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Location Does Not Matter
Several months ago, this 7-year-old girl noticed a lesion on her outer vagina. In addition to growing larger, the lesion has begun to itch.
The patient’s mother has attempted treatment with anti-yeast cream and 1% hydrocortisone cream; neither has helped.
Both mother and daughter deny any recent trauma to the area, presence of similar lesions, or family history of skin disease or arthritis.
The child is well in all other respects; she takes no medications and has no history of serious illnesses or surgeries.
EXAMINATION
A solitary, 8- x 2-cm, salmon-pink plaque covered with uniform tenacious white scale is located on the left labia majora in a vertical orientation. The margins are sharply defined. There is no tenderness or increased warmth on palpation.
No similar changes are seen on the elbows, knees, scalp, trunk, or nails.
A biopsy of the lesion is performed. The pathology report shows parakeratosis and elongation of rete ridges.
What is the diagnosis?
DISCUSSION
The morphology of this lesion is a perfect fit for psoriasis, a very common disease affecting about 3% of the white population in this country. Mentally repositioning this lesion to the elbow, trunk, or knee would have made the diagnosis obvious; these are the most commonly affected areas, while the genitals are among the least common. But a white-feathered bird with an orange bill and feet who greets you with a quack is probably a duck, even if it’s sitting on your dining room table.
Even for an experienced dermatology provider (35 years in the field), seeing this lesion in this location was a momentary shock. After all, there’s an 18-item differential for genital rashes—but very few look like this.
Lichen sclerosis et atrophicus is commonly seen on young girls in this area, but it is atrophic with almost no scale. Lichen simplex chronicus can be scaly and plaquish, but it rarely appears this organized.
In most primary care settings, this would be (and was) called a “yeast infection.” Not only do yeast infections not look a thing like this, there also needs to be an underlying reason for that diagnosis (eg, use of antibiotics, history of diabetes).
Biopsy is the only way to confirm this diagnosis, to give the family some peace of mind and guide appropriate therapy.
We discussed the diagnosis thoroughly with the parents, including the etiology, potential treatments, and prognosis. Treatment was initiated with topical triamcinolone 0.1% cream bid. If it proves necessary, we could increase the potency of the steroid, inject the lesion with steroid, or even start her on methotrexate.
She’ll also be closely followed for signs of worsening disease and for psoriatic arthropathy, which affects almost 25% of patients with psoriasis. She’ll be fortunate if this is the extent of her disease.
TAKE-HOME LEARNING POINTS
- Salmon-pink, scaly plaques are psoriatic until proven otherwise.
- Psoriasis is common, affecting almost 3% of the white population.
- Though most often seen on extensor surfaces of arms, legs, and trunk, psoriasis can appear virtually anywhere.
- Mentally transpositioning a lesion to another location can be helpful in sorting through this differential.
Several months ago, this 7-year-old girl noticed a lesion on her outer vagina. In addition to growing larger, the lesion has begun to itch.
The patient’s mother has attempted treatment with anti-yeast cream and 1% hydrocortisone cream; neither has helped.
Both mother and daughter deny any recent trauma to the area, presence of similar lesions, or family history of skin disease or arthritis.
The child is well in all other respects; she takes no medications and has no history of serious illnesses or surgeries.
EXAMINATION
A solitary, 8- x 2-cm, salmon-pink plaque covered with uniform tenacious white scale is located on the left labia majora in a vertical orientation. The margins are sharply defined. There is no tenderness or increased warmth on palpation.
No similar changes are seen on the elbows, knees, scalp, trunk, or nails.
A biopsy of the lesion is performed. The pathology report shows parakeratosis and elongation of rete ridges.
What is the diagnosis?
DISCUSSION
The morphology of this lesion is a perfect fit for psoriasis, a very common disease affecting about 3% of the white population in this country. Mentally repositioning this lesion to the elbow, trunk, or knee would have made the diagnosis obvious; these are the most commonly affected areas, while the genitals are among the least common. But a white-feathered bird with an orange bill and feet who greets you with a quack is probably a duck, even if it’s sitting on your dining room table.
Even for an experienced dermatology provider (35 years in the field), seeing this lesion in this location was a momentary shock. After all, there’s an 18-item differential for genital rashes—but very few look like this.
Lichen sclerosis et atrophicus is commonly seen on young girls in this area, but it is atrophic with almost no scale. Lichen simplex chronicus can be scaly and plaquish, but it rarely appears this organized.
In most primary care settings, this would be (and was) called a “yeast infection.” Not only do yeast infections not look a thing like this, there also needs to be an underlying reason for that diagnosis (eg, use of antibiotics, history of diabetes).
Biopsy is the only way to confirm this diagnosis, to give the family some peace of mind and guide appropriate therapy.
We discussed the diagnosis thoroughly with the parents, including the etiology, potential treatments, and prognosis. Treatment was initiated with topical triamcinolone 0.1% cream bid. If it proves necessary, we could increase the potency of the steroid, inject the lesion with steroid, or even start her on methotrexate.
She’ll also be closely followed for signs of worsening disease and for psoriatic arthropathy, which affects almost 25% of patients with psoriasis. She’ll be fortunate if this is the extent of her disease.
TAKE-HOME LEARNING POINTS
- Salmon-pink, scaly plaques are psoriatic until proven otherwise.
- Psoriasis is common, affecting almost 3% of the white population.
- Though most often seen on extensor surfaces of arms, legs, and trunk, psoriasis can appear virtually anywhere.
- Mentally transpositioning a lesion to another location can be helpful in sorting through this differential.
Several months ago, this 7-year-old girl noticed a lesion on her outer vagina. In addition to growing larger, the lesion has begun to itch.
The patient’s mother has attempted treatment with anti-yeast cream and 1% hydrocortisone cream; neither has helped.
Both mother and daughter deny any recent trauma to the area, presence of similar lesions, or family history of skin disease or arthritis.
The child is well in all other respects; she takes no medications and has no history of serious illnesses or surgeries.
EXAMINATION
A solitary, 8- x 2-cm, salmon-pink plaque covered with uniform tenacious white scale is located on the left labia majora in a vertical orientation. The margins are sharply defined. There is no tenderness or increased warmth on palpation.
No similar changes are seen on the elbows, knees, scalp, trunk, or nails.
A biopsy of the lesion is performed. The pathology report shows parakeratosis and elongation of rete ridges.
What is the diagnosis?
DISCUSSION
The morphology of this lesion is a perfect fit for psoriasis, a very common disease affecting about 3% of the white population in this country. Mentally repositioning this lesion to the elbow, trunk, or knee would have made the diagnosis obvious; these are the most commonly affected areas, while the genitals are among the least common. But a white-feathered bird with an orange bill and feet who greets you with a quack is probably a duck, even if it’s sitting on your dining room table.
Even for an experienced dermatology provider (35 years in the field), seeing this lesion in this location was a momentary shock. After all, there’s an 18-item differential for genital rashes—but very few look like this.
Lichen sclerosis et atrophicus is commonly seen on young girls in this area, but it is atrophic with almost no scale. Lichen simplex chronicus can be scaly and plaquish, but it rarely appears this organized.
In most primary care settings, this would be (and was) called a “yeast infection.” Not only do yeast infections not look a thing like this, there also needs to be an underlying reason for that diagnosis (eg, use of antibiotics, history of diabetes).
Biopsy is the only way to confirm this diagnosis, to give the family some peace of mind and guide appropriate therapy.
We discussed the diagnosis thoroughly with the parents, including the etiology, potential treatments, and prognosis. Treatment was initiated with topical triamcinolone 0.1% cream bid. If it proves necessary, we could increase the potency of the steroid, inject the lesion with steroid, or even start her on methotrexate.
She’ll also be closely followed for signs of worsening disease and for psoriatic arthropathy, which affects almost 25% of patients with psoriasis. She’ll be fortunate if this is the extent of her disease.
TAKE-HOME LEARNING POINTS
- Salmon-pink, scaly plaques are psoriatic until proven otherwise.
- Psoriasis is common, affecting almost 3% of the white population.
- Though most often seen on extensor surfaces of arms, legs, and trunk, psoriasis can appear virtually anywhere.
- Mentally transpositioning a lesion to another location can be helpful in sorting through this differential.
Rash on arm
The FP looked closely at the so-called rash and realized that while it could be nummular eczema it could also be a superficial basal cell carcinoma (BCC).
He explained the differential diagnosis to the patient and suggested that he perform a shave biopsy that day. The patient consented to the biopsy, and the physician numbed the area with 1% lidocaine and epinephrine. He used a DermaBlade and obtained hemostasis with aluminum chloride in water. (See the Watch & Learn video on “Shave biopsy.”) The biopsy result confirmed the FP’s suspicion: The lesion was a superficial BCC.
On the follow-up visit the FP explained the options for treatment, including electrodesiccation and curettage, cryosurgery, or an elliptical excision. He told the patient that the cure rates are about the same, regardless of which of these treatments were chosen. He also explained that either of the 2 destructive methods could be performed immediately, whereas the elliptical excision would require scheduling a longer appointment.
The patient chose the cryosurgery. (See the Watch & Learn video on cryosurgery.) After numbing the area with 1% lidocaine and epinephrine, the physician froze the lesion with a 3 mm halo for 30 seconds using liquid nitrogen spray. At follow-up 3 months later, there was some hypopigmentation, but no evidence of the BCC.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP looked closely at the so-called rash and realized that while it could be nummular eczema it could also be a superficial basal cell carcinoma (BCC).
He explained the differential diagnosis to the patient and suggested that he perform a shave biopsy that day. The patient consented to the biopsy, and the physician numbed the area with 1% lidocaine and epinephrine. He used a DermaBlade and obtained hemostasis with aluminum chloride in water. (See the Watch & Learn video on “Shave biopsy.”) The biopsy result confirmed the FP’s suspicion: The lesion was a superficial BCC.
On the follow-up visit the FP explained the options for treatment, including electrodesiccation and curettage, cryosurgery, or an elliptical excision. He told the patient that the cure rates are about the same, regardless of which of these treatments were chosen. He also explained that either of the 2 destructive methods could be performed immediately, whereas the elliptical excision would require scheduling a longer appointment.
The patient chose the cryosurgery. (See the Watch & Learn video on cryosurgery.) After numbing the area with 1% lidocaine and epinephrine, the physician froze the lesion with a 3 mm halo for 30 seconds using liquid nitrogen spray. At follow-up 3 months later, there was some hypopigmentation, but no evidence of the BCC.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP looked closely at the so-called rash and realized that while it could be nummular eczema it could also be a superficial basal cell carcinoma (BCC).
