of our subanalyses.”
She reported having no financial conflicts regarding her study.
SOURCE: Ravn NH. THE EADV CONGRESS.
REPORTING FROM The EADV CONGRESS
Key clinical point: Pediatric atopic dermatitis risk varies according to type of parental history of atopic disease.
Major finding: A parental history of atopic dermatitis is associated with a 3.3-fold increased risk of atopic dermatitis in the child, twice the risk associated with parental asthma or allergic rhinitis.
Study details: This was a systematic review and meta-analysis of 149 published studies with 656,711 participants.
Disclosures: The presenter reported having no financial conflicts regarding the study, conducted free of commercial support.
Source: Ravn NH. The EADV Congress.
Ultrasound improves specificity of psoriatic arthritis referrals
The use of ultrasound in screening for psoriatic arthritis in patients with psoriasis could reduce the number of unnecessary referrals to rheumatologists, according to a research letter published in the British Journal of Dermatology.
Up to one-third of patients with psoriasis have underlying psoriatic arthritis (PsA), but half of all patients with psoriasis experience nonspecific musculoskeletal complaints.
“Different screening tools have been developed for the dermatology practice to distinguish patients with a higher likelihood of having PsA; however, the low specificities of these tools limit their use in clinical practice,” wrote Dilek Solmaz, MD, and colleagues at the University of Ottawa.
In this prospective study, 51 patients with psoriasis were screened for referral to a rheumatologist using the Early Arthritis for Psoriatic Patients and Psoriasis Epidemiology Screening Tool questionnaires. They also underwent a limited ultrasound scanning of wrists, hands, feet, and the most painful joint, which was reviewed by experienced rheumatologists.
A dermatologist was asked to make a decision on referral based on the questionnaire data alone, then invited to revisit that decision after viewing the ultrasound results. When basing their decision on the questionnaires only, the dermatologist decided to refer 92% of patients to a rheumatologist. Of these patients, 40% were subsequently diagnosed with PsA, which represented a sensitivity of 95% but specificity of just 9%.
After reviewing the ultrasound data, the dermatologist revised their recommendations and only referred 43% of patients. Of these, 68% were later diagnosed with psoriatic arthritis. Among the patients who were not referred after the ultrasound review, five were diagnosed with PsA, but two had isolated axial involvement with no peripheral joint disease. Excluding these two cases, the sensitivity decreased to 88% but specificity increased to 77%.
“Screening tools in psoriasis that have high sensitivities usually have low specificities, which means a higher number of patients to be referred to rheumatology than needed,” the authors wrote. “Our study demonstrated that a musculoskeletal [ultrasound] based on a predefined protocol improves the referrals made to rheumatology.”
The authors did note that the ultrasounds were reviewed by experienced rheumatologists, so the results might not be generalizable to less-experienced sonographers without experience in musculoskeletal disorders.
The study was funded by AbbVie. One author declared receiving funding for a fellowship from UCB. Two authors declared honoraria and advisory consultancies with the pharmaceutical sector, including AbbVie.
SOURCE: Solmaz D et al. Br J Dermatol. 2019 Nov 28. doi: 10.1111/bjd.18515.
The use of ultrasound in screening for psoriatic arthritis in patients with psoriasis could reduce the number of unnecessary referrals to rheumatologists, according to a research letter published in the British Journal of Dermatology.
Up to one-third of patients with psoriasis have underlying psoriatic arthritis (PsA), but half of all patients with psoriasis experience nonspecific musculoskeletal complaints.
“Different screening tools have been developed for the dermatology practice to distinguish patients with a higher likelihood of having PsA; however, the low specificities of these tools limit their use in clinical practice,” wrote Dilek Solmaz, MD, and colleagues at the University of Ottawa.
In this prospective study, 51 patients with psoriasis were screened for referral to a rheumatologist using the Early Arthritis for Psoriatic Patients and Psoriasis Epidemiology Screening Tool questionnaires. They also underwent a limited ultrasound scanning of wrists, hands, feet, and the most painful joint, which was reviewed by experienced rheumatologists.
A dermatologist was asked to make a decision on referral based on the questionnaire data alone, then invited to revisit that decision after viewing the ultrasound results. When basing their decision on the questionnaires only, the dermatologist decided to refer 92% of patients to a rheumatologist. Of these patients, 40% were subsequently diagnosed with PsA, which represented a sensitivity of 95% but specificity of just 9%.
After reviewing the ultrasound data, the dermatologist revised their recommendations and only referred 43% of patients. Of these, 68% were later diagnosed with psoriatic arthritis. Among the patients who were not referred after the ultrasound review, five were diagnosed with PsA, but two had isolated axial involvement with no peripheral joint disease. Excluding these two cases, the sensitivity decreased to 88% but specificity increased to 77%.
“Screening tools in psoriasis that have high sensitivities usually have low specificities, which means a higher number of patients to be referred to rheumatology than needed,” the authors wrote. “Our study demonstrated that a musculoskeletal [ultrasound] based on a predefined protocol improves the referrals made to rheumatology.”
The authors did note that the ultrasounds were reviewed by experienced rheumatologists, so the results might not be generalizable to less-experienced sonographers without experience in musculoskeletal disorders.
The study was funded by AbbVie. One author declared receiving funding for a fellowship from UCB. Two authors declared honoraria and advisory consultancies with the pharmaceutical sector, including AbbVie.
SOURCE: Solmaz D et al. Br J Dermatol. 2019 Nov 28. doi: 10.1111/bjd.18515.
The use of ultrasound in screening for psoriatic arthritis in patients with psoriasis could reduce the number of unnecessary referrals to rheumatologists, according to a research letter published in the British Journal of Dermatology.
Up to one-third of patients with psoriasis have underlying psoriatic arthritis (PsA), but half of all patients with psoriasis experience nonspecific musculoskeletal complaints.
“Different screening tools have been developed for the dermatology practice to distinguish patients with a higher likelihood of having PsA; however, the low specificities of these tools limit their use in clinical practice,” wrote Dilek Solmaz, MD, and colleagues at the University of Ottawa.
In this prospective study, 51 patients with psoriasis were screened for referral to a rheumatologist using the Early Arthritis for Psoriatic Patients and Psoriasis Epidemiology Screening Tool questionnaires. They also underwent a limited ultrasound scanning of wrists, hands, feet, and the most painful joint, which was reviewed by experienced rheumatologists.
