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Dermatology

A 30-Year-Old White Female Presented With a 4-Month History of Scaly, Erythematous Patches and Plaques on Her … – MDedge

Tumor necrosis factor (TNF)-alpha inhibitors are used to treat a variety of autoimmune conditions including psoriasis, psoriatic arthritis, rheumatoid arthritis (RA), spondyloarthritis, and inflammatory bowel disease (IBD). Interestingly, they have also been observed to cause paradoxical psoriasis with an incidence between 0.6%-5.3%, most commonly occurring in patients with underlying Crohns disease and rheumatoid arthritis (RA). Infliximab is the most common TNF inhibitor associated with this condition (52.6%-62.6% of cases) followed by etanercept (12%-29%). TNF inhibitor-induced psoriasis most often presents as plaque or palmoplantar psoriasis, but other subtypes have also been documented.

Psoriasis is traditionally divided into two types. Patients with type I psoriasis have a family history, develop symptoms before the age of 40 and are often positive for HLA-Cw6. Type II psoriasis is not related to HLA-Cw6, lacks a family history, and typically manifests after age 40. Psoriatic lesions are well-defined, erythematous plaques with silvery scales most commonly appearing on extensor surfaces and the scalp. Variants include nail psoriasis, pustular psoriasis, inverse psoriasis, and guttate psoriasis.

Although psoriasis is typically a clinical diagnosis, histologic examination may be used to differentiate from other dermatoses if necessary. The lesions of TNF inhibitor-induced psoriasis characteristically display patterns similar to primary psoriasis, including parakeratosis, microabscesses, and rete ridges. Eosinophilic hypersensitivity reactions and features overlapping with eczematous hypersensitivity (psoriasiform dermatitis) may also be present.

The pathogenesis of this condition is not well understood, but theories include a variety of immune processes including interferon overproduction, interleukin and T-cell activation, and the presence of an infectious nidus. Classical psoriasis is related to type 1 interferon release, so theoretically, immunosuppression caused by TNF inhibitor treatment may permit uncontrolled production of interferons, resulting in psoriatic lesions. Another theory is that interleukin (IL)-23, a pro-inflammatory cytokine, promotes activation of T-helper 17 (Th17) cells. Th17 cells are part of the pathogenesis of primary psoriasis and other inflammatory conditions, such as RA and inflammatory bowel disease. Of note, individuals with gastrointestinal inflammatory diseases are already known to be at a greater risk for developing psoriasis. Immunosuppression caused by a TNF inhibitor may leave patients more susceptible to other infections, which may induce psoriatic plaques.

There are multiple approaches to treatment depending on the severity of the disease. If the psoriatic eruption is mild, the medication may be continued. This treat-through method is often considered when stopping the current immunotherapy would cause the patient significant issues. Moderate to severe cases of TNF inhibitor-induced psoriasis may warrant switching TNF inhibitor therapy or completely changing the drug class used in the treatment of the underlying autoimmune condition. Additional treatments include topical and oral steroids, UV therapy, methotrexate, cyclosporine, and acitretin.

This case and the photo were submitted by Lucas Shapiro, BS, of Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Leon S. Maratchi, MD, Gastro Health, Hollywood, Florida. The column was edited by Donna Bilu Martin, MD.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.

1. Li SJ et al. J Psoriasis Psoriatic Arthritis. 2019 Apr;4(2):70-80. doi: 10.1177/2475530318810851.

2. Lu J and Lu Y. J Transl Autoimmun. 2023 Sep 6:7:100211. doi: 10.1016/j.jtauto.2023.100211.

3. Nair PA and Badri T. Psoriasis. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: http://www.ncbi.nlm.nih.gov/books/NBK448194/

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A 30-Year-Old White Female Presented With a 4-Month History of Scaly, Erythematous Patches and Plaques on Her ... - MDedge

Dermatology

9 Best Baby Eczema Creams of 2024 to Soothe Delicate Skin, According to Dermatologists – Allure

Editor Tip: Since this is recommended for toddlers over two years old, check with your pediatrician first to make sure it's okay to use. (Some might prefer to write their own prescription instead, too.)

Key Ingredients: Hydrocortisone, ceramides, hyaluronic acid

Aveeno

Aveeno Baby Eczema Therapy Moisturizing Cream

Why It's Worth It: The Aveeno Baby Eczema goes all-in on oats, which is why Dr. Chang is a fan. Along with oat oil and oat extract, "it's formulated with colloidal oatmeal to moisturize and calm down irritated, itchy skin due to eczema," she says. Plus, she likes that it's unscented and doesn't contain common allergens like parabens, phthalates, and fragrances, making it a good option if other formulas tend to set off or worsen flares.