He explained the differential diagnosis to the patient and suggested that he perform a shave biopsy that day. The patient consented to the biopsy, and the physician numbed the area with 1% lidocaine and epinephrine. He used a DermaBlade and obtained hemostasis with aluminum chloride in water. (See the Watch & Learn video on “Shave biopsy.”) The biopsy result confirmed the FP’s suspicion: The lesion was a superficial BCC.
On the follow-up visit the FP explained the options for treatment, including electrodesiccation and curettage, cryosurgery, or an elliptical excision. He told the patient that the cure rates are about the same, regardless of which of these treatments were chosen. He also explained that either of the 2 destructive methods could be performed immediately, whereas the elliptical excision would require scheduling a longer appointment.
The patient chose the cryosurgery. (See the Watch & Learn video on cryosurgery.) After numbing the area with 1% lidocaine and epinephrine, the physician froze the lesion with a 3 mm halo for 30 seconds using liquid nitrogen spray. At follow-up 3 months later, there was some hypopigmentation, but no evidence of the BCC.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
Consider different etiologies in patients with vaginal pruritus
CHICAGO – Diagnosing the cause of vaginal itching, which can have a significant negative impact on a woman’s quality of life, can be particularly difficult for multiple reasons, according to Rachel Kornik, MD, of the departments of dermatology and obstetrics and gynecology at the University of Wisconsin, Madison.
“The anatomy is really challenging in this area, and there’s a broad differential. Often there’s more than one thing happening,” Dr. Kornik said during a session on diagnosing and managing genital pruritus in women at the American Academy of Dermatology summer meeting. Like hair loss, vaginal pruritus is also very emotionally distressing.
“Patients are very anxious when they have all this itching,” she said. “It has an impact on personal relationships. Some patients find it difficult to talk about because it’s a taboo subject, so we have to make them comfortable.”
Dr. Kornik showed a chart of the inflammatory, neoplastic, infections, infestations, environmental, neuropathic, and hormonal. But she focused her presentation primarily on the most common causes: contact dermatitis, lichen sclerosus, and lichen simplex chronicus.
Contact dermatitis
The most common factors that contribute to contact dermatitis are friction, hygiene practices, unique body exposures (such as body fluids and menstrual and personal care products), and occlusion/maceration, which facilitates penetration of external agents. Estrogen deficiency may also play a role.
Taking a thorough history from the patient is key to finding out possible causes. Dr. Kornik provided a list of common irritants to consider.
- Hygiene-related irritants, such as frequent washing and the use of soaps, wash cloths, loofahs, wipes, bath oil, bubbles, and water.
- Laundry products, such as fabric softeners or dryer sheets.
- Menstrual products, such as panty liners, pads, and scents or additives for retaining moisture.
- Over-the-counter itch products, such as those containing benzocaine.
- Medications, such as alcohol-based creams and gels, trichloroacetic acid, fluorouracil (Efudex), imiquimod, and topical antifungals.
- Heat-related irritants, such as use of hair dryers and heating pads.
- Body fluids, including urine, feces, menstrual blood, sweat, semen, and excessive discharge.
It’s also important to consider whether there is an allergic cause. “Contact dermatitis and allergic dermatitis can look very similar both clinically and histologically, and patients can even have them both at the same time,” Dr. Kornik said. “So really, patch testing is essential sometimes to identify a true allergic contact dermatitis.”
She cited a study that identified the top five most common allergens as fragrance mixes, balsam of Peru, benzocaine, terconazole, and quaternium-15 (a formaldehyde-releasing preservative) (Dermatitis. 2013 Mar-Apr;24(2):64-72).
“If somebody’s coming into your office and they have vulvar itching for any reason, the No. 1 thing is making sure that they eliminate and not use any products with fragrances,” Dr. Kornik said. “It’s also important to note that over time, industries’ use of preservatives does change, the concentrations change, and so we may see more emerging allergens or different ones over time.”
The causative allergens are rarely consumed orally, but they may be ectopic, such as shampoo or nail polish.
“What I’ve learned over the years in treating patients with vulvar itching is that they don’t always think to tell you about everything they are applying,” Dr. Kornik said. “You have to ask specific questions. Are you using any wipes or using any lubricants? What is the type and brand of menstrual pad you’re using?”
Patients might also think they can eliminate the cause of irritation by changing products, but “there are cross reactants in many preservatives and fragrances in many products, so they might not eliminate exposure, and intermittent exposures can lead to chronic dermatitis,” she pointed out.
One example is wipes: Some women may use them only periodically, such as after a yoga class, and not think of this as a possibility or realize that wipes could perpetuate chronic dermatitis.
Research has also found that it’s very common for patients with allergic contact dermatitis to have a concomitant vulvar diagnosis. In one study, more than half of patients had another condition, the most common of which was lichen sclerosus. Others included simplex chronicus, atopic dermatitis, condyloma acuminatum, psoriasis, and Paget disease.
Therefore, if patients are not responding as expected, it’s important to consider that the condition is multifactorial “and consider allergic contact dermatitis in addition to whatever other underlying dermatosis they have,” Dr. Kornik said.
Lichen sclerosus
Prevalence of the scarring disorder lichen sclerosus ranges from 1.7% to 3% in the research literature and pathogenesis is likely multifactorial.
“It’s a very frustrating condition for patients and for physicians because we don’t know exactly what causes it, but it definitely has a predilection for the vulva area, and it affects women of all ages,” she said. “I also think it’s more common than we think.”
Loss of normal anatomical structures are a key feature, so physicians need to know their anatomy well to look for what’s not there. Lichen sclerosus involves modified mucous membranes and the perianal area, and it may spread to the crural folds and upper thighs. Symptoms can include periclitoral edema, white patches, pale skin, textural changes (such as wrinkling, waxiness, or hyperkeratosis), fissures, melanosis, and sometimes ulcerations or erosions from scratching.
There is no standardized treatment for lichen sclerosus. Research suggests using a high potency topical steroid treatment daily until skin texture normalizes, which can take anywhere from 6 weeks to 5 months, depending on severity, Dr. Kornik said. Few data are available for management if topical steroids do not work, she added.*
If dealing with recalcitrant disease, she recommends first checking the patients’ compliance and then considering alternative diagnoses or secondary conditions. Do patch testing, rule out contact dermatitis, and rebiopsy if needed. Other options are to add tacrolimus ointment, offer intralesional triamcinolone, consider a systemic agent (acitretin, methotrexate, or possibly hydroxychloroquine), or try laser or photodynamic therapy. She emphasizes the importance of demonstrating to the patient where to apply ointment, since they may not be applying to the right areas.*
Lichen simplex chronicus
Lichen simplex chronicus is a clinical description of the result of chronic rubbing and scratching. It might be triggered by something that has now resolved or be linked to other itching conditions, but clinicians need to consider the possibility of neuropathic itch as well.
Features of lichen simplex chronicus can include bilateral or unilateral involvement of the labia majora, erythematous plaques with lichenification, hyper- or hypopigmentation, or angulated excoriations and hypertrophy of labia caused by thickened skin, though the signs may be subtle, she said.
Treatment requires management of the skin problem itself – the underlying cause of the itch – as well as the behavioral component. Topical steroids are first line, plus an antihistamine at night as needed to stop the scratching. If those are insufficient, the next treatments to consider are intralesional triamcinolone (Kenalog), tacrolimus ointment, topical or oral doxepin, mirtazapine, or even selective serotonin reuptake inhibitors.
Women using topical steroids should also be aware of the possible side effects, including atrophy, infections, and allergic contact dermatitis if the steroid itself or the cream it’s in is an allergen. If stinging or burning occurs, switch to a steroid without propylene glycol, she added.
If no changes occur in the skin, clinicians may have to consider the existence of neuropathic pruritus diagnosis, an injury or dysfunction along the afferent itch pathway. Burning is more common with this neuropathy, but itching can occur too.
Other issues include symptoms that worsen with sitting and pain that worsens throughout the day. Causes can include childbirth, surgery, pelvic trauma, infection, and chemoradiation, and diagnosis requires imaging to rule out other possible causes. Treatment involves pelvic floor physical therapy, pudendal nerve block, or gabapentin.
Dr. Kornik wrapped up with a reminder that vulvar itch is often multifactorial, so clinicians need to chip away at the potential causes – sometimes with cultures, scrapes, and biopsies as needed.
She reported no financial disclosures.
Correction, 10/26/18: Dr. Kornik's treatment recommendations for lichen sclerosus were misstated.
CHICAGO – Diagnosing the cause of vaginal itching, which can have a significant negative impact on a woman’s quality of life, can be particularly difficult for multiple reasons, according to Rachel Kornik, MD, of the departments of dermatology and obstetrics and gynecology at the University of Wisconsin, Madison.
“The anatomy is really challenging in this area, and there’s a broad differential. Often there’s more than one thing happening,” Dr. Kornik said during a session on diagnosing and managing genital pruritus in women at the American Academy of Dermatology summer meeting. Like hair loss, vaginal pruritus is also very emotionally distressing.
“Patients are very anxious when they have all this itching,” she said. “It has an impact on personal relationships. Some patients find it difficult to talk about because it’s a taboo subject, so we have to make them comfortable.”
Dr. Kornik showed a chart of the inflammatory, neoplastic, infections, infestations, environmental, neuropathic, and hormonal. But she focused her presentation primarily on the most common causes: contact dermatitis, lichen sclerosus, and lichen simplex chronicus.
Contact dermatitis
The most common factors that contribute to contact dermatitis are friction, hygiene practices, unique body exposures (such as body fluids and menstrual and personal care products), and occlusion/maceration, which facilitates penetration of external agents. Estrogen deficiency may also play a role.
Taking a thorough history from the patient is key to finding out possible causes. Dr. Kornik provided a list of common irritants to consider.
- Hygiene-related irritants, such as frequent washing and the use of soaps, wash cloths, loofahs, wipes, bath oil, bubbles, and water.
- Laundry products, such as fabric softeners or dryer sheets.
- Menstrual products, such as panty liners, pads, and scents or additives for retaining moisture.
- Over-the-counter itch products, such as those containing benzocaine.
- Medications, such as alcohol-based creams and gels, trichloroacetic acid, fluorouracil (Efudex), imiquimod, and topical antifungals.
- Heat-related irritants, such as use of hair dryers and heating pads.
- Body fluids, including urine, feces, menstrual blood, sweat, semen, and excessive discharge.