A dermatologist was asked to make a decision on referral based on the questionnaire data alone, then invited to revisit that decision after viewing the ultrasound results. When basing their decision on the questionnaires only, the dermatologist decided to refer 92% of patients to a rheumatologist. Of these patients, 40% were subsequently diagnosed with PsA, which represented a sensitivity of 95% but specificity of just 9%.
After reviewing the ultrasound data, the dermatologist revised their recommendations and only referred 43% of patients. Of these, 68% were later diagnosed with psoriatic arthritis. Among the patients who were not referred after the ultrasound review, five were diagnosed with PsA, but two had isolated axial involvement with no peripheral joint disease. Excluding these two cases, the sensitivity decreased to 88% but specificity increased to 77%.
“Screening tools in psoriasis that have high sensitivities usually have low specificities, which means a higher number of patients to be referred to rheumatology than needed,” the authors wrote. “Our study demonstrated that a musculoskeletal [ultrasound] based on a predefined protocol improves the referrals made to rheumatology.”
The authors did note that the ultrasounds were reviewed by experienced rheumatologists, so the results might not be generalizable to less-experienced sonographers without experience in musculoskeletal disorders.
The study was funded by AbbVie. One author declared receiving funding for a fellowship from UCB. Two authors declared honoraria and advisory consultancies with the pharmaceutical sector, including AbbVie.
SOURCE: Solmaz D et al. Br J Dermatol. 2019 Nov 28. doi: 10.1111/bjd.18515.
FROM THE BRITISH JOURNAL OF DERMATOLOGY
Make the Diagnosis
A skin biopsy of one of the lesions showed granulomatous inflammation composed of lymphocytes, macrophages, and giant cells around hair follicles with negative mycobacterium stains and fungal stains, consistent with granulomatous periorificial dermatitis. Tissue cultures from a skin biopsy for aerobic bacteria, mycobacteria, and fungus all were negative.
The patient initially was treated with erythromycin, but after 2 weeks, he reported abdominal pain and nausea and was unable to tolerate the medication. He was switched to clarithromycin, which he took for 6 weeks with clearance of the lesions.
A year later, some of the lesions recurred. He was treated again with clarithromycin and the lesions resolved.
Childhood granulomatous periorificial dermatitis (CGPD) is a benign skin eruption that occurs in prepubertal children. It also has been called facial Afro-Caribbean childhood eruption (FACE), and it tends to occur most commonly in children of darker skin types.1 but there are some cases reported of extra facial involvement.2 The lesions usually are not symptomatic, and they are more common in boys. The cause of this condition is not known, but possible triggers could include prior exposure to topical and systemic corticosteroids, as well as exposure to certain allergens such as formaldehyde.1
In histopathology, the lesions are characterized by granulomatous infiltrates around the hair follicles and the upper dermis. The granulomas are formed of macrophages, lymphocytes, and giant cell, as were seen in our patient.3
Several conditions can look very similar to CGPD; these include sarcoidosis, lupus miliaris disseminatus faciei (LMDF), and granulomatous rosacea.
Sarcoidosis is a rare condition in children, and the lesions can be similar to the ones seen in our patient. Patients with sarcoidosis usually present with other systemic symptoms including fever, weight loss, respiratory symptoms, and fatigue; none of these were seen in our patient. Under the microscope, the lesions are characterized by “naked granulomas” instead of the inflammatory granulomas seen on our patient.
Lupus miliaris disseminatus faciei is a rare inflammatory skin condition commonly seen in young adults and is thought to be a variant of rosacea. It is characterized by skin-color to pink to yellow dome-shaped papules on the central face. Histologically, the lesions present as dermal epithelioid cell granulomas with central necrosis and surrounding lymphocytic infiltrate with multinucleate giant cells.4
Granulomatous rosacea and CGPD are considered two separate entities. Granulomatous rosacea tends to have a more chronic course, is not that common in children, and clinically presents with pustules, papules, and cysts around the eyes and cheeks.
Infectious processes like tuberculosis and fungal infections were ruled out in our patient with cultures and histopathology. Allergic contact dermatitis on the face can present with skin-color to pink papules, but they usually are very pruritic and improve with topical corticosteroids, while these medications can worsen CGPD.
CGPD can be a self-limiting condition. When mild, it can be treated with topical metronidazole, topical erythromycin, topical clindamycin solution, or pimecrolimus. Our patient failed treatment with pimecrolimus. For severe presentations, oral tetracyclines, erythromycin, and other macrolides, metronidazole, and oral isotretinoin can help clear the lesions.5
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Ann Dermatol. 2011 Aug;23(3):386-8.
2. Int J Dermatol. 2007 Feb;46(2):143-5.
3. J Cutan Med Surg. 2009 Feb 28;13(2):115-8.
4. An Bras Dermatol. 2017 Nov-Dec;92(6):851-3.
5. Indian Dermatol Online J. 2018 Jan-Feb; 9(1):68-70.
A skin biopsy of one of the lesions showed granulomatous inflammation composed of lymphocytes, macrophages, and giant cells around hair follicles with negative mycobacterium stains and fungal stains, consistent with granulomatous periorificial dermatitis. Tissue cultures from a skin biopsy for aerobic bacteria, mycobacteria, and fungus all were negative.
The patient initially was treated with erythromycin, but after 2 weeks, he reported abdominal pain and nausea and was unable to tolerate the medication. He was switched to clarithromycin, which he took for 6 weeks with clearance of the lesions.
A year later, some of the lesions recurred. He was treated again with clarithromycin and the lesions resolved.
Childhood granulomatous periorificial dermatitis (CGPD) is a benign skin eruption that occurs in prepubertal children. It also has been called facial Afro-Caribbean childhood eruption (FACE), and it tends to occur most commonly in children of darker skin types.1 but there are some cases reported of extra facial involvement.2 The lesions usually are not symptomatic, and they are more common in boys. The cause of this condition is not known, but possible triggers could include prior exposure to topical and systemic corticosteroids, as well as exposure to certain allergens such as formaldehyde.1
In histopathology, the lesions are characterized by granulomatous infiltrates around the hair follicles and the upper dermis. The granulomas are formed of macrophages, lymphocytes, and giant cell, as were seen in our patient.3
Several conditions can look very similar to CGPD; these include sarcoidosis, lupus miliaris disseminatus faciei (LMDF), and granulomatous rosacea.