Editor Tip: The brand also has an Overnight Balm to seal in moisture overnight for healthier, more comfortable skin by the A.M.

Key Ingredients: Oat oil, colloidal oatmeal, panthenol

There's no one cause of eczema in babies, but it's "likely caused by a combination of genetic and environmental factors," says Dr. Melnick. Eczema can also be triggered by external factors such as common allergens (like fragrance in skin-care products and laundry detergents), dry air, saliva or sweat, or long, hot baths, says Dr. Chang. The good news? Getting rid of these triggers can help alleviate or even prevent an eczema flare-up.

For itching, your baby's pediatrician might prescribe a steroid cream, which is "often prescribed to treat eczema flares and to use intermittently for relief of itch symptoms," says Dr. Chang. The key word here is "intermittently," since these shouldn't be used continuously for months on end. In fact, when used regularly over an extended period of time, steroids can actually weaken or thin skin, causing skin irritation and leaving it more vulnerable to infection. "A simple rule I use is two weeks on and two weeks off, and only as needed," Dr. Chang notes.

Consider moisturizer as your baseline, with or without a steroid cream. "One of the most important parts of treating eczema is maintaining a strong skin barrier by using frequent and liberal applications of emollients," says Nava Greenfield, MD, a board-certified dermatologist at Schweiger Dermatology Group in New York City. "Healthy skin is less prone to flares," Dr. Greenfield attests.

But not all moisturizers are created equal, and your go-to face lotion won't cut it. "For babies with eczema, I recommend using a gentle, non-fragranced, and hypoallergenic moisturizer," says Dr. Chang, noting that she also keeps an eye out for common allergens and irritants. "I typically recommend using thicker creams over more lightweight gels and lotions, which are more effective at moisturizing the skin due to a higher oil content," Dr. Chang adds.

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9 Best Baby Eczema Creams of 2024 to Soothe Delicate Skin, According to Dermatologists - Allure

Dermatology

QUIZ: Test Your Knowledge of Rosacea Etiology, Types, and Triggers – Dermatology Times

April is Rosacea Awareness Month, a period of time dedicated to raising awareness about the chronic skin condition that affects millions worldwide.

Through initiatives like Rosacea Awareness Month, the medical community aims to shed light on the condition's complexities, reduce stigma, and empower individuals to seek appropriate care.

As we delve into this awareness month, Dermatology Times remains committed to educating and engaging our audience with weekly quizzes aimed at increasing understanding and promoting proactive management strategies. Throughout the month of April, we will be sharing 5-question quizzes each Monday designed to test knowledge on rosacea symptoms, triggers, treatment options, and lifestyle management strategies.

Each quiz will cover different aspects of rosacea, drawing from the latest research and expert insights. In addition to the weekly quizzes, Dermatology Times will recap the answers later in the week, providing detailed explanations and additional resources for further learning.

Dermatology Times invites you to join us in advancing understanding, promoting dialogue, and ultimately improving outcomes for individuals living with rosacea. Stay tuned for our weekly quizzes, and let's work together to make a difference this Rosacea Awareness Month.

Which of the following is not considered a trigger of rosacea?

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QUIZ: Test Your Knowledge of Rosacea Etiology, Types, and Triggers - Dermatology Times

Dermatology

Empowering Patients: Effective Dermatologic Treatment Selection for Hand and Feet AD – Dermatology Times

This is a video synopsis of a discussion involving Alexandra Golant, MD, Assistant Professor at the Icahn School of Medicine at Mount Sinai, focusing on treatment options for patients with atopic dermatitis (AD), particularly those with hand and foot involvement.

Dr. Golant advocates for providing patients with a comprehensive overview of treatment options and discourages reliance solely on topical therapies without considering alternative approaches. She emphasizes early discussions about transitioning to systemic treatments if topical therapies fail to provide adequate control, offering patients a backup plan and instilling hope for improved outcomes.

In assessing patients for systemic therapy, Dr. Golant considers factors such as disease control, treatment burden, and quality of life. She discusses various systemic options, including biologics like dupilumab and tralokinumab, as well as oral Janus kinase (JAK) inhibitors. Each option is tailored based on patient preferences, comorbidities, and safety considerations.

Dupilumab, in particular, has shown consistent efficacy in hand and foot AD, with recent studies supporting its use in these areas. Dr. Golant recommends regular follow-up visits to monitor treatment response and adjust therapy as needed, with closer monitoring for patients on oral JAK inhibitors due to safety concerns.