It’s also important to consider whether there is an allergic cause. “Contact dermatitis and allergic dermatitis can look very similar both clinically and histologically, and patients can even have them both at the same time,” Dr. Kornik said. “So really, patch testing is essential sometimes to identify a true allergic contact dermatitis.”
She cited a study that identified the top five most common allergens as fragrance mixes, balsam of Peru, benzocaine, terconazole, and quaternium-15 (a formaldehyde-releasing preservative) (Dermatitis. 2013 Mar-Apr;24(2):64-72).
“If somebody’s coming into your office and they have vulvar itching for any reason, the No. 1 thing is making sure that they eliminate and not use any products with fragrances,” Dr. Kornik said. “It’s also important to note that over time, industries’ use of preservatives does change, the concentrations change, and so we may see more emerging allergens or different ones over time.”
The causative allergens are rarely consumed orally, but they may be ectopic, such as shampoo or nail polish.
“What I’ve learned over the years in treating patients with vulvar itching is that they don’t always think to tell you about everything they are applying,” Dr. Kornik said. “You have to ask specific questions. Are you using any wipes or using any lubricants? What is the type and brand of menstrual pad you’re using?”
Patients might also think they can eliminate the cause of irritation by changing products, but “there are cross reactants in many preservatives and fragrances in many products, so they might not eliminate exposure, and intermittent exposures can lead to chronic dermatitis,” she pointed out.
One example is wipes: Some women may use them only periodically, such as after a yoga class, and not think of this as a possibility or realize that wipes could perpetuate chronic dermatitis.
Research has also found that it’s very common for patients with allergic contact dermatitis to have a concomitant vulvar diagnosis. In one study, more than half of patients had another condition, the most common of which was lichen sclerosus. Others included simplex chronicus, atopic dermatitis, condyloma acuminatum, psoriasis, and Paget disease.
Therefore, if patients are not responding as expected, it’s important to consider that the condition is multifactorial “and consider allergic contact dermatitis in addition to whatever other underlying dermatosis they have,” Dr. Kornik said.
Lichen sclerosus
Prevalence of the scarring disorder lichen sclerosus ranges from 1.7% to 3% in the research literature and pathogenesis is likely multifactorial.
“It’s a very frustrating condition for patients and for physicians because we don’t know exactly what causes it, but it definitely has a predilection for the vulva area, and it affects women of all ages,” she said. “I also think it’s more common than we think.”
Loss of normal anatomical structures are a key feature, so physicians need to know their anatomy well to look for what’s not there. Lichen sclerosus involves modified mucous membranes and the perianal area, and it may spread to the crural folds and upper thighs. Symptoms can include periclitoral edema, white patches, pale skin, textural changes (such as wrinkling, waxiness, or hyperkeratosis), fissures, melanosis, and sometimes ulcerations or erosions from scratching.
There is no standardized treatment for lichen sclerosus. Research suggests using a high potency topical steroid treatment daily until skin texture normalizes, which can take anywhere from 6 weeks to 5 months, depending on severity, Dr. Kornik said. Few data are available for management if topical steroids do not work, she added.*
If dealing with recalcitrant disease, she recommends first checking the patients’ compliance and then considering alternative diagnoses or secondary conditions. Do patch testing, rule out contact dermatitis, and rebiopsy if needed. Other options are to add tacrolimus ointment, offer intralesional triamcinolone, consider a systemic agent (acitretin, methotrexate, or possibly hydroxychloroquine), or try laser or photodynamic therapy. She emphasizes the importance of demonstrating to the patient where to apply ointment, since they may not be applying to the right areas.*
Lichen simplex chronicus
Lichen simplex chronicus is a clinical description of the result of chronic rubbing and scratching. It might be triggered by something that has now resolved or be linked to other itching conditions, but clinicians need to consider the possibility of neuropathic itch as well.
Features of lichen simplex chronicus can include bilateral or unilateral involvement of the labia majora, erythematous plaques with lichenification, hyper- or hypopigmentation, or angulated excoriations and hypertrophy of labia caused by thickened skin, though the signs may be subtle, she said.
Treatment requires management of the skin problem itself – the underlying cause of the itch – as well as the behavioral component. Topical steroids are first line, plus an antihistamine at night as needed to stop the scratching. If those are insufficient, the next treatments to consider are intralesional triamcinolone (Kenalog), tacrolimus ointment, topical or oral doxepin, mirtazapine, or even selective serotonin reuptake inhibitors.
Women using topical steroids should also be aware of the possible side effects, including atrophy, infections, and allergic contact dermatitis if the steroid itself or the cream it’s in is an allergen. If stinging or burning occurs, switch to a steroid without propylene glycol, she added.
If no changes occur in the skin, clinicians may have to consider the existence of neuropathic pruritus diagnosis, an injury or dysfunction along the afferent itch pathway. Burning is more common with this neuropathy, but itching can occur too.
Other issues include symptoms that worsen with sitting and pain that worsens throughout the day. Causes can include childbirth, surgery, pelvic trauma, infection, and chemoradiation, and diagnosis requires imaging to rule out other possible causes. Treatment involves pelvic floor physical therapy, pudendal nerve block, or gabapentin.
Dr. Kornik wrapped up with a reminder that vulvar itch is often multifactorial, so clinicians need to chip away at the potential causes – sometimes with cultures, scrapes, and biopsies as needed.
She reported no financial disclosures.
Correction, 10/26/18: Dr. Kornik's treatment recommendations for lichen sclerosus were misstated.
CHICAGO – Diagnosing the cause of vaginal itching, which can have a significant negative impact on a woman’s quality of life, can be particularly difficult for multiple reasons, according to Rachel Kornik, MD, of the departments of dermatology and obstetrics and gynecology at the University of Wisconsin, Madison.
“The anatomy is really challenging in this area, and there’s a broad differential. Often there’s more than one thing happening,” Dr. Kornik said during a session on diagnosing and managing genital pruritus in women at the American Academy of Dermatology summer meeting. Like hair loss, vaginal pruritus is also very emotionally distressing.
“Patients are very anxious when they have all this itching,” she said. “It has an impact on personal relationships. Some patients find it difficult to talk about because it’s a taboo subject, so we have to make them comfortable.”
Dr. Kornik showed a chart of the inflammatory, neoplastic, infections, infestations, environmental, neuropathic, and hormonal. But she focused her presentation primarily on the most common causes: contact dermatitis, lichen sclerosus, and lichen simplex chronicus.
Contact dermatitis
The most common factors that contribute to contact dermatitis are friction, hygiene practices, unique body exposures (such as body fluids and menstrual and personal care products), and occlusion/maceration, which facilitates penetration of external agents. Estrogen deficiency may also play a role.
Taking a thorough history from the patient is key to finding out possible causes. Dr. Kornik provided a list of common irritants to consider.
- Hygiene-related irritants, such as frequent washing and the use of soaps, wash cloths, loofahs, wipes, bath oil, bubbles, and water.
- Laundry products, such as fabric softeners or dryer sheets.
- Menstrual products, such as panty liners, pads, and scents or additives for retaining moisture.
- Over-the-counter itch products, such as those containing benzocaine.
- Medications, such as alcohol-based creams and gels, trichloroacetic acid, fluorouracil (Efudex), imiquimod, and topical antifungals.
- Heat-related irritants, such as use of hair dryers and heating pads.
- Body fluids, including urine, feces, menstrual blood, sweat, semen, and excessive discharge.
It’s also important to consider whether there is an allergic cause. “Contact dermatitis and allergic dermatitis can look very similar both clinically and histologically, and patients can even have them both at the same time,” Dr. Kornik said. “So really, patch testing is essential sometimes to identify a true allergic contact dermatitis.”
She cited a study that identified the top five most common allergens as fragrance mixes, balsam of Peru, benzocaine, terconazole, and quaternium-15 (a formaldehyde-releasing preservative) (Dermatitis. 2013 Mar-Apr;24(2):64-72).
“If somebody’s coming into your office and they have vulvar itching for any reason, the No. 1 thing is making sure that they eliminate and not use any products with fragrances,” Dr. Kornik said. “It’s also important to note that over time, industries’ use of preservatives does change, the concentrations change, and so we may see more emerging allergens or different ones over time.”
The causative allergens are rarely consumed orally, but they may be ectopic, such as shampoo or nail polish.
“What I’ve learned over the years in treating patients with vulvar itching is that they don’t always think to tell you about everything they are applying,” Dr. Kornik said. “You have to ask specific questions. Are you using any wipes or using any lubricants? What is the type and brand of menstrual pad you’re using?”
Patients might also think they can eliminate the cause of irritation by changing products, but “there are cross reactants in many preservatives and fragrances in many products, so they might not eliminate exposure, and intermittent exposures can lead to chronic dermatitis,” she pointed out.
One example is wipes: Some women may use them only periodically, such as after a yoga class, and not think of this as a possibility or realize that wipes could perpetuate chronic dermatitis.
Research has also found that it’s very common for patients with allergic contact dermatitis to have a concomitant vulvar diagnosis. In one study, more than half of patients had another condition, the most common of which was lichen sclerosus. Others included simplex chronicus, atopic dermatitis, condyloma acuminatum, psoriasis, and Paget disease.
Therefore, if patients are not responding as expected, it’s important to consider that the condition is multifactorial “and consider allergic contact dermatitis in addition to whatever other underlying dermatosis they have,” Dr. Kornik said.
Lichen sclerosus
Prevalence of the scarring disorder lichen sclerosus ranges from 1.7% to 3% in the research literature and pathogenesis is likely multifactorial.
“It’s a very frustrating condition for patients and for physicians because we don’t know exactly what causes it, but it definitely has a predilection for the vulva area, and it affects women of all ages,” she said. “I also think it’s more common than we think.”
Loss of normal anatomical structures are a key feature, so physicians need to know their anatomy well to look for what’s not there. Lichen sclerosus involves modified mucous membranes and the perianal area, and it may spread to the crural folds and upper thighs. Symptoms can include periclitoral edema, white patches, pale skin, textural changes (such as wrinkling, waxiness, or hyperkeratosis), fissures, melanosis, and sometimes ulcerations or erosions from scratching.