Sarcoidosis is a rare condition in children, and the lesions can be similar to the ones seen in our patient. Patients with sarcoidosis usually present with other systemic symptoms including fever, weight loss, respiratory symptoms, and fatigue; none of these were seen in our patient. Under the microscope, the lesions are characterized by “naked granulomas” instead of the inflammatory granulomas seen on our patient.
Lupus miliaris disseminatus faciei is a rare inflammatory skin condition commonly seen in young adults and is thought to be a variant of rosacea. It is characterized by skin-color to pink to yellow dome-shaped papules on the central face. Histologically, the lesions present as dermal epithelioid cell granulomas with central necrosis and surrounding lymphocytic infiltrate with multinucleate giant cells.4
Granulomatous rosacea and CGPD are considered two separate entities. Granulomatous rosacea tends to have a more chronic course, is not that common in children, and clinically presents with pustules, papules, and cysts around the eyes and cheeks.
Infectious processes like tuberculosis and fungal infections were ruled out in our patient with cultures and histopathology. Allergic contact dermatitis on the face can present with skin-color to pink papules, but they usually are very pruritic and improve with topical corticosteroids, while these medications can worsen CGPD.
CGPD can be a self-limiting condition. When mild, it can be treated with topical metronidazole, topical erythromycin, topical clindamycin solution, or pimecrolimus. Our patient failed treatment with pimecrolimus. For severe presentations, oral tetracyclines, erythromycin, and other macrolides, metronidazole, and oral isotretinoin can help clear the lesions.5
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Ann Dermatol. 2011 Aug;23(3):386-8.
2. Int J Dermatol. 2007 Feb;46(2):143-5.
3. J Cutan Med Surg. 2009 Feb 28;13(2):115-8.
4. An Bras Dermatol. 2017 Nov-Dec;92(6):851-3.
5. Indian Dermatol Online J. 2018 Jan-Feb; 9(1):68-70.
A skin biopsy of one of the lesions showed granulomatous inflammation composed of lymphocytes, macrophages, and giant cells around hair follicles with negative mycobacterium stains and fungal stains, consistent with granulomatous periorificial dermatitis. Tissue cultures from a skin biopsy for aerobic bacteria, mycobacteria, and fungus all were negative.
The patient initially was treated with erythromycin, but after 2 weeks, he reported abdominal pain and nausea and was unable to tolerate the medication. He was switched to clarithromycin, which he took for 6 weeks with clearance of the lesions.
A year later, some of the lesions recurred. He was treated again with clarithromycin and the lesions resolved.
Childhood granulomatous periorificial dermatitis (CGPD) is a benign skin eruption that occurs in prepubertal children. It also has been called facial Afro-Caribbean childhood eruption (FACE), and it tends to occur most commonly in children of darker skin types.1 but there are some cases reported of extra facial involvement.2 The lesions usually are not symptomatic, and they are more common in boys. The cause of this condition is not known, but possible triggers could include prior exposure to topical and systemic corticosteroids, as well as exposure to certain allergens such as formaldehyde.1
In histopathology, the lesions are characterized by granulomatous infiltrates around the hair follicles and the upper dermis. The granulomas are formed of macrophages, lymphocytes, and giant cell, as were seen in our patient.3
Several conditions can look very similar to CGPD; these include sarcoidosis, lupus miliaris disseminatus faciei (LMDF), and granulomatous rosacea.
Sarcoidosis is a rare condition in children, and the lesions can be similar to the ones seen in our patient. Patients with sarcoidosis usually present with other systemic symptoms including fever, weight loss, respiratory symptoms, and fatigue; none of these were seen in our patient. Under the microscope, the lesions are characterized by “naked granulomas” instead of the inflammatory granulomas seen on our patient.
Lupus miliaris disseminatus faciei is a rare inflammatory skin condition commonly seen in young adults and is thought to be a variant of rosacea. It is characterized by skin-color to pink to yellow dome-shaped papules on the central face. Histologically, the lesions present as dermal epithelioid cell granulomas with central necrosis and surrounding lymphocytic infiltrate with multinucleate giant cells.4
Granulomatous rosacea and CGPD are considered two separate entities. Granulomatous rosacea tends to have a more chronic course, is not that common in children, and clinically presents with pustules, papules, and cysts around the eyes and cheeks.
Infectious processes like tuberculosis and fungal infections were ruled out in our patient with cultures and histopathology. Allergic contact dermatitis on the face can present with skin-color to pink papules, but they usually are very pruritic and improve with topical corticosteroids, while these medications can worsen CGPD.
CGPD can be a self-limiting condition. When mild, it can be treated with topical metronidazole, topical erythromycin, topical clindamycin solution, or pimecrolimus. Our patient failed treatment with pimecrolimus. For severe presentations, oral tetracyclines, erythromycin, and other macrolides, metronidazole, and oral isotretinoin can help clear the lesions.5
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Ann Dermatol. 2011 Aug;23(3):386-8.
2. Int J Dermatol. 2007 Feb;46(2):143-5.
3. J Cutan Med Surg. 2009 Feb 28;13(2):115-8.
4. An Bras Dermatol. 2017 Nov-Dec;92(6):851-3.
5. Indian Dermatol Online J. 2018 Jan-Feb; 9(1):68-70.
An 8-year-old African American male presented to our pediatric dermatology clinic for evaluation of a 3-month history of flesh-colored bumps on the face. According to the patient's mother, the lesions started with small pimple-like lesions around the nose and then spread to the whole face. Some lesions were crusty and somewhat itchy. He was treated with cephalexin and pimecrolimus with no improvement. The mother was very concerned because the lesions were close to the eyes and spreading.
He had no fevers, arthritis, or upper respiratory or gastrointestinal symptoms. He recently came back from a trip to Africa to visit his family. No other family members were affected. He used some new soaps, sunscreens, and moisturizers while he was in Africa.
On physical examination, the boy was in no acute distress. He had multiple flesh-colored papules on the face, especially around the eyes, nose, and mouth, where some lesions appeared crusted. There were no other skin lesions elsewhere on his body. There was no lymphadenopathy or hepatosplenomegaly.
Red lesion on back
Dermoscopy was performed, which confirmed that this was a cherry angioma, also called a cherry hemangioma or Campbell de Morgan spot.