Overall, Dr. Golant highlights the array of effective treatment options available for AD in 2024, emphasizing the importance of individualized care and shared decision-making to optimize outcomes for patients with this chronic condition.

Video synopsis is AI-generated and reviewed by Dermatology Timeseditorial staff.

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Empowering Patients: Effective Dermatologic Treatment Selection for Hand and Feet AD - Dermatology Times

Dermatology

How To Treat Strawberry Legs, According To Dermatologists – Women’s Health

If youre someone who suffers from

Read ahead to learn more.

Meet the experts: Sapna Palep, MD, is a board-certified dermatologist at Spring Street Dermatology in New York City. Dendy Engelman, MD, FACMS, FAAD, is a board-certified cosmetic dermatologist and Mohs surgeon at Shafer Clinic in New York City. Leonard Bernstein, MD, is a board-certified dermatologist at the Laser & Skin Surgery Center in New York City.

"Strawberry legs" are dark spots that resemble small black dots. The term comes from the dotted or pitted appearance that resembles the skin and seeds of a strawberry, says Sapna Palep, MD, a board-certified dermatologist at Spring Street Dermatology in New York City.

The open comedones that cause the appearance of strawberry legs are hair follicles or enlarged pores that contain a trapped mixture of oil, bacteria, and dead skin. When the follicle or pore is exposed to air after shaving, it may darken, explains Dr. Palep.

You can see the spots caused by keratosis, a.k.a. "strawberry legs," on this womans skin.

For starters, you can treat strawberry legs by first swapping out your razor more regularly. Always use shaving cream or bar soap when shaving to ensure the area is moisturized before it comes into contact with a razor. Dr. Bernstein suggests using an antibacterial soap such as Dial or Lever 2000 to decrease bacteria on the surface of the skin. After shaving, make sure to always moisturize your skin. Dr. Palep suggests using moisturizers with lactic acid or urea that will exfoliate the skin as well to help prevent ingrown hairs.

Body Wash

Body Wash

Lotion

Lotion

To prevent strawberry legs, experts suggest that you:

If at-home remedies aren't working, Dr. Engelman recommends talking to your doctor about getting an in-office chemical peel to exfoliate the skin and reduce the appearance of bumps. You can also consider laser hair removal to reduce the potential of shaving-related skin issues, such as ingrown hairs. Anything that kills the hair at the root like laser hair removal (which is a permanent solution) or an epilator (which can be painful)" would help prevent strawberry legs, says Dr. Palep.

Daley Quinn is a Connecticut-born, Texas-bred beauty and wellness writer living in New York City. Her work has appeared in Family Circle magazine, WWD.com, TheCut.com, TheFinancialDiet.com, and San Antonio magazine. In her off hours, you can find Daley stalking her queen, Vanessa Carlton. You canfind more of her work on herwebsiteor check outher blog,The Daley Dose.

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How To Treat Strawberry Legs, According To Dermatologists - Women's Health

Dermatology

Rosacea Awareness Month: Resources to Share With Your Patients – Dermatology Times

According to the National Rosacea Society (NRS), approximately 16 million Americans have rosacea.1

Furthermore, a report most recently updated in August 2023 notes that the worldwide incidence of rosacea is upwards of 5% of the global population.2 In 2018, the NRS shared details of a study indicating that approximately 415 million individuals are affected by rosacea globally.3

April is Rosacea Awareness Month, and Dermatology Times is spotlighting a variety of resources to share with your patients. If you have a specific resource or association that you recommend to patients with rosacea, email us at DTEditor@mmhgroup.com to share with us.

The American Academy of Dermatology's Rosacea Resource Center boasts a variety of patient resources, including an overview of rosacea, a rundown of available treatment options, skin care tips and advice for avoidance of triggers, and insider tips for newly-diagnosed patients, including potential risks associated with rosacea.

The National Rosacea Society offers resources to help the estimated 16 million Americans with rosacea better understand and manage their condition. They provide information on symptoms, treatments, triggers, and support. Resources include educational materials like newsletters, booklets, and patient guides, as well as photographs depicting symptoms and treatment results. The society also offers a Physician Finder service to help individuals locate healthcare professionals familiar with rosacea.

The American Acne and Rosacea Society offers a range of resources to assist patients with managing their conditions. These resources may include educational materials on understanding acne and rosacea, tips for skin care and symptom management, information on treatment options, and guidance on lifestyle modifications to minimize flare-ups.