There is no standardized treatment for lichen sclerosus. Research suggests using a high potency topical steroid treatment daily until skin texture normalizes, which can take anywhere from 6 weeks to 5 months, depending on severity, Dr. Kornik said. Few data are available for management if topical steroids do not work, she added.*
If dealing with recalcitrant disease, she recommends first checking the patients’ compliance and then considering alternative diagnoses or secondary conditions. Do patch testing, rule out contact dermatitis, and rebiopsy if needed. Other options are to add tacrolimus ointment, offer intralesional triamcinolone, consider a systemic agent (acitretin, methotrexate, or possibly hydroxychloroquine), or try laser or photodynamic therapy. She emphasizes the importance of demonstrating to the patient where to apply ointment, since they may not be applying to the right areas.*
Lichen simplex chronicus
Lichen simplex chronicus is a clinical description of the result of chronic rubbing and scratching. It might be triggered by something that has now resolved or be linked to other itching conditions, but clinicians need to consider the possibility of neuropathic itch as well.
Features of lichen simplex chronicus can include bilateral or unilateral involvement of the labia majora, erythematous plaques with lichenification, hyper- or hypopigmentation, or angulated excoriations and hypertrophy of labia caused by thickened skin, though the signs may be subtle, she said.
Treatment requires management of the skin problem itself – the underlying cause of the itch – as well as the behavioral component. Topical steroids are first line, plus an antihistamine at night as needed to stop the scratching. If those are insufficient, the next treatments to consider are intralesional triamcinolone (Kenalog), tacrolimus ointment, topical or oral doxepin, mirtazapine, or even selective serotonin reuptake inhibitors.
Women using topical steroids should also be aware of the possible side effects, including atrophy, infections, and allergic contact dermatitis if the steroid itself or the cream it’s in is an allergen. If stinging or burning occurs, switch to a steroid without propylene glycol, she added.
If no changes occur in the skin, clinicians may have to consider the existence of neuropathic pruritus diagnosis, an injury or dysfunction along the afferent itch pathway. Burning is more common with this neuropathy, but itching can occur too.
Other issues include symptoms that worsen with sitting and pain that worsens throughout the day. Causes can include childbirth, surgery, pelvic trauma, infection, and chemoradiation, and diagnosis requires imaging to rule out other possible causes. Treatment involves pelvic floor physical therapy, pudendal nerve block, or gabapentin.
Dr. Kornik wrapped up with a reminder that vulvar itch is often multifactorial, so clinicians need to chip away at the potential causes – sometimes with cultures, scrapes, and biopsies as needed.
She reported no financial disclosures.
Correction, 10/26/18: Dr. Kornik's treatment recommendations for lichen sclerosus were misstated.
EXPERT ANALYSIS FROM SUMMER AAD 2018
Rosacea likely underdiagnosed, suboptimally treated in skin of color
in this population, according to the authors of a clinical review article on the topic.
“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.
Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.
The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.
The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.
A low index of suspicion for rosacea in skin of color may lead to delayed diagnosis, and consequently, advanced disease that could include disfigurement with disease progression (such as rhinophyma and otophyma) and, in the case of ocular disease, loss of sight, Dr. Alexis and his coauthors pointed out.
One clinical aspect of rosacea in skin of color is that persistent facial erythema is less frequently reported than are papules and pustules. That may be due to the difficulty of visualizing erythema in darker skin, they suggested, noting that the postinflammatory hyperpigmentation that is more common in skin of color could also mask erythema.
A rosacea variant seen more often in these patients is the granulomatous subtype, which may not present with flushing, persistent erythema, or other typical rosacea signs, they pointed out.
One key to accurately diagnosing rosacea in skin of color is the patient’s own observations, such as whether they experience flushing or a warm sensation in the face, according to the authors, who said patients may report stinging or burning with certain skin care products.
Dr. Alexis and his coauthors said they have tried various strategies to assess dark skin for erythema and telangiectasia. Photographing subjects on a dark-blue background may better highlight any redness, they said, while using a dermatoscope may help differentiate skin pigment from blood vessels.
A magnifying glass or microscope slide can be used to test skin for blanching: “If the skin pales when pressed under the glass or slide, erythema is present,” they wrote.
Although data on treatment of rosacea in skin of color is limited, the general treatment approach is similar to that of lighter skin and may include topical and oral therapies, laser or light-based treatment, or surgery. “Patients with skin of color may have unique clinical features that need to be addressed during the treatment of rosacea, such as postinflammatory pigment alteration or risk of developing this complication with laser/light-based therapies,” they noted.
In the review, they referred to a few studies of oral or topical treatments that suggest similar benefits in Fitzpatrick skin phototypes I-III (lighter) and IV-VI (darker) that the authors describe in their review.
Allergan sponsored development of the paper, which was developed with editorial assistance from Peloton Advantage. Dr. Alexis and his coauthors provided disclosures related to Allergan, BioPharmx, Galderma, Bayer, Beiersdorf, Croma-Pharma, Aclaris, and Unilever.
SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.
in this population, according to the authors of a clinical review article on the topic.
“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.
Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.
The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.
The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.
A low index of suspicion for rosacea in skin of color may lead to delayed diagnosis, and consequently, advanced disease that could include disfigurement with disease progression (such as rhinophyma and otophyma) and, in the case of ocular disease, loss of sight, Dr. Alexis and his coauthors pointed out.
One clinical aspect of rosacea in skin of color is that persistent facial erythema is less frequently reported than are papules and pustules. That may be due to the difficulty of visualizing erythema in darker skin, they suggested, noting that the postinflammatory hyperpigmentation that is more common in skin of color could also mask erythema.
A rosacea variant seen more often in these patients is the granulomatous subtype, which may not present with flushing, persistent erythema, or other typical rosacea signs, they pointed out.
One key to accurately diagnosing rosacea in skin of color is the patient’s own observations, such as whether they experience flushing or a warm sensation in the face, according to the authors, who said patients may report stinging or burning with certain skin care products.
Dr. Alexis and his coauthors said they have tried various strategies to assess dark skin for erythema and telangiectasia. Photographing subjects on a dark-blue background may better highlight any redness, they said, while using a dermatoscope may help differentiate skin pigment from blood vessels.
A magnifying glass or microscope slide can be used to test skin for blanching: “If the skin pales when pressed under the glass or slide, erythema is present,” they wrote.
Although data on treatment of rosacea in skin of color is limited, the general treatment approach is similar to that of lighter skin and may include topical and oral therapies, laser or light-based treatment, or surgery. “Patients with skin of color may have unique clinical features that need to be addressed during the treatment of rosacea, such as postinflammatory pigment alteration or risk of developing this complication with laser/light-based therapies,” they noted.
In the review, they referred to a few studies of oral or topical treatments that suggest similar benefits in Fitzpatrick skin phototypes I-III (lighter) and IV-VI (darker) that the authors describe in their review.
Allergan sponsored development of the paper, which was developed with editorial assistance from Peloton Advantage. Dr. Alexis and his coauthors provided disclosures related to Allergan, BioPharmx, Galderma, Bayer, Beiersdorf, Croma-Pharma, Aclaris, and Unilever.
SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.
in this population, according to the authors of a clinical review article on the topic.
“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.
Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.
The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.
The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.
A low index of suspicion for rosacea in skin of color may lead to delayed diagnosis, and consequently, advanced disease that could include disfigurement with disease progression (such as rhinophyma and otophyma) and, in the case of ocular disease, loss of sight, Dr. Alexis and his coauthors pointed out.
One clinical aspect of rosacea in skin of color is that persistent facial erythema is less frequently reported than are papules and pustules. That may be due to the difficulty of visualizing erythema in darker skin, they suggested, noting that the postinflammatory hyperpigmentation that is more common in skin of color could also mask erythema.
A rosacea variant seen more often in these patients is the granulomatous subtype, which may not present with flushing, persistent erythema, or other typical rosacea signs, they pointed out.
One key to accurately diagnosing rosacea in skin of color is the patient’s own observations, such as whether they experience flushing or a warm sensation in the face, according to the authors, who said patients may report stinging or burning with certain skin care products.
Dr. Alexis and his coauthors said they have tried various strategies to assess dark skin for erythema and telangiectasia. Photographing subjects on a dark-blue background may better highlight any redness, they said, while using a dermatoscope may help differentiate skin pigment from blood vessels.
A magnifying glass or microscope slide can be used to test skin for blanching: “If the skin pales when pressed under the glass or slide, erythema is present,” they wrote.
Although data on treatment of rosacea in skin of color is limited, the general treatment approach is similar to that of lighter skin and may include topical and oral therapies, laser or light-based treatment, or surgery. “Patients with skin of color may have unique clinical features that need to be addressed during the treatment of rosacea, such as postinflammatory pigment alteration or risk of developing this complication with laser/light-based therapies,” they noted.
In the review, they referred to a few studies of oral or topical treatments that suggest similar benefits in Fitzpatrick skin phototypes I-III (lighter) and IV-VI (darker) that the authors describe in their review.
Allergan sponsored development of the paper, which was developed with editorial assistance from Peloton Advantage. Dr. Alexis and his coauthors provided disclosures related to Allergan, BioPharmx, Galderma, Bayer, Beiersdorf, Croma-Pharma, Aclaris, and Unilever.
SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Acne more common in adults with hidradenitis suppurativa
, according to Sara Wertenteil and her colleagues in the department of dermatology at Hofstra University in Hempstead, N.Y.
Using data collected by IBM Watson Health, the study authors examined a total of 48,050 adults with HS and 16.9 million adults in the general U.S. population. In this study population, 15.2% of adults with HS had acne, compared with only 2.9% of adults in the general population (P less than .0001), the investigators wrote in the Journal of the American Academy of Dermatology.
After adjusting for age, sex, obesity, smoking status, and polycystic ovarian syndrome (PCOS) status, the odds ratio of adults with HS having acne was 4.51 over those without HS (95% confidence interval, 4.40-4.63). In all subgroups measured (male; female; adults aged 18-44 years, 45-64 years, and 65 years and older; white; nonwhite; obese; nonobese; smoker; nonsmoker; positive for PCOS; non-PCOS) adults with HS were significantly more likely to have acne. The strongest association was in patients who were aged 65 years and older (odds ratio, 10.14; 95% CI, 8.97-11.46).
“Patients with HS have an increased prevalence of [acne vulgaris]. Clinicians treating HS patients should be aware of this burden and its potential implications including a further impact on quality of life. Management strategies should include consideration of both conditions, either with treatments that have overlapping efficacy, or with concomitant therapies,” the authors concluded.
The study was sponsored in part by AbbVie. One coauthor reported having served as an advisor for AbbVie, Pfizer, Janssen, and Asana Biosciences.
SOURCE: Wertentiel S et al. J Am Acad Dermatol. 2018 Oct 1. doi: 10.1016/j.jaad.2018.09.040.