Cherry angiomas are benign proliferations that typically appear after age 30 as tiny bright erythematous macules that, over time, enlarge into papules. In their early, and smaller, stages they are typically maraschino cherry red, hence the name cherry angiomas. As they enlarge or become thrombosed, some lesions become darker red or even black in color. (The dermoscopy image shown here demonstrates the bright red globular red pattern that is classically seen with cherry angiomas.)
Cherry angiomas do not require treatment. If treatment is desired for cosmetic purposes, they can be treated with electrocautery, cryosurgery, or laser. The patient in this case was not worried about the appearance of the lesion and opted to leave it alone unless he developed symptoms.
Images and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
Dermoscopy was performed, which confirmed that this was a cherry angioma, also called a cherry hemangioma or Campbell de Morgan spot.
Cherry angiomas are benign proliferations that typically appear after age 30 as tiny bright erythematous macules that, over time, enlarge into papules. In their early, and smaller, stages they are typically maraschino cherry red, hence the name cherry angiomas. As they enlarge or become thrombosed, some lesions become darker red or even black in color. (The dermoscopy image shown here demonstrates the bright red globular red pattern that is classically seen with cherry angiomas.)
Cherry angiomas do not require treatment. If treatment is desired for cosmetic purposes, they can be treated with electrocautery, cryosurgery, or laser. The patient in this case was not worried about the appearance of the lesion and opted to leave it alone unless he developed symptoms.
Images and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
Dermoscopy was performed, which confirmed that this was a cherry angioma, also called a cherry hemangioma or Campbell de Morgan spot.
Cherry angiomas are benign proliferations that typically appear after age 30 as tiny bright erythematous macules that, over time, enlarge into papules. In their early, and smaller, stages they are typically maraschino cherry red, hence the name cherry angiomas. As they enlarge or become thrombosed, some lesions become darker red or even black in color. (The dermoscopy image shown here demonstrates the bright red globular red pattern that is classically seen with cherry angiomas.)
Cherry angiomas do not require treatment. If treatment is desired for cosmetic purposes, they can be treated with electrocautery, cryosurgery, or laser. The patient in this case was not worried about the appearance of the lesion and opted to leave it alone unless he developed symptoms.
Images and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
New guideline provides recommendations for radiation therapy of basal cell, squamous cell cancers
who are not candidates for surgery, according to a new guideline from an American Society for Radiation Oncology task force.
“We hope that the dermatology community will find this guideline helpful, especially when it comes to defining clinical and pathological characteristics that may necessitate a discussion about the merits of postoperative radiation therapy,” said lead author Anna Likhacheva, MD, of the Sutter Medical Center in Sacramento, Calif., in an email. The guideline was published in Practical Radiation Oncology.
To address five key questions in regard to radiation therapy (RT) for the two most common skin cancers, the American Society for Radiation Oncology convened a task force of radiation, medical, and surgical oncologists; dermatopathologists; a radiation oncology resident; a medical physicist; and a dermatologist. They reviewed studies of adults with nonmetastatic, invasive basal cell carcinoma (BCC) or cutaneous squamous cell carcinoma (cSCC) that were published between May 1998 and June 2018, with the caveat that “there are limited, well-conducted modern randomized trials” in this area. As such, the majority of the recommendations have low to moderate quality of evidence designations.
“The conspicuous lack of prospective and randomized data should serve as a reminder to open clinical trials and collect outcomes data in a prospective fashion,” added Dr. Likhacheva, noting that “improving the quality of data on this topic will ultimately serve our common goal of improving patient outcomes.”
Their first recommendation was to strongly consider definitive RT as an alternative to surgery for BCC and cSCC, especially in areas where a surgical procedure would potentially compromise function or cosmesis. However, they did discourage its use in patients with genetic conditions associated with increased radiosensitivity.
Their second recommendation was to strongly consider postoperative radiation therapy for clinically or radiologically apparent gross perineural spread. They also strongly recommended PORT for cSCC patients with close or positive margins, with T3 or T4 tumors, or with desmoplastic or infiltrative tumors.
Their third recommendation was to strongly consider therapeutic lymphadenectomy followed by adjuvant RT in patients with cSCC or BCC that has metastasized to the regional lymph nodes. They also recommended definitive RT in medically inoperable patients with the same metastasized cSCC or BCC. In addition, patients with BCC or cSCC undergoing adjuvant RT after therapeutic lymphadenectomy were recommended a dose of 6,000-6,600 cGy, while patients with cSCC undergoing elective RT without a lymphadenectomy were recommended a dose of 5,000-5,400 cGy.
Their fourth recommendation focused on techniques and dose-fractionation schedules for RT in the definitive or postoperative setting. For patients with BCC and cSCC receiving definitive RT, the biologically effective dose (BED10) range for conventional fractionation – defined as 180-200 cGy/fraction – should be 70-93.5 and the BED10 range for hypofractionation – defined as 210-500 cGy/fraction – should be 56-88. For patients with BCC and cSCC receiving postoperative RT, the BED10 range for conventional fractionation should be 59.5-79.2 and the BED10 range for hypofractionation should be 56-70.2.
Finally, their fifth recommendation was to not add concurrent carboplatin to adjuvant RT in patients with resected, locally advanced cSCC. They also conditionally recommended adding concurrent drug therapies to definitive RT in patients with unresected, locally advanced cSCC.
Several of the authors reported receiving honoraria and travel expenses from medical and pharmaceutical companies, along with serving on their advisory boards. The others reported no conflicts of interest.
SOURCE: Likhacheva A et al. Pract Radiat Oncol. 2019 Dec 9. doi: 10.1016/j.prro.2019.10.014.
who are not candidates for surgery, according to a new guideline from an American Society for Radiation Oncology task force.
“We hope that the dermatology community will find this guideline helpful, especially when it comes to defining clinical and pathological characteristics that may necessitate a discussion about the merits of postoperative radiation therapy,” said lead author Anna Likhacheva, MD, of the Sutter Medical Center in Sacramento, Calif., in an email. The guideline was published in Practical Radiation Oncology.