The Rosacea Support Group was established in October 1998. With over 7,500 registered members as of July 2009, the group offers a platform for sharing experiences, discussing symptoms, treatments, skin care products, and insights from health care professionals. Complementing the email group is the Rosacea Support Community, a bulletin board-style interface launched in mid-2007, catering to those who prefer a different interaction format. The Rosacea Blog features over 800 articles covering a wide array of topics for patients with rosacea.

References

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Rosacea Awareness Month: Resources to Share With Your Patients - Dermatology Times

Dermatology

Understanding Drug Interactions in Systemic Treatment: Impact on Atopic Dermatitis Symptoms – Dermatology Times

This is a video synopsis of a discussion involving Alexandra Golant, MD, Assistant Professor at the Icahn School of Medicine at Mount Sinai, focusing on a case study of a 17-year-old African-American female with moderate to severe atopic dermatitis (AD), particularly affecting her hands and feet.

The patient, a student and waitress, has struggled with AD since childhood, experiencing persistent severe involvement despite various topical treatments, including topical calcineurin inhibitors and corticosteroids. Her occupation exacerbates her condition, with long periods of standing aggravating her foot symptoms, and visible hand lesions causing embarrassment in her customer service role.

Dr. Golant underscores the impact of AD on the patient's quality of life, especially during adolescence when self-confidence is developing. Given the failure of numerous topical treatments, Dr. Golant opts for a systemic approach, initiating dupilumab therapy due to its efficacy and favorable safety profile, even in combination with oral contraceptive pills and oral isotretinoin for acne.

Dupilumab's compatibility with other medications makes it a preferred choice, providing comprehensive disease control without significant drug interactions or adverse effects. Dr. Golant discusses the option of combining dupilumab with topical steroids for localized flare-ups, highlighting its safety and efficacy based on clinical trial data.

In summary, Dr. Golant's approach emphasizes tailoring treatment to the patient's individual needs, addressing both disease severity and psychosocial factors to improve overall well-being and treatment outcomes.

Video synopsis is AI-generated and reviewed by Dermatology Timeseditorial staff.

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Understanding Drug Interactions in Systemic Treatment: Impact on Atopic Dermatitis Symptoms - Dermatology Times

Immunology

Fellow Focus in Four: Marat Kribis, MD, Rheumatology, Allergy and Immunology – Yale School of Medicine

Why did you choose medicine?

I have liked both natural sciences and humanities since childhood. Choosing medicine was gradual, partly influenced by my mom, who enrolled me in premedical classes at age 15, when I hardly knew anything about medicine. I did not know any doctors, but I was influenced by reading the collective image of a doctor from Russian literature, an ironically or tragically described intellectual, strivingand often strugglingto help people in the face of the merciless nature of biology and societal problems. Once in medical school, my interest solidified as I became fascinated by the logic of pathophysiology and met real patients.

I liked the people I interviewed with; even through Zoom, I sensed a friendly and supportive atmosphere. The Section of Rheumatology, Allergy and Immunology at Yale offers outstanding research opportunities, incredible mentors who are experts in their fields, and a wide range of clinical cases. The Department of Immunobiology is among the worlds best, providing a unique chance to learn from people who have made discoveries in the field. For me, the decision was obvious.

I did my internal medicine residency at a Bridgeport Hospital program affiliated with Yale and stayed there as an academic hospitalist for a few years. Rheumatology has fascinated me since medical school, and when I decided to pursue a fellowship, the opportunity to train at Yale presented itself.

I have a cat named after Leo Tolstoy.

Yale School of Medicines Section of Rheumatology, Allergy and Immunology is dedicated to providing care for patients with rheumatic, allergic, and immunologic disorders; educating future generations of thought leaders in the field; and conducting research into fundamental questions of autoimmunity and immunology. To learn more, visit Rheumatology, Allergy & Immunology.

Submitted by Serena Crawford on April 10, 2024

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Fellow Focus in Four: Marat Kribis, MD, Rheumatology, Allergy and Immunology - Yale School of Medicine

Immunology

Long COVID Can Now Be Detected in the Blood – Technology Networks

People with long COVID have distinct patterns of inflammation detectable in the blood, which could potentially be targeted with immune therapies.

Findings from the largest UK study of patients hospitalised with SARS-CoV-2 infection show that long COVID leads to ongoing inflammation which can be detected in the blood.

In an analysis of more than 650 people who had been hospitalised with severe COVID-19, patients with prolonged symptoms showed evidence of immune system activation.

The exact pattern of this activation varied depending on the sort of symptoms that they predominantly had for example, mainly fatigue or cognitive impairment.

The research, led by Imperial College London, suggests that existing drugs which modulate the bodys immune system could be helpful in treating long COVID and should be investigated in future clinical trials.