, according to Sara Wertenteil and her colleagues in the department of dermatology at Hofstra University in Hempstead, N.Y.
Using data collected by IBM Watson Health, the study authors examined a total of 48,050 adults with HS and 16.9 million adults in the general U.S. population. In this study population, 15.2% of adults with HS had acne, compared with only 2.9% of adults in the general population (P less than .0001), the investigators wrote in the Journal of the American Academy of Dermatology.
After adjusting for age, sex, obesity, smoking status, and polycystic ovarian syndrome (PCOS) status, the odds ratio of adults with HS having acne was 4.51 over those without HS (95% confidence interval, 4.40-4.63). In all subgroups measured (male; female; adults aged 18-44 years, 45-64 years, and 65 years and older; white; nonwhite; obese; nonobese; smoker; nonsmoker; positive for PCOS; non-PCOS) adults with HS were significantly more likely to have acne. The strongest association was in patients who were aged 65 years and older (odds ratio, 10.14; 95% CI, 8.97-11.46).
“Patients with HS have an increased prevalence of [acne vulgaris]. Clinicians treating HS patients should be aware of this burden and its potential implications including a further impact on quality of life. Management strategies should include consideration of both conditions, either with treatments that have overlapping efficacy, or with concomitant therapies,” the authors concluded.
The study was sponsored in part by AbbVie. One coauthor reported having served as an advisor for AbbVie, Pfizer, Janssen, and Asana Biosciences.
SOURCE: Wertentiel S et al. J Am Acad Dermatol. 2018 Oct 1. doi: 10.1016/j.jaad.2018.09.040.
, according to Sara Wertenteil and her colleagues in the department of dermatology at Hofstra University in Hempstead, N.Y.
Using data collected by IBM Watson Health, the study authors examined a total of 48,050 adults with HS and 16.9 million adults in the general U.S. population. In this study population, 15.2% of adults with HS had acne, compared with only 2.9% of adults in the general population (P less than .0001), the investigators wrote in the Journal of the American Academy of Dermatology.
After adjusting for age, sex, obesity, smoking status, and polycystic ovarian syndrome (PCOS) status, the odds ratio of adults with HS having acne was 4.51 over those without HS (95% confidence interval, 4.40-4.63). In all subgroups measured (male; female; adults aged 18-44 years, 45-64 years, and 65 years and older; white; nonwhite; obese; nonobese; smoker; nonsmoker; positive for PCOS; non-PCOS) adults with HS were significantly more likely to have acne. The strongest association was in patients who were aged 65 years and older (odds ratio, 10.14; 95% CI, 8.97-11.46).
“Patients with HS have an increased prevalence of [acne vulgaris]. Clinicians treating HS patients should be aware of this burden and its potential implications including a further impact on quality of life. Management strategies should include consideration of both conditions, either with treatments that have overlapping efficacy, or with concomitant therapies,” the authors concluded.
The study was sponsored in part by AbbVie. One coauthor reported having served as an advisor for AbbVie, Pfizer, Janssen, and Asana Biosciences.
SOURCE: Wertentiel S et al. J Am Acad Dermatol. 2018 Oct 1. doi: 10.1016/j.jaad.2018.09.040.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
In rosacea, a single treatment may not be enough
MONTEREY, CALIF. – , a dermatologist said at the annual Coastal Dermatology Symposium. Don’t assume you can just prescribe one drug like you might with acne, she advised.
“Treat everything that you see,” said dermatologist Julie C. Harper, MD, of Birmingham, Ala. “That may mean a laser or something you’re using off-label. Different lesions and signs of rosacea will require multiple modes of treatment.”
Dr. Harper offered these other pearls to consider when treating rosacea:
- Don’t get hung up on subtypes.
The four subtypes of rosacea should be used to classify lesions, not people, she said. That’s because patients can fall into more than one of the four categories – erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea, she noted.
“Document the redness you see and ask them what’s bothering them the most,” she said. And ask yourself, she added, “Do I have them on everything that I should have them on?”
- Talk to patients about triggers.
For the first visit, “we have to talk to patients about skin care and triggers,” Dr. Harper noted. According to the American Academy of Dermatology, common rosacea triggers include sunlight, hairspray, heat, stress, alcohol, and spicy foods.
- Consider an ivermectin-brimonidine combination.
“Targeting inflammation in papules and pustules doesn’t necessarily translate to less background erythema,” Dr. Harper said. What to do? She pointed to a 2017 study that examined a combination treatment of ivermectin 1% topical cream (Soolantra) and brimonidine 0.33% topical gel (Mirvaso) for patients with rosacea with moderate to severe persistent erythema and inflammatory lesions. Ivermectin is indicated for inflammatory lesions, while brimonidine treats persistent erythema.
At week 12, the proportion of patients who achieved investigator global assessment of clear or almost clear was 55.8% in the combination group, versus 36.8% of those in the vehicle group (P = .007), according to the study (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Dr. Harper highlighted the effect of brimonidine when added to ivermectin. “In a period of 3 hours,” she said, “we had twice as many people fall into clear or almost clear.”
- Consider adding botulinum toxin to your toolbox.
This “really does work,” Dr. Harper said. She pointed to a 2015 report of botulinum toxin use in two cases of refractory flushing and erythema and a 2012 report of 13 cases in patients with the same symptoms (Dermatology. 2015;230:299-301; J Drugs Dermatol. 2012 Dec;11[12]:e76-9). Dr. Harper said that she usually uses the full 50-unit dose of Botox.
- Consider a beta-blocker.
According to a 2018 report, the beta-blocker carvedilol (Coreg) showed benefit when added to other treatments in five patients with facial flushing and persistent erythema.
- Keep isotretinoin in mind.
A 2016 report suggested low-dose isotretinoin had value for difficult-to-treat papulopustular rosacea. As Dr. Harper noted, 57% of those who took isotretinoin reached the primary endpoint, versus 10% of those taking the placebo. However, relapses over 4 months were common, which is a sign that it may be wise to prescribe low doses over the long term, but not in females of child-bearing potential, she said.
The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, LaRoche Posay, and Ortho and has served as investigator for Bayer.
MONTEREY, CALIF. – , a dermatologist said at the annual Coastal Dermatology Symposium. Don’t assume you can just prescribe one drug like you might with acne, she advised.
“Treat everything that you see,” said dermatologist Julie C. Harper, MD, of Birmingham, Ala. “That may mean a laser or something you’re using off-label. Different lesions and signs of rosacea will require multiple modes of treatment.”
Dr. Harper offered these other pearls to consider when treating rosacea:
- Don’t get hung up on subtypes.
The four subtypes of rosacea should be used to classify lesions, not people, she said. That’s because patients can fall into more than one of the four categories – erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea, she noted.
“Document the redness you see and ask them what’s bothering them the most,” she said. And ask yourself, she added, “Do I have them on everything that I should have them on?”
- Talk to patients about triggers.
For the first visit, “we have to talk to patients about skin care and triggers,” Dr. Harper noted. According to the American Academy of Dermatology, common rosacea triggers include sunlight, hairspray, heat, stress, alcohol, and spicy foods.
- Consider an ivermectin-brimonidine combination.
“Targeting inflammation in papules and pustules doesn’t necessarily translate to less background erythema,” Dr. Harper said. What to do? She pointed to a 2017 study that examined a combination treatment of ivermectin 1% topical cream (Soolantra) and brimonidine 0.33% topical gel (Mirvaso) for patients with rosacea with moderate to severe persistent erythema and inflammatory lesions. Ivermectin is indicated for inflammatory lesions, while brimonidine treats persistent erythema.
At week 12, the proportion of patients who achieved investigator global assessment of clear or almost clear was 55.8% in the combination group, versus 36.8% of those in the vehicle group (P = .007), according to the study (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Dr. Harper highlighted the effect of brimonidine when added to ivermectin. “In a period of 3 hours,” she said, “we had twice as many people fall into clear or almost clear.”
- Consider adding botulinum toxin to your toolbox.
This “really does work,” Dr. Harper said. She pointed to a 2015 report of botulinum toxin use in two cases of refractory flushing and erythema and a 2012 report of 13 cases in patients with the same symptoms (Dermatology. 2015;230:299-301; J Drugs Dermatol. 2012 Dec;11[12]:e76-9). Dr. Harper said that she usually uses the full 50-unit dose of Botox.
- Consider a beta-blocker.
According to a 2018 report, the beta-blocker carvedilol (Coreg) showed benefit when added to other treatments in five patients with facial flushing and persistent erythema.
- Keep isotretinoin in mind.
A 2016 report suggested low-dose isotretinoin had value for difficult-to-treat papulopustular rosacea. As Dr. Harper noted, 57% of those who took isotretinoin reached the primary endpoint, versus 10% of those taking the placebo. However, relapses over 4 months were common, which is a sign that it may be wise to prescribe low doses over the long term, but not in females of child-bearing potential, she said.
The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, LaRoche Posay, and Ortho and has served as investigator for Bayer.
MONTEREY, CALIF. – , a dermatologist said at the annual Coastal Dermatology Symposium. Don’t assume you can just prescribe one drug like you might with acne, she advised.
“Treat everything that you see,” said dermatologist Julie C. Harper, MD, of Birmingham, Ala. “That may mean a laser or something you’re using off-label. Different lesions and signs of rosacea will require multiple modes of treatment.”
Dr. Harper offered these other pearls to consider when treating rosacea:
- Don’t get hung up on subtypes.
The four subtypes of rosacea should be used to classify lesions, not people, she said. That’s because patients can fall into more than one of the four categories – erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea, she noted.
“Document the redness you see and ask them what’s bothering them the most,” she said. And ask yourself, she added, “Do I have them on everything that I should have them on?”
- Talk to patients about triggers.
For the first visit, “we have to talk to patients about skin care and triggers,” Dr. Harper noted. According to the American Academy of Dermatology, common rosacea triggers include sunlight, hairspray, heat, stress, alcohol, and spicy foods.
- Consider an ivermectin-brimonidine combination.
“Targeting inflammation in papules and pustules doesn’t necessarily translate to less background erythema,” Dr. Harper said. What to do? She pointed to a 2017 study that examined a combination treatment of ivermectin 1% topical cream (Soolantra) and brimonidine 0.33% topical gel (Mirvaso) for patients with rosacea with moderate to severe persistent erythema and inflammatory lesions. Ivermectin is indicated for inflammatory lesions, while brimonidine treats persistent erythema.