To address five key questions in regard to radiation therapy (RT) for the two most common skin cancers, the American Society for Radiation Oncology convened a task force of radiation, medical, and surgical oncologists; dermatopathologists; a radiation oncology resident; a medical physicist; and a dermatologist. They reviewed studies of adults with nonmetastatic, invasive basal cell carcinoma (BCC) or cutaneous squamous cell carcinoma (cSCC) that were published between May 1998 and June 2018, with the caveat that “there are limited, well-conducted modern randomized trials” in this area. As such, the majority of the recommendations have low to moderate quality of evidence designations.
“The conspicuous lack of prospective and randomized data should serve as a reminder to open clinical trials and collect outcomes data in a prospective fashion,” added Dr. Likhacheva, noting that “improving the quality of data on this topic will ultimately serve our common goal of improving patient outcomes.”
Their first recommendation was to strongly consider definitive RT as an alternative to surgery for BCC and cSCC, especially in areas where a surgical procedure would potentially compromise function or cosmesis. However, they did discourage its use in patients with genetic conditions associated with increased radiosensitivity.
Their second recommendation was to strongly consider postoperative radiation therapy for clinically or radiologically apparent gross perineural spread. They also strongly recommended PORT for cSCC patients with close or positive margins, with T3 or T4 tumors, or with desmoplastic or infiltrative tumors.
Their third recommendation was to strongly consider therapeutic lymphadenectomy followed by adjuvant RT in patients with cSCC or BCC that has metastasized to the regional lymph nodes. They also recommended definitive RT in medically inoperable patients with the same metastasized cSCC or BCC. In addition, patients with BCC or cSCC undergoing adjuvant RT after therapeutic lymphadenectomy were recommended a dose of 6,000-6,600 cGy, while patients with cSCC undergoing elective RT without a lymphadenectomy were recommended a dose of 5,000-5,400 cGy.
Their fourth recommendation focused on techniques and dose-fractionation schedules for RT in the definitive or postoperative setting. For patients with BCC and cSCC receiving definitive RT, the biologically effective dose (BED10) range for conventional fractionation – defined as 180-200 cGy/fraction – should be 70-93.5 and the BED10 range for hypofractionation – defined as 210-500 cGy/fraction – should be 56-88. For patients with BCC and cSCC receiving postoperative RT, the BED10 range for conventional fractionation should be 59.5-79.2 and the BED10 range for hypofractionation should be 56-70.2.
Finally, their fifth recommendation was to not add concurrent carboplatin to adjuvant RT in patients with resected, locally advanced cSCC. They also conditionally recommended adding concurrent drug therapies to definitive RT in patients with unresected, locally advanced cSCC.
Several of the authors reported receiving honoraria and travel expenses from medical and pharmaceutical companies, along with serving on their advisory boards. The others reported no conflicts of interest.
SOURCE: Likhacheva A et al. Pract Radiat Oncol. 2019 Dec 9. doi: 10.1016/j.prro.2019.10.014.
who are not candidates for surgery, according to a new guideline from an American Society for Radiation Oncology task force.
“We hope that the dermatology community will find this guideline helpful, especially when it comes to defining clinical and pathological characteristics that may necessitate a discussion about the merits of postoperative radiation therapy,” said lead author Anna Likhacheva, MD, of the Sutter Medical Center in Sacramento, Calif., in an email. The guideline was published in Practical Radiation Oncology.
To address five key questions in regard to radiation therapy (RT) for the two most common skin cancers, the American Society for Radiation Oncology convened a task force of radiation, medical, and surgical oncologists; dermatopathologists; a radiation oncology resident; a medical physicist; and a dermatologist. They reviewed studies of adults with nonmetastatic, invasive basal cell carcinoma (BCC) or cutaneous squamous cell carcinoma (cSCC) that were published between May 1998 and June 2018, with the caveat that “there are limited, well-conducted modern randomized trials” in this area. As such, the majority of the recommendations have low to moderate quality of evidence designations.
“The conspicuous lack of prospective and randomized data should serve as a reminder to open clinical trials and collect outcomes data in a prospective fashion,” added Dr. Likhacheva, noting that “improving the quality of data on this topic will ultimately serve our common goal of improving patient outcomes.”
Their first recommendation was to strongly consider definitive RT as an alternative to surgery for BCC and cSCC, especially in areas where a surgical procedure would potentially compromise function or cosmesis. However, they did discourage its use in patients with genetic conditions associated with increased radiosensitivity.
Their second recommendation was to strongly consider postoperative radiation therapy for clinically or radiologically apparent gross perineural spread. They also strongly recommended PORT for cSCC patients with close or positive margins, with T3 or T4 tumors, or with desmoplastic or infiltrative tumors.
Their third recommendation was to strongly consider therapeutic lymphadenectomy followed by adjuvant RT in patients with cSCC or BCC that has metastasized to the regional lymph nodes. They also recommended definitive RT in medically inoperable patients with the same metastasized cSCC or BCC. In addition, patients with BCC or cSCC undergoing adjuvant RT after therapeutic lymphadenectomy were recommended a dose of 6,000-6,600 cGy, while patients with cSCC undergoing elective RT without a lymphadenectomy were recommended a dose of 5,000-5,400 cGy.
Their fourth recommendation focused on techniques and dose-fractionation schedules for RT in the definitive or postoperative setting. For patients with BCC and cSCC receiving definitive RT, the biologically effective dose (BED10) range for conventional fractionation – defined as 180-200 cGy/fraction – should be 70-93.5 and the BED10 range for hypofractionation – defined as 210-500 cGy/fraction – should be 56-88. For patients with BCC and cSCC receiving postoperative RT, the BED10 range for conventional fractionation should be 59.5-79.2 and the BED10 range for hypofractionation should be 56-70.2.
Finally, their fifth recommendation was to not add concurrent carboplatin to adjuvant RT in patients with resected, locally advanced cSCC. They also conditionally recommended adding concurrent drug therapies to definitive RT in patients with unresected, locally advanced cSCC.
Several of the authors reported receiving honoraria and travel expenses from medical and pharmaceutical companies, along with serving on their advisory boards. The others reported no conflicts of interest.
SOURCE: Likhacheva A et al. Pract Radiat Oncol. 2019 Dec 9. doi: 10.1016/j.prro.2019.10.014.
FROM PRACTICAL RADIATION ONCOLOGY
Identifying bacterial infections in setting of atopic dermatitis
While of infections in AD and features common to both can make it difficult to make a clinical diagnosis of infections.