The study, published in the journalNature Immunology, is the latest research from two collaborative UK-wide consortia, PHOSP-COVID and ISARIC-4C.

These involve scientists and clinicians from Imperial alongside collaborators from the Universities of Leicester, Edinburgh and Liverpool among others and funded by UK Research and Innovation (UKRI) and the National Institute for Health and Care Research (NIHR).

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Professor Peter Openshaw, from Imperials National Heart & Lung Institute and an ISARIC-4C lead investigator, said: With one in ten SARS-CoV-2 infections leading to long COVID and an estimated 65 million people around the world suffering from ongoing symptoms, we urgently need more research to understand this condition. At the moment, its very hard to diagnose and treat.

This study, which includes detailed clinical data on symptoms and a raft of inflammatory blood plasma markers, is an important step forward and provides crucial insights into what causes long COVID.

In the latest study, researchers included a total of 426 people who were experiencing symptoms consistent with long COVID having been admitted to hospital with COVID-19 infection at least six months prior to the study.

They were compared with 233 people who were also hospitalised for COVID-19 but who had fully recovered. The researchers took samples of blood plasma and measured a total of 368 proteins known to be involved in inflammation and immune system modulation.

They found that, relative to patients who had fully recovered, those with long COVID showed a pattern of immune system activation indicating inflammation of myeloid cells and activation of a family of immune system proteins called the complement system.

Myeloid cells are formed in the bone marrow and produce various types of white blood cells that circulate in the blood and migrate into organs and tissues where they respond to damage and infection.

The complement system consists of a cascade of linked proteins that are activated in response to infection or tissue damage. Notably, overactivation of the complement system is known to be associated with many autoimmune and inflammatory conditions.

Dr Felicity Liew, from Imperials National Heart & Lung Institute, said: Our findings indicate that complement activation and myeloid inflammation could be a common feature of long COVID after hospitalisation, regardless of symptom type.

It is unusual to find evidence of ongoing complement activation several months after acute infection has resolved, suggesting that long COVID symptoms are a result of active inflammation.

"However, we cant be sure that this is applicable to all types of long COVID, especially if symptoms occur after non-hospitalised infection.

The researchers were also able to obtain comprehensive information about the range of symptoms that patients were experiencing, and which ones were most common.

They found that certain groups of symptoms appeared to be associated with specific proteins. For example, people with gastrointestinal symptoms had increased levels of a marker called SCG3, which has previously been linked to impaired communication between the gut and the brain.

Overall, there were five overlapping subtypes of long COVID with different immune signatures, despite some commonalities, namely: fatigue; cognitive impairment; anxiety and depression; cardiorespiratory; and gastrointestinal.

The researchers stress, however, that these groups are not mutually exclusive, and people can fall between groups depending on their symptoms.

Nevertheless, these long COVID subtypes seem to represent clear biological mechanisms of disease and highlight that different symptoms may have different underlying causes. The researchers suggest this could be useful in designing clinical trials, especially for treatments that target immune responses and inflammation.

One such treatment could include drugs called IL-1 antagonists, such as anakinra, which is commonly used to treat rheumatoid arthritis, as well as another drug class called JAK inhibitors, used to treat some types of cancers and severe forms of rheumatoid arthritis. Both drug types work by targeting components of the immune system that might be activated in long COVID.

The researchers highlight that one limitation of their study was that it only included people who had severe SARS-CoV-2 infections and who were hospitalised as a result. Yet a sizeable proportion of people who develop long COVID in the wider population only report mild initial SARS-CoV-2 infection and its unclear if the same immune mechanisms are at work.

Professor Openshaw concludes: This work provides strong evidence that long COVID is caused by post-viral inflammation but shows layers of complexity.

"We hope that our work opens the way to the development of specific tests and treatments for the various types of long COVID and believe that a one size fits all approach to treatment may not work.

COVID-19 will continue to have far reaching effects long after the initial infection has passed, impacting many lives. Understanding whats happening in the body, and how the immune system responds, is key to helping those affected.

Reference:Liew F, Efstathiou C, Fontanella S, et al. Large-scale phenotyping of patients with long COVID post-hospitalization reveals mechanistic subtypes of disease. Nat Immunol. 2024. doi: 10.1038/s41590-024-01778-0

This article has been republished from the following materials. Note: material may have been edited for length and content. For further information, please contact the cited source.

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Long COVID Can Now Be Detected in the Blood - Technology Networks

Cardiology

Applications of Nanotechnology in the Field of Cardiology – Cureus

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Applications of Nanotechnology in the Field of Cardiology - Cureus