At week 12, the proportion of patients who achieved investigator global assessment of clear or almost clear was 55.8% in the combination group, versus 36.8% of those in the vehicle group (P = .007), according to the study (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Dr. Harper highlighted the effect of brimonidine when added to ivermectin. “In a period of 3 hours,” she said, “we had twice as many people fall into clear or almost clear.”
- Consider adding botulinum toxin to your toolbox.
This “really does work,” Dr. Harper said. She pointed to a 2015 report of botulinum toxin use in two cases of refractory flushing and erythema and a 2012 report of 13 cases in patients with the same symptoms (Dermatology. 2015;230:299-301; J Drugs Dermatol. 2012 Dec;11[12]:e76-9). Dr. Harper said that she usually uses the full 50-unit dose of Botox.
- Consider a beta-blocker.
According to a 2018 report, the beta-blocker carvedilol (Coreg) showed benefit when added to other treatments in five patients with facial flushing and persistent erythema.
- Keep isotretinoin in mind.
A 2016 report suggested low-dose isotretinoin had value for difficult-to-treat papulopustular rosacea. As Dr. Harper noted, 57% of those who took isotretinoin reached the primary endpoint, versus 10% of those taking the placebo. However, relapses over 4 months were common, which is a sign that it may be wise to prescribe low doses over the long term, but not in females of child-bearing potential, she said.
The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, LaRoche Posay, and Ortho and has served as investigator for Bayer.
EXPERT ANALYSIS FROM THE COASTAL DERMATOLOGY SYMPOSIUM
Sunscreens: Misleading labels, poor performance, and hype about their risks
MONTEREY, CALIF. – Heads up! “Natural” mineral-based sunscreens don’t provide the protection of their rivals. Patients may get burned by scary hype about the supposed dangers of sunscreen. And sunscreen spray is great for the scalp of people whose hair is thinning.
In a presentation on sunscreens at the annual Coastal Dermatology Symposium, Vincent DeLeo, MD, of the University of Southern California, Los Angeles, offered the following tips on sunscreen and more.
Here’s a roundup of his pearls:
Sunscreens are getting better and are faring poorly, too.
Dr. DeLeo said. A 2013 comparison of sunscreens in 1997 and 2009 found that, among available sunscreens, the percentage of those with low SPF (under 15) fell from 27% to 6% during that time. (The Food and Drug Administration declared in 2011 that manufacturers must tell consumers that low SPF and/or non–broad spectrum sunscreens protect only against sunburn, not against skin cancer or skin aging.) The study also found that the percentage of sunscreens with UVA-1 (such as avobenzone or zinc oxide) filters grew from 5% to 70% (Photochem Photobiol Sci. 2013 Jan;12[1]:197-202).
But the label of sunscreens may not always be accurate. Earlier this year, Consumer Reports wrote that 36 of 73 sunscreens tested failed to correctly list their SPF protection level; 23 sunscreens missed their listed SPF levels by more than half. “Natural” or “mineral-only” sunscreens, which rely on such blockers as zinc oxide or titanium dioxide, performed the worst. Some patients prefer to use these sunscreens because they aren’t chemical based, and “may want to have a more natural sunscreen,” Dr. DeLeo said. “But they should be aware the sunscreens don’t always live up to the SPF level on the label.”
Beware of warnings about sunscreens.
Reports have warned Americans about supposed risks of sunscreen use such as low vitamin D levels from the lack of sun exposure, the exposure to titanium dioxide and zinc oxide nanoparticles, and the exposure to retinyl palmitate in sunscreen. Hawaiian officials, meanwhile, are banning some types of sunscreen chemicals in order to protect coral reefs.
Typical use of sunscreen will not dangerously lower vitamin D levels, Dr. DeLeo said, but people who use it every day may want to be cautious. He dismissed the concerns about nanoparticles and retinyl palmitate.
Dr. DeLeo said two sunscreen risks are real; sunscreens can trigger irritation, at a rate as high as 20%, and, rarely, allergic reactions, as well.
American sunscreens don’t stack up worldwide.
Simplicity often is a virtue. But, Dr. DeLeo said, it’s not helpful when it comes to the components of American sunscreens.
U.S. regulations only allow 16 ingredients in sunscreen while several more are allowed in Europe, he said. According to him, this helps explain why European sunscreens do a better job. European sunscreens “are much more absorbent, much better at absorbing radiation than the U.S. sunscreens,” he said. “It’s because we don’t have the same products as they have in Europe.”
The good news, he said, is that the FDA is considering expanding the number of ingredients allowed in sunscreen. The Sunscreen Innovation Act of 2014, a law passed by Congress, allows the FDA to use efficacy and safety data from Europe without requiring manufacturers to launch new, multimillion dollar tests, he said.
That’s good news for companies that want to improve U.S. sunscreens by selling a wider variety of types. “Sooner or later,” he said, “we will probably get these.”
Sunscreen sprays are tops at scalp protection.
Sunscreen sprays shouldn’t be applied to the face in children, Dr. DeLeo said, but they’re great for solo people because they facilitate protecting the back when there isn’t someone around to help them apply topical sunscreen.
How much spray should people use? A lot, he said. He added that sunscreen sprays are especially useful for the scalps of people with thinning hair.
Dr. DeLeo disclosed consulting work for Estée Lauder.
The meeting is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
MONTEREY, CALIF. – Heads up! “Natural” mineral-based sunscreens don’t provide the protection of their rivals. Patients may get burned by scary hype about the supposed dangers of sunscreen. And sunscreen spray is great for the scalp of people whose hair is thinning.
In a presentation on sunscreens at the annual Coastal Dermatology Symposium, Vincent DeLeo, MD, of the University of Southern California, Los Angeles, offered the following tips on sunscreen and more.
Here’s a roundup of his pearls:
Sunscreens are getting better and are faring poorly, too.
Dr. DeLeo said. A 2013 comparison of sunscreens in 1997 and 2009 found that, among available sunscreens, the percentage of those with low SPF (under 15) fell from 27% to 6% during that time. (The Food and Drug Administration declared in 2011 that manufacturers must tell consumers that low SPF and/or non–broad spectrum sunscreens protect only against sunburn, not against skin cancer or skin aging.) The study also found that the percentage of sunscreens with UVA-1 (such as avobenzone or zinc oxide) filters grew from 5% to 70% (Photochem Photobiol Sci. 2013 Jan;12[1]:197-202).
But the label of sunscreens may not always be accurate. Earlier this year, Consumer Reports wrote that 36 of 73 sunscreens tested failed to correctly list their SPF protection level; 23 sunscreens missed their listed SPF levels by more than half. “Natural” or “mineral-only” sunscreens, which rely on such blockers as zinc oxide or titanium dioxide, performed the worst. Some patients prefer to use these sunscreens because they aren’t chemical based, and “may want to have a more natural sunscreen,” Dr. DeLeo said. “But they should be aware the sunscreens don’t always live up to the SPF level on the label.”
Beware of warnings about sunscreens.
Reports have warned Americans about supposed risks of sunscreen use such as low vitamin D levels from the lack of sun exposure, the exposure to titanium dioxide and zinc oxide nanoparticles, and the exposure to retinyl palmitate in sunscreen. Hawaiian officials, meanwhile, are banning some types of sunscreen chemicals in order to protect coral reefs.
Typical use of sunscreen will not dangerously lower vitamin D levels, Dr. DeLeo said, but people who use it every day may want to be cautious. He dismissed the concerns about nanoparticles and retinyl palmitate.
Dr. DeLeo said two sunscreen risks are real; sunscreens can trigger irritation, at a rate as high as 20%, and, rarely, allergic reactions, as well.
American sunscreens don’t stack up worldwide.
Simplicity often is a virtue. But, Dr. DeLeo said, it’s not helpful when it comes to the components of American sunscreens.
U.S. regulations only allow 16 ingredients in sunscreen while several more are allowed in Europe, he said. According to him, this helps explain why European sunscreens do a better job. European sunscreens “are much more absorbent, much better at absorbing radiation than the U.S. sunscreens,” he said. “It’s because we don’t have the same products as they have in Europe.”
The good news, he said, is that the FDA is considering expanding the number of ingredients allowed in sunscreen. The Sunscreen Innovation Act of 2014, a law passed by Congress, allows the FDA to use efficacy and safety data from Europe without requiring manufacturers to launch new, multimillion dollar tests, he said.
That’s good news for companies that want to improve U.S. sunscreens by selling a wider variety of types. “Sooner or later,” he said, “we will probably get these.”
Sunscreen sprays are tops at scalp protection.
Sunscreen sprays shouldn’t be applied to the face in children, Dr. DeLeo said, but they’re great for solo people because they facilitate protecting the back when there isn’t someone around to help them apply topical sunscreen.
How much spray should people use? A lot, he said. He added that sunscreen sprays are especially useful for the scalps of people with thinning hair.
Dr. DeLeo disclosed consulting work for Estée Lauder.
The meeting is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
MONTEREY, CALIF. – Heads up! “Natural” mineral-based sunscreens don’t provide the protection of their rivals. Patients may get burned by scary hype about the supposed dangers of sunscreen. And sunscreen spray is great for the scalp of people whose hair is thinning.
In a presentation on sunscreens at the annual Coastal Dermatology Symposium, Vincent DeLeo, MD, of the University of Southern California, Los Angeles, offered the following tips on sunscreen and more.
Here’s a roundup of his pearls:
Sunscreens are getting better and are faring poorly, too.
Dr. DeLeo said. A 2013 comparison of sunscreens in 1997 and 2009 found that, among available sunscreens, the percentage of those with low SPF (under 15) fell from 27% to 6% during that time. (The Food and Drug Administration declared in 2011 that manufacturers must tell consumers that low SPF and/or non–broad spectrum sunscreens protect only against sunburn, not against skin cancer or skin aging.) The study also found that the percentage of sunscreens with UVA-1 (such as avobenzone or zinc oxide) filters grew from 5% to 70% (Photochem Photobiol Sci. 2013 Jan;12[1]:197-202).
But the label of sunscreens may not always be accurate. Earlier this year, Consumer Reports wrote that 36 of 73 sunscreens tested failed to correctly list their SPF protection level; 23 sunscreens missed their listed SPF levels by more than half. “Natural” or “mineral-only” sunscreens, which rely on such blockers as zinc oxide or titanium dioxide, performed the worst. Some patients prefer to use these sunscreens because they aren’t chemical based, and “may want to have a more natural sunscreen,” Dr. DeLeo said. “But they should be aware the sunscreens don’t always live up to the SPF level on the label.”
Beware of warnings about sunscreens.