Addressing this issue, the International Eczema Council Skin Infection Group reviewed the most current evidence on the clinical features of bacterial infections and the interaction between host and bacterial factors that affect severity and morbidity in people with atopic dermatitis (AD). Recurrent skin infections, especially from Staphylococcus aureus and occasionally from beta-hemolytic streptococci, are more common in people with AD than those who do not have AD for a variety of reasons, Helen Alexander, MD, from the unit for population-based dermatology research at St. John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, and associates wrote in the review article published in the British Journal of Dermatology.
“The reduced skin barrier, cutaneous innate and adaptive immune abnormalities and trauma from scratching all contribute to the increased risk of skin infection,” they wrote. “However, the wide variability in clinical presentation of bacterial infection in AD and the inherent features of AD – cutaneous erythema and warmth, oozing associated with edema, and regional lymphadenopathy – overlap with those of infection, making clinical diagnosis challenging.”
The clinical appearance of AD may also mask signs of the bacterial infection, they added, and providers cannot rely on positive skin swab culture from the possibly infected area since S. aureus is so common in AD. An added challenge can occur in patients of different ethnicities, in whom both AD and bacterial infection may manifest differently. For example, perifollicular accentuation often occurs with AD in dark-skinned patients with violet-colored, often muted erythema.
An estimated 70% of lesional and 39% of nonlesional AD skin is colonized with S. aureus, the authors noted, but it’s not clear how best to recognize and manage asymptomatic S. aureus colonization. Among the factors that can increase susceptibility to S. aureus colonization and infection are impaired skin barriers, type 2 inflammation and lower levels of microbial diversity in the skin microbiome.
Specific clinical features of S. aureus in patients with AD include “weeping, honey-colored crusts and pustules, both interfollicular and follicular based,” and the pustules, though not common, can involve pain and itching. By comparison, signs of beta-hemolytic streptococcal infection may include “well-defined, bright red erythema, thick-walled pustules and heavy crusting,” the authors wrote.
Fever and lymphadenopathy may occur in severe cases, as well as abscesses, particularly with methicillin-resistant S. aureus (MRSA) infection. It’s unclear whether MRSA occurs more often in people with AD since its incidence varies so widely geographically, they noted.
In the differential diagnosis, providers should consider the possibility that a patient has a concomitant viral or fungal infection. Eczema herpeticum from herpes simplex virus is a common viral infection with risk factors that include “moderate to severe AD, filaggrin loss-of-function mutation, a history of S. aureus skin infection, greater allergen sensitization and type 2 immunity,” the authors wrote.
The yeast Malassezia is implicated in inflammation in patients with dermatitis that affects the head, neck, upper chest, back, and other areas high in sebaceous glands. Some patients have greater sensitivity to Malassezia, and “cross-reactivity between Malassezia-specific IgE and Candida albicans” has occurred as well, they wrote. Current evidence favors benefit from antifungal drugs, though not conclusively.
“Although we have some understanding of how S. aureus colonizes the skin and causes inflammation in AD, many questions related to this complex relationship remain unanswered,” the authors concluded. They added that better understanding the mechanisms of S. aureus and downstream host immune mediators of inflammatory pathways involving S. aureus could potentially lead to new therapeutic targets for infection in AD patients.
The statement was funded in part by the senior author’s fellowships from the National Institutes of Health Research, and the International Eczema Council received sponsorship from AbbVie, Amgen, Asana Biosciences, Celgene, Chugai, Dermavant, Dermira, Eli Lilly, Galderma, Incyte, LEO Pharma, Kyowa Kirin, Novartis, Pierre Fabre, Pfizer, Sanofi Genzyme, Regeneron Pharmaceuticals, Sienna and Valeant. Of the 16 authors, 13 disclosed financial ties to a wide range of pharmaceutical companies, including those listed above.
SOURCE: Alexander H et al. Br J Dermatol. 2019 Nov 1. doi: 10.1111/bjd.1864319.
While of infections in AD and features common to both can make it difficult to make a clinical diagnosis of infections.
Addressing this issue, the International Eczema Council Skin Infection Group reviewed the most current evidence on the clinical features of bacterial infections and the interaction between host and bacterial factors that affect severity and morbidity in people with atopic dermatitis (AD). Recurrent skin infections, especially from Staphylococcus aureus and occasionally from beta-hemolytic streptococci, are more common in people with AD than those who do not have AD for a variety of reasons, Helen Alexander, MD, from the unit for population-based dermatology research at St. John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, and associates wrote in the review article published in the British Journal of Dermatology.
“The reduced skin barrier, cutaneous innate and adaptive immune abnormalities and trauma from scratching all contribute to the increased risk of skin infection,” they wrote. “However, the wide variability in clinical presentation of bacterial infection in AD and the inherent features of AD – cutaneous erythema and warmth, oozing associated with edema, and regional lymphadenopathy – overlap with those of infection, making clinical diagnosis challenging.”
The clinical appearance of AD may also mask signs of the bacterial infection, they added, and providers cannot rely on positive skin swab culture from the possibly infected area since S. aureus is so common in AD. An added challenge can occur in patients of different ethnicities, in whom both AD and bacterial infection may manifest differently. For example, perifollicular accentuation often occurs with AD in dark-skinned patients with violet-colored, often muted erythema.
An estimated 70% of lesional and 39% of nonlesional AD skin is colonized with S. aureus, the authors noted, but it’s not clear how best to recognize and manage asymptomatic S. aureus colonization. Among the factors that can increase susceptibility to S. aureus colonization and infection are impaired skin barriers, type 2 inflammation and lower levels of microbial diversity in the skin microbiome.
Specific clinical features of S. aureus in patients with AD include “weeping, honey-colored crusts and pustules, both interfollicular and follicular based,” and the pustules, though not common, can involve pain and itching. By comparison, signs of beta-hemolytic streptococcal infection may include “well-defined, bright red erythema, thick-walled pustules and heavy crusting,” the authors wrote.
Fever and lymphadenopathy may occur in severe cases, as well as abscesses, particularly with methicillin-resistant S. aureus (MRSA) infection. It’s unclear whether MRSA occurs more often in people with AD since its incidence varies so widely geographically, they noted.
In the differential diagnosis, providers should consider the possibility that a patient has a concomitant viral or fungal infection. Eczema herpeticum from herpes simplex virus is a common viral infection with risk factors that include “moderate to severe AD, filaggrin loss-of-function mutation, a history of S. aureus skin infection, greater allergen sensitization and type 2 immunity,” the authors wrote.
