Amir Al-Dabagh

Systemic corticosteroids are frequently prescribed for psoriasis.

Background: The use of systemic corticosteroids is discouraged in major psoriasis treatment guidelines. Purpose: Our objective was to assess how often systemic corticosteroids are prescribed for psoriasis and trends in their use over time. Methods: We used National Ambulatory Medical Care Survey (NAMCS) data to determine the systemic medications prescribed for psoriasis from 1989 to 2010. We confirmed the findings by analysis of 2003–2007 MarketScan Medicaid data. Results: Systemic corticosteroids were prescribed at 650,000 (95% CI 380,000–920,000) of 21,000,000 psoriasis visits; 93% of these visits were to dermatologists. Of the top nine systemic medications listed at psoriasis visits, three of them were corticosteroids. Corticosteroids were the second most commonly prescribed systemic medication for psoriasis. No significant change in the use of systemic corticosteroids for psoriasis over time was observed (p = .27). In the MarketScan data, prednisone was prescribed more commonly than either methotrexate or etanercept. Limitations: Corticosteroid doses and the length of treatment were not recorded in the NAMCS data. Conclusions: Systemic corticosteroids are among the most common systemic treatments used for psoriasis despite current guidelines. Data are acutely needed on the risks and benefits so that physicians and patients can make evidence-based decisions about their use.

A disease of the present: scurvy in "well-nourished" patients.

To the Editor: Scurvy, vitamin C (ascorbic acid) deficiency, is linked historically to sailors and unbalanced diets. Despite current accessibility to foods containing ascorbic acid, we present two recent cases of scurvy in otherwise apparently “well fed” individuals. A 30-year-old man was admitted for anemia (hemoglobin 7.9 g/dL), leg hematoma, and rash. The patient had been healthy, but exclusively ate fast food with almost no intake of fresh fruits or vegetables. He had poor dentition without gingival bleeding and multiple perifollicular papules on the legs with corkscrew hairs (Fig 1). A biopsy of one of the petechial lesions on the leg revealed histologic findings consistent with scurvy (Fig 2). The patients serum vitamin C level was less than 0.12 mg/dL (normal 0.2-1.9 mg/dL). After the patient was prescribed 2000 mg of ascorbic acid daily, his eruption improved. Fig 1 Scurvy. Multiple perifollicular papules and petechiae with corkscrew hairs on the legs of Patient 1. Fig 2 Scurvy. Routinehematoxylin-eosin stain at 10× showing a superficial perivascular and perifollicular lymphohistiocytic infiltrate (black arrows) with numerous perifollicular extravasated red blood cells. Follicular hyperkeratosis (red arrowhead ... A 55-year-old woman with a history of hypothyroidism, hepatic hemangioma, and fatty liver presented with a new leg rash. She had small, nonpruritic, petechial perifollicular macules on bilateral lower extremities. Based on clinical findings and serum vitamin C level less than 0.12 mg/dL, scurvy was diagnosed. After several days of multivitamin supplementation, her eruption improved. Retrospectively, she reported eating only ½ cup or less of fruits and no vegetables daily and consuming 10 to 14 meals per week at common fast food restaurants. She drank several cans of diet soda 3 or more times per day, expressed a dislike for orange juice, and had been taking no multivitamins. Fast food intake has dramatically increased since the 1970s.1 Time constraints, convenience, and lifestyle have increased the contribution of fast food in the American diet,2 accounting for nearly 50% of an average familys food budget.3,4 Fast food intake is associated with a higher intake of fried potato, hamburger, pizza, and soft drinks, and lower intake of fruits, vegetables, and milk.1,2 While many fast food restaurants offer more healthful choices, patrons may not select these items. Despite availability of healthy fast food options in Australian restaurants, a small minority of Australians were purchasing them.5 A cultural change may be needed before Americans choose healthier substitutes over the traditional burger and fries. Even though scurvy had become rare in the developed world, a resurgence of scurvy may be another indication of the larger problem with the American diet, a diet with insufficient intake of fresh foods and with implications for obesity and diabetes.

Are corticosteroids effective for prevention of scar formation after second-degree skin burn?

Background: Superficial second-degree skin burns only need re-epithelialization to heal without a scar. After re-epithelialization, inflammation in the dermis contributes to changes in skin architecture and scarring. Suppression of inflammation and fibroblast activation immediately after re-epithelialization may prevent scar formation. Corticosteroids are the mainstay of treatment for keloids and hypertrophic scars. Objective: To assess the available data on use of corticosteroids for prevention of scars. Methods: A review of literature was performed seeking clinical trials using corticosteroids for prevention of scars. Results: Corticosteroids have been used to prevent recurrence after keloid or hypertrophic scar excision with variable success. We did not find any report involving the clinical use of corticosteroids for the prevention of scar formation in other settings, including after skin burns. Conclusion: Theoretically, topical corticosteroids can suppress inflammation and fibroblast activation after skin burn, decreasing the incidence of scar formation. However, there is no study evaluating this hypothesis.

Adherence in Acne

Poor adherence is a common cause for treatment failure in treatable diseases such as acne. Numerous studies have examined this relationship, along with the reasons why patients tend to not adhere to their acne medications and methods that may improve their adherence. Poor adherence can include failure to obtain the medication, “drug holidays,” early discontinuation, or simply misunderstanding how the medication is supposed to be used. Insufficient adherence leads to the addition of unnecessary acne treatments, patient frustration and dissatisfaction, and increase in medical expense. Only about 50 % of patients may adhere properly to the therapeutic regimen defined