Reports have warned Americans about supposed risks of sunscreen use such as low vitamin D levels from the lack of sun exposure, the exposure to titanium dioxide and zinc oxide nanoparticles, and the exposure to retinyl palmitate in sunscreen. Hawaiian officials, meanwhile, are banning some types of sunscreen chemicals in order to protect coral reefs.
Typical use of sunscreen will not dangerously lower vitamin D levels, Dr. DeLeo said, but people who use it every day may want to be cautious. He dismissed the concerns about nanoparticles and retinyl palmitate.
Dr. DeLeo said two sunscreen risks are real; sunscreens can trigger irritation, at a rate as high as 20%, and, rarely, allergic reactions, as well.
American sunscreens don’t stack up worldwide.
Simplicity often is a virtue. But, Dr. DeLeo said, it’s not helpful when it comes to the components of American sunscreens.
U.S. regulations only allow 16 ingredients in sunscreen while several more are allowed in Europe, he said. According to him, this helps explain why European sunscreens do a better job. European sunscreens “are much more absorbent, much better at absorbing radiation than the U.S. sunscreens,” he said. “It’s because we don’t have the same products as they have in Europe.”
The good news, he said, is that the FDA is considering expanding the number of ingredients allowed in sunscreen. The Sunscreen Innovation Act of 2014, a law passed by Congress, allows the FDA to use efficacy and safety data from Europe without requiring manufacturers to launch new, multimillion dollar tests, he said.
That’s good news for companies that want to improve U.S. sunscreens by selling a wider variety of types. “Sooner or later,” he said, “we will probably get these.”
Sunscreen sprays are tops at scalp protection.
Sunscreen sprays shouldn’t be applied to the face in children, Dr. DeLeo said, but they’re great for solo people because they facilitate protecting the back when there isn’t someone around to help them apply topical sunscreen.
How much spray should people use? A lot, he said. He added that sunscreen sprays are especially useful for the scalps of people with thinning hair.
Dr. DeLeo disclosed consulting work for Estée Lauder.
The meeting is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
REPORTING FROM THE COASTAL DERMATOLOGY SYMPOSIUM
Allergen of the year may be nearer than you think
MONTEREY, CALIF. – It’s only found in 2%-3% of allergy cases. So Because, a dermatologist told colleagues, it’s so common.
“If you’re allergic to it, it’s tough to stay away from it,” said Joseph F. Fowler Jr., MD, clinical professor of dermatology at the University of Louisville (Ky.) in a presentation about contact dermatitis at the annual Coastal Dermatology Symposium.
Indeed, the synthetic compound PG is found in skin care products and cosmetics, coated pills, topical medications such as corticosteroids, foods (including bread, food coloring, and such flavorings as vanilla extracts). “It’s in every topical acne product I know of,” and is even in brake fluid and so-called nontoxic antifreeze, he said. (Propylene glycol shouldn’t be confused with the poisonous toxin ethylene glycol, which also is found in antifreeze.)
Patients can be tested for allergy to PG, Dr. Fowler pointed out, but it’s important to understand that it can trigger an irritation reaction that can be mistaken for an allergic reaction.
Dr. Fowler offered the following tips related to contact dermatitis and allergens. Be aware that metals, topical antibiotics, fragrances, and preservatives are most likely to cause allergic contact dermatitis. According to 2016 figures on allergen prevalence from the North American Contact Dermatitis Group (NACDG), allergy to the metal nickel is the most common (16%); followed by neomycin (9%); fragrance mix I, a mixture of fragrances used in allergen testing (9%); bacitracin (8%); and myroxylon, also known as balsam of Peru, which is used for a variety of purposes in food, medicines, and fragrances (7%).
These are followed by the metal cobalt (6%); the preservatives quaternium 15 and formaldehyde (both 6%); para-phenylenediamine, also known as PPD, which is used in hair dye (5%); and the fragrance mix II (5%), another mix of fragrances used in allergen testing.
Dr. Fowler cautioned that nickel can trigger an intense body-wide allergic reaction in children with atopic dermatitis. “In this situation, it’s really good to be compulsive and tell parents to absolutely keep that person away from nickel as much as humanly possible,” he said.
Keep an eye out for allergens that aren’t on the NACDG list, which includes 70 items. According to Dr. Fowler, more than 20% of his patients were positive to allergens not on the NACDG list.
Contact dermatitis is as common in children as in adults and can even be more common in children. An Italian study published in 2012 found that 70% of children aged 1-15 years tested via patch test were allergic to at least one allergen, a number that’s similar in adults (Dermatitis. 2012 Nov-Dec;23[6]:275-80). There are wide disparities in reported levels of children who are allergic to nickel, cobalt, and myroxylon, Dr. Fowler said.
The T.R.U.E. Test patch test system has value, compared with standard patch tests, but beware of its limitations, he advised. T.R.U.E. is easy to use and requires no prep time, he said, but the number of allergens is limited. By contrast, his clinic mostly uses the Finn Chambers on Scanpor tape system, which can test for many more allergens and is cheaper if used at least 5-10 times a month.
He cautioned that T.R.U.E. could miss the cause of contact dermatitis as often as 39% of the time, as demonstrated in one study of children undergoing patch testing (Arch Dermatol. 2008 Oct;144[10]:1329-36). However, he said, the T.R.U.E test has value in detecting allergies to nickel, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), and neomycin (J Am Acad Dermatol. 2001 Dec;45[6]:836-9).
Consider patch testing in a child with eczema if the eczema is not in normal atopic areas, it spreads beyond normal areas, it doesn’t respond to usual treatments, or it begins later than 5 years of age.
And, Dr. Fowler added, it’s fine to perform patch testing on patients who are taking antihistamines, tumor necrosis factor–alpha inhibitors, NSAIDs, or methotrexate.
Dr. Fowler disclosed consulting for IntraDerm, serving on speakers bureaus for SmartPractice and Regeneron/Sanofi, and serving as an investigator for companies that include AbbVie, Allergan, Bayer, Dow, Galderma, Johnson & Johnson, Eli Lilly, Merck, Regeneron, SmartPractice, and Valeant (now Bausch).
The meeting was jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
MONTEREY, CALIF. – It’s only found in 2%-3% of allergy cases. So Because, a dermatologist told colleagues, it’s so common.
“If you’re allergic to it, it’s tough to stay away from it,” said Joseph F. Fowler Jr., MD, clinical professor of dermatology at the University of Louisville (Ky.) in a presentation about contact dermatitis at the annual Coastal Dermatology Symposium.
Indeed, the synthetic compound PG is found in skin care products and cosmetics, coated pills, topical medications such as corticosteroids, foods (including bread, food coloring, and such flavorings as vanilla extracts). “It’s in every topical acne product I know of,” and is even in brake fluid and so-called nontoxic antifreeze, he said. (Propylene glycol shouldn’t be confused with the poisonous toxin ethylene glycol, which also is found in antifreeze.)
Patients can be tested for allergy to PG, Dr. Fowler pointed out, but it’s important to understand that it can trigger an irritation reaction that can be mistaken for an allergic reaction.
Dr. Fowler offered the following tips related to contact dermatitis and allergens. Be aware that metals, topical antibiotics, fragrances, and preservatives are most likely to cause allergic contact dermatitis. According to 2016 figures on allergen prevalence from the North American Contact Dermatitis Group (NACDG), allergy to the metal nickel is the most common (16%); followed by neomycin (9%); fragrance mix I, a mixture of fragrances used in allergen testing (9%); bacitracin (8%); and myroxylon, also known as balsam of Peru, which is used for a variety of purposes in food, medicines, and fragrances (7%).
These are followed by the metal cobalt (6%); the preservatives quaternium 15 and formaldehyde (both 6%); para-phenylenediamine, also known as PPD, which is used in hair dye (5%); and the fragrance mix II (5%), another mix of fragrances used in allergen testing.
Dr. Fowler cautioned that nickel can trigger an intense body-wide allergic reaction in children with atopic dermatitis. “In this situation, it’s really good to be compulsive and tell parents to absolutely keep that person away from nickel as much as humanly possible,” he said.
Keep an eye out for allergens that aren’t on the NACDG list, which includes 70 items. According to Dr. Fowler, more than 20% of his patients were positive to allergens not on the NACDG list.
Contact dermatitis is as common in children as in adults and can even be more common in children. An Italian study published in 2012 found that 70% of children aged 1-15 years tested via patch test were allergic to at least one allergen, a number that’s similar in adults (Dermatitis. 2012 Nov-Dec;23[6]:275-80). There are wide disparities in reported levels of children who are allergic to nickel, cobalt, and myroxylon, Dr. Fowler said.
The T.R.U.E. Test patch test system has value, compared with standard patch tests, but beware of its limitations, he advised. T.R.U.E. is easy to use and requires no prep time, he said, but the number of allergens is limited. By contrast, his clinic mostly uses the Finn Chambers on Scanpor tape system, which can test for many more allergens and is cheaper if used at least 5-10 times a month.
He cautioned that T.R.U.E. could miss the cause of contact dermatitis as often as 39% of the time, as demonstrated in one study of children undergoing patch testing (Arch Dermatol. 2008 Oct;144[10]:1329-36). However, he said, the T.R.U.E test has value in detecting allergies to nickel, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), and neomycin (J Am Acad Dermatol. 2001 Dec;45[6]:836-9).
Consider patch testing in a child with eczema if the eczema is not in normal atopic areas, it spreads beyond normal areas, it doesn’t respond to usual treatments, or it begins later than 5 years of age.
And, Dr. Fowler added, it’s fine to perform patch testing on patients who are taking antihistamines, tumor necrosis factor–alpha inhibitors, NSAIDs, or methotrexate.
Dr. Fowler disclosed consulting for IntraDerm, serving on speakers bureaus for SmartPractice and Regeneron/Sanofi, and serving as an investigator for companies that include AbbVie, Allergan, Bayer, Dow, Galderma, Johnson & Johnson, Eli Lilly, Merck, Regeneron, SmartPractice, and Valeant (now Bausch).
The meeting was jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
MONTEREY, CALIF. – It’s only found in 2%-3% of allergy cases. So Because, a dermatologist told colleagues, it’s so common.
“If you’re allergic to it, it’s tough to stay away from it,” said Joseph F. Fowler Jr., MD, clinical professor of dermatology at the University of Louisville (Ky.) in a presentation about contact dermatitis at the annual Coastal Dermatology Symposium.