The yeast Malassezia is implicated in inflammation in patients with dermatitis that affects the head, neck, upper chest, back, and other areas high in sebaceous glands. Some patients have greater sensitivity to Malassezia, and “cross-reactivity between Malassezia-specific IgE and Candida albicans” has occurred as well, they wrote. Current evidence favors benefit from antifungal drugs, though not conclusively.
“Although we have some understanding of how S. aureus colonizes the skin and causes inflammation in AD, many questions related to this complex relationship remain unanswered,” the authors concluded. They added that better understanding the mechanisms of S. aureus and downstream host immune mediators of inflammatory pathways involving S. aureus could potentially lead to new therapeutic targets for infection in AD patients.
The statement was funded in part by the senior author’s fellowships from the National Institutes of Health Research, and the International Eczema Council received sponsorship from AbbVie, Amgen, Asana Biosciences, Celgene, Chugai, Dermavant, Dermira, Eli Lilly, Galderma, Incyte, LEO Pharma, Kyowa Kirin, Novartis, Pierre Fabre, Pfizer, Sanofi Genzyme, Regeneron Pharmaceuticals, Sienna and Valeant. Of the 16 authors, 13 disclosed financial ties to a wide range of pharmaceutical companies, including those listed above.
SOURCE: Alexander H et al. Br J Dermatol. 2019 Nov 1. doi: 10.1111/bjd.1864319.
While of infections in AD and features common to both can make it difficult to make a clinical diagnosis of infections.
Addressing this issue, the International Eczema Council Skin Infection Group reviewed the most current evidence on the clinical features of bacterial infections and the interaction between host and bacterial factors that affect severity and morbidity in people with atopic dermatitis (AD). Recurrent skin infections, especially from Staphylococcus aureus and occasionally from beta-hemolytic streptococci, are more common in people with AD than those who do not have AD for a variety of reasons, Helen Alexander, MD, from the unit for population-based dermatology research at St. John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, and associates wrote in the review article published in the British Journal of Dermatology.
“The reduced skin barrier, cutaneous innate and adaptive immune abnormalities and trauma from scratching all contribute to the increased risk of skin infection,” they wrote. “However, the wide variability in clinical presentation of bacterial infection in AD and the inherent features of AD – cutaneous erythema and warmth, oozing associated with edema, and regional lymphadenopathy – overlap with those of infection, making clinical diagnosis challenging.”
The clinical appearance of AD may also mask signs of the bacterial infection, they added, and providers cannot rely on positive skin swab culture from the possibly infected area since S. aureus is so common in AD. An added challenge can occur in patients of different ethnicities, in whom both AD and bacterial infection may manifest differently. For example, perifollicular accentuation often occurs with AD in dark-skinned patients with violet-colored, often muted erythema.
An estimated 70% of lesional and 39% of nonlesional AD skin is colonized with S. aureus, the authors noted, but it’s not clear how best to recognize and manage asymptomatic S. aureus colonization. Among the factors that can increase susceptibility to S. aureus colonization and infection are impaired skin barriers, type 2 inflammation and lower levels of microbial diversity in the skin microbiome.
Specific clinical features of S. aureus in patients with AD include “weeping, honey-colored crusts and pustules, both interfollicular and follicular based,” and the pustules, though not common, can involve pain and itching. By comparison, signs of beta-hemolytic streptococcal infection may include “well-defined, bright red erythema, thick-walled pustules and heavy crusting,” the authors wrote.
Fever and lymphadenopathy may occur in severe cases, as well as abscesses, particularly with methicillin-resistant S. aureus (MRSA) infection. It’s unclear whether MRSA occurs more often in people with AD since its incidence varies so widely geographically, they noted.
In the differential diagnosis, providers should consider the possibility that a patient has a concomitant viral or fungal infection. Eczema herpeticum from herpes simplex virus is a common viral infection with risk factors that include “moderate to severe AD, filaggrin loss-of-function mutation, a history of S. aureus skin infection, greater allergen sensitization and type 2 immunity,” the authors wrote.
The yeast Malassezia is implicated in inflammation in patients with dermatitis that affects the head, neck, upper chest, back, and other areas high in sebaceous glands. Some patients have greater sensitivity to Malassezia, and “cross-reactivity between Malassezia-specific IgE and Candida albicans” has occurred as well, they wrote. Current evidence favors benefit from antifungal drugs, though not conclusively.
“Although we have some understanding of how S. aureus colonizes the skin and causes inflammation in AD, many questions related to this complex relationship remain unanswered,” the authors concluded. They added that better understanding the mechanisms of S. aureus and downstream host immune mediators of inflammatory pathways involving S. aureus could potentially lead to new therapeutic targets for infection in AD patients.
The statement was funded in part by the senior author’s fellowships from the National Institutes of Health Research, and the International Eczema Council received sponsorship from AbbVie, Amgen, Asana Biosciences, Celgene, Chugai, Dermavant, Dermira, Eli Lilly, Galderma, Incyte, LEO Pharma, Kyowa Kirin, Novartis, Pierre Fabre, Pfizer, Sanofi Genzyme, Regeneron Pharmaceuticals, Sienna and Valeant. Of the 16 authors, 13 disclosed financial ties to a wide range of pharmaceutical companies, including those listed above.
SOURCE: Alexander H et al. Br J Dermatol. 2019 Nov 1. doi: 10.1111/bjd.1864319.
FROM THE BRITISH JOURNAL OF DERMATOLOGY
iPLEDGE vexes dermatologists treating transgender patients
Physicians treating transgender patients – in particular, transgender men who were born female – are faced with a confusing process when prescribing isotretinoin for severe acne.
A research letter published in the Journal of the American Academy of Dermatology reports that established to prevent female patients from starting isotretinoin therapy while pregnant or from becoming pregnant while exposed to the teratogenic medication.
Nearly 90% of respondents favored changing the current gender-specific categories in iPLEDGE to gender-neutral ones, classifying patients only by whether or not they have the ability to become pregnant.