Indeed, the synthetic compound PG is found in skin care products and cosmetics, coated pills, topical medications such as corticosteroids, foods (including bread, food coloring, and such flavorings as vanilla extracts). “It’s in every topical acne product I know of,” and is even in brake fluid and so-called nontoxic antifreeze, he said. (Propylene glycol shouldn’t be confused with the poisonous toxin ethylene glycol, which also is found in antifreeze.)
Patients can be tested for allergy to PG, Dr. Fowler pointed out, but it’s important to understand that it can trigger an irritation reaction that can be mistaken for an allergic reaction.
Dr. Fowler offered the following tips related to contact dermatitis and allergens. Be aware that metals, topical antibiotics, fragrances, and preservatives are most likely to cause allergic contact dermatitis. According to 2016 figures on allergen prevalence from the North American Contact Dermatitis Group (NACDG), allergy to the metal nickel is the most common (16%); followed by neomycin (9%); fragrance mix I, a mixture of fragrances used in allergen testing (9%); bacitracin (8%); and myroxylon, also known as balsam of Peru, which is used for a variety of purposes in food, medicines, and fragrances (7%).
These are followed by the metal cobalt (6%); the preservatives quaternium 15 and formaldehyde (both 6%); para-phenylenediamine, also known as PPD, which is used in hair dye (5%); and the fragrance mix II (5%), another mix of fragrances used in allergen testing.
Dr. Fowler cautioned that nickel can trigger an intense body-wide allergic reaction in children with atopic dermatitis. “In this situation, it’s really good to be compulsive and tell parents to absolutely keep that person away from nickel as much as humanly possible,” he said.
Keep an eye out for allergens that aren’t on the NACDG list, which includes 70 items. According to Dr. Fowler, more than 20% of his patients were positive to allergens not on the NACDG list.
Contact dermatitis is as common in children as in adults and can even be more common in children. An Italian study published in 2012 found that 70% of children aged 1-15 years tested via patch test were allergic to at least one allergen, a number that’s similar in adults (Dermatitis. 2012 Nov-Dec;23[6]:275-80). There are wide disparities in reported levels of children who are allergic to nickel, cobalt, and myroxylon, Dr. Fowler said.
The T.R.U.E. Test patch test system has value, compared with standard patch tests, but beware of its limitations, he advised. T.R.U.E. is easy to use and requires no prep time, he said, but the number of allergens is limited. By contrast, his clinic mostly uses the Finn Chambers on Scanpor tape system, which can test for many more allergens and is cheaper if used at least 5-10 times a month.
He cautioned that T.R.U.E. could miss the cause of contact dermatitis as often as 39% of the time, as demonstrated in one study of children undergoing patch testing (Arch Dermatol. 2008 Oct;144[10]:1329-36). However, he said, the T.R.U.E test has value in detecting allergies to nickel, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), and neomycin (J Am Acad Dermatol. 2001 Dec;45[6]:836-9).
Consider patch testing in a child with eczema if the eczema is not in normal atopic areas, it spreads beyond normal areas, it doesn’t respond to usual treatments, or it begins later than 5 years of age.
And, Dr. Fowler added, it’s fine to perform patch testing on patients who are taking antihistamines, tumor necrosis factor–alpha inhibitors, NSAIDs, or methotrexate.
Dr. Fowler disclosed consulting for IntraDerm, serving on speakers bureaus for SmartPractice and Regeneron/Sanofi, and serving as an investigator for companies that include AbbVie, Allergan, Bayer, Dow, Galderma, Johnson & Johnson, Eli Lilly, Merck, Regeneron, SmartPractice, and Valeant (now Bausch).
The meeting was jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.
EXPERT ANALYSIS FROM THE COASTAL DERMATOLOGY SYMPOSIUM
FDA approves omadacycline for pneumonia and skin infections
The, for treating community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI) in adults, the manufacturer, Paratek, announced in a press release.
The company expects that omadacycline will be available in the first quarter of 2019. Administered once-daily in either oral or IV formulations, the antibiotic was effective and well tolerated across multiple trials, which altogether included almost 2,000 patients, according to Paratek. As part of the approval, the company has agreed to conduct postmarketing studies, specifically, more studies in CABP and in pediatric populations. “To reduce the development of drug-resistant bacteria and maintain the effectiveness of Nuzyra and other antibacterial drugs, Nuzyra should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria,” according to a statement in the indications section of the prescribing information.
Omadacycline is contraindicated for patients with a known hypersensitivity to the drug or any members of the tetracycline class of antibacterial drugs; hypersensitivity reactions have been observed, so use should be discontinued if one is suspected. Use of this drug during later stages of pregnancy can lead to irreversible discoloration of the infant’s teeth and inhibition of bone growth; it should also not be used during breastfeeding.
Because omadacycline is structurally similar to tetracycline class drugs, some adverse reactions to those drugs may be seen with this one, such as photosensitivity, pseudotumor cerebri, and antianabolic action. Adverse reactions known to have an association with omadacycline include nausea, vomiting, hypertension, insomnia, diarrhea, constipation, and increases of alanine aminotransferase, aspartate aminotransferase, and/or gamma-glutamyl transferase.
Drug interactions may occur with anticoagulants, so dosage of those drugs may need to be reduced while treating with omadacycline. Antacids also are believed to have a drug interaction – specifically, impairing absorption of omadacycline
The, for treating community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI) in adults, the manufacturer, Paratek, announced in a press release.
The company expects that omadacycline will be available in the first quarter of 2019. Administered once-daily in either oral or IV formulations, the antibiotic was effective and well tolerated across multiple trials, which altogether included almost 2,000 patients, according to Paratek. As part of the approval, the company has agreed to conduct postmarketing studies, specifically, more studies in CABP and in pediatric populations. “To reduce the development of drug-resistant bacteria and maintain the effectiveness of Nuzyra and other antibacterial drugs, Nuzyra should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria,” according to a statement in the indications section of the prescribing information.
Omadacycline is contraindicated for patients with a known hypersensitivity to the drug or any members of the tetracycline class of antibacterial drugs; hypersensitivity reactions have been observed, so use should be discontinued if one is suspected. Use of this drug during later stages of pregnancy can lead to irreversible discoloration of the infant’s teeth and inhibition of bone growth; it should also not be used during breastfeeding.
Because omadacycline is structurally similar to tetracycline class drugs, some adverse reactions to those drugs may be seen with this one, such as photosensitivity, pseudotumor cerebri, and antianabolic action. Adverse reactions known to have an association with omadacycline include nausea, vomiting, hypertension, insomnia, diarrhea, constipation, and increases of alanine aminotransferase, aspartate aminotransferase, and/or gamma-glutamyl transferase.
Drug interactions may occur with anticoagulants, so dosage of those drugs may need to be reduced while treating with omadacycline. Antacids also are believed to have a drug interaction – specifically, impairing absorption of omadacycline
The, for treating community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI) in adults, the manufacturer, Paratek, announced in a press release.
The company expects that omadacycline will be available in the first quarter of 2019. Administered once-daily in either oral or IV formulations, the antibiotic was effective and well tolerated across multiple trials, which altogether included almost 2,000 patients, according to Paratek. As part of the approval, the company has agreed to conduct postmarketing studies, specifically, more studies in CABP and in pediatric populations. “To reduce the development of drug-resistant bacteria and maintain the effectiveness of Nuzyra and other antibacterial drugs, Nuzyra should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria,” according to a statement in the indications section of the prescribing information.
Omadacycline is contraindicated for patients with a known hypersensitivity to the drug or any members of the tetracycline class of antibacterial drugs; hypersensitivity reactions have been observed, so use should be discontinued if one is suspected. Use of this drug during later stages of pregnancy can lead to irreversible discoloration of the infant’s teeth and inhibition of bone growth; it should also not be used during breastfeeding.
Because omadacycline is structurally similar to tetracycline class drugs, some adverse reactions to those drugs may be seen with this one, such as photosensitivity, pseudotumor cerebri, and antianabolic action. Adverse reactions known to have an association with omadacycline include nausea, vomiting, hypertension, insomnia, diarrhea, constipation, and increases of alanine aminotransferase, aspartate aminotransferase, and/or gamma-glutamyl transferase.
Drug interactions may occur with anticoagulants, so dosage of those drugs may need to be reduced while treating with omadacycline. Antacids also are believed to have a drug interaction – specifically, impairing absorption of omadacycline
Growth on nose
The FP made the presumptive diagnosis of a nodular basal cell carcinoma.
He explained the importance of performing a biopsy and obtained informed consent. On the same day of the patient’s visit, he injected 1% lidocaine with epinephrine under the lesion with a single stick of a 30 gauge needle. He knew that it was safe to use epinephrine on the nose, and that it would prevent excessive bleeding during the biopsy. Contrary to the myth frequently taught in medical school, the nose is a very vascular area. The physician performed a shave biopsy that removed the top of the lesion flush with the skin around it. (See the Watch & Learn video on “Shave biopsy.”)
The pathology report came back as a nodular basal cell carcinoma. On the following visit, the physician recommended Mohs surgery as a way to preserve the vital anatomy of the nasal ala and achieve the highest cure rate.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP made the presumptive diagnosis of a nodular basal cell carcinoma.
He explained the importance of performing a biopsy and obtained informed consent. On the same day of the patient’s visit, he injected 1% lidocaine with epinephrine under the lesion with a single stick of a 30 gauge needle. He knew that it was safe to use epinephrine on the nose, and that it would prevent excessive bleeding during the biopsy. Contrary to the myth frequently taught in medical school, the nose is a very vascular area. The physician performed a shave biopsy that removed the top of the lesion flush with the skin around it. (See the Watch & Learn video on “Shave biopsy.”)
The pathology report came back as a nodular basal cell carcinoma. On the following visit, the physician recommended Mohs surgery as a way to preserve the vital anatomy of the nasal ala and achieve the highest cure rate.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP made the presumptive diagnosis of a nodular basal cell carcinoma.
He explained the importance of performing a biopsy and obtained informed consent. On the same day of the patient’s visit, he injected 1% lidocaine with epinephrine under the lesion with a single stick of a 30 gauge needle. He knew that it was safe to use epinephrine on the nose, and that it would prevent excessive bleeding during the biopsy. Contrary to the myth frequently taught in medical school, the nose is a very vascular area. The physician performed a shave biopsy that removed the top of the lesion flush with the skin around it. (See the Watch & Learn video on “Shave biopsy.”)
The pathology report came back as a nodular basal cell carcinoma. On the following visit, the physician recommended Mohs surgery as a way to preserve the vital anatomy of the nasal ala and achieve the highest cure rate.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