For their research, Courtney Ensslin, MD, of the department of dermatology at Johns Hopkins University, Baltimore, and colleagues, distributed an 18-point questionnaire to 385 members of the Association of Professors of Dermatology that included questions assessing clinicians’ knowledge about the reproductive potential of transgender men and women. The recipients were asked to distribute it to faculty members and residents. The survey also described three clinical scenarios in which the physician needed to decide how to register a patient in iPLEDGE. The clinicians largely opted to class transgender men as women with childbearing potential, even if the category conflicted with the patient’s self-identified and legally recognized male gender.
Of the 136 clinicians who responded, 60% were women, almost half were aged 25-34 years. About 12% of respondents said the complexities of prescribing isotretinoin to a transgender patient led them to choose alternative therapies. And the survey revealed some gaps on providers’ general literacy on transgender patients and their reproductive potential. For example, fewer than a third of respondents answered correctly as to whether testosterone treatment decreases the quality and development of an immature ovum.
The researchers wrote that the survey results, while limited by a small sample of respondents that skewed toward younger women providers, suggest that “continued education on fertility in transgender patients is needed because prescribers must fully understand each patient’s reproductive potential to safely prescribe teratogenic medications.” Additionally, they pointed out, the results support ongoing efforts to reform iPLEDGE, as the current categories “do not offer an inclusive approach to care for transgender patients.”
Earlier this year the American Academy of Dermatology issued a position statement that described a number of ongoing initiatives aimed at improving treatment for patients who are members of gender and sexual minorities. These included the “revision of the AAD position statement on isotretinoin to support a gender-neutral categorization model for [iPLEDGE] … based on child-bearing potential rather than on gender identity,” the statement said.
Dr. Ensslin and colleagues reported conflicts of interest related to their research. The study was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health.
SOURCE: Ensslin C et al. J Am Acad Dermatol. 2019 Dec;81(6):1426-9.
Physicians treating transgender patients – in particular, transgender men who were born female – are faced with a confusing process when prescribing isotretinoin for severe acne.
A research letter published in the Journal of the American Academy of Dermatology reports that established to prevent female patients from starting isotretinoin therapy while pregnant or from becoming pregnant while exposed to the teratogenic medication.
Nearly 90% of respondents favored changing the current gender-specific categories in iPLEDGE to gender-neutral ones, classifying patients only by whether or not they have the ability to become pregnant.
For their research, Courtney Ensslin, MD, of the department of dermatology at Johns Hopkins University, Baltimore, and colleagues, distributed an 18-point questionnaire to 385 members of the Association of Professors of Dermatology that included questions assessing clinicians’ knowledge about the reproductive potential of transgender men and women. The recipients were asked to distribute it to faculty members and residents. The survey also described three clinical scenarios in which the physician needed to decide how to register a patient in iPLEDGE. The clinicians largely opted to class transgender men as women with childbearing potential, even if the category conflicted with the patient’s self-identified and legally recognized male gender.
Of the 136 clinicians who responded, 60% were women, almost half were aged 25-34 years. About 12% of respondents said the complexities of prescribing isotretinoin to a transgender patient led them to choose alternative therapies. And the survey revealed some gaps on providers’ general literacy on transgender patients and their reproductive potential. For example, fewer than a third of respondents answered correctly as to whether testosterone treatment decreases the quality and development of an immature ovum.
The researchers wrote that the survey results, while limited by a small sample of respondents that skewed toward younger women providers, suggest that “continued education on fertility in transgender patients is needed because prescribers must fully understand each patient’s reproductive potential to safely prescribe teratogenic medications.” Additionally, they pointed out, the results support ongoing efforts to reform iPLEDGE, as the current categories “do not offer an inclusive approach to care for transgender patients.”
Earlier this year the American Academy of Dermatology issued a position statement that described a number of ongoing initiatives aimed at improving treatment for patients who are members of gender and sexual minorities. These included the “revision of the AAD position statement on isotretinoin to support a gender-neutral categorization model for [iPLEDGE] … based on child-bearing potential rather than on gender identity,” the statement said.
Dr. Ensslin and colleagues reported conflicts of interest related to their research. The study was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health.
SOURCE: Ensslin C et al. J Am Acad Dermatol. 2019 Dec;81(6):1426-9.
Physicians treating transgender patients – in particular, transgender men who were born female – are faced with a confusing process when prescribing isotretinoin for severe acne.
A research letter published in the Journal of the American Academy of Dermatology reports that established to prevent female patients from starting isotretinoin therapy while pregnant or from becoming pregnant while exposed to the teratogenic medication.
Nearly 90% of respondents favored changing the current gender-specific categories in iPLEDGE to gender-neutral ones, classifying patients only by whether or not they have the ability to become pregnant.
For their research, Courtney Ensslin, MD, of the department of dermatology at Johns Hopkins University, Baltimore, and colleagues, distributed an 18-point questionnaire to 385 members of the Association of Professors of Dermatology that included questions assessing clinicians’ knowledge about the reproductive potential of transgender men and women. The recipients were asked to distribute it to faculty members and residents. The survey also described three clinical scenarios in which the physician needed to decide how to register a patient in iPLEDGE. The clinicians largely opted to class transgender men as women with childbearing potential, even if the category conflicted with the patient’s self-identified and legally recognized male gender.
Of the 136 clinicians who responded, 60% were women, almost half were aged 25-34 years. About 12% of respondents said the complexities of prescribing isotretinoin to a transgender patient led them to choose alternative therapies. And the survey revealed some gaps on providers’ general literacy on transgender patients and their reproductive potential. For example, fewer than a third of respondents answered correctly as to whether testosterone treatment decreases the quality and development of an immature ovum.
The researchers wrote that the survey results, while limited by a small sample of respondents that skewed toward younger women providers, suggest that “continued education on fertility in transgender patients is needed because prescribers must fully understand each patient’s reproductive potential to safely prescribe teratogenic medications.” Additionally, they pointed out, the results support ongoing efforts to reform iPLEDGE, as the current categories “do not offer an inclusive approach to care for transgender patients.”
Earlier this year the American Academy of Dermatology issued a position statement that described a number of ongoing initiatives aimed at improving treatment for patients who are members of gender and sexual minorities. These included the “revision of the AAD position statement on isotretinoin to support a gender-neutral categorization model for [iPLEDGE] … based on child-bearing potential rather than on gender identity,” the statement said.
Dr. Ensslin and colleagues reported conflicts of interest related to their research. The study was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health.
SOURCE: Ensslin C et al. J Am Acad Dermatol. 2019 Dec;81(6):1426-9.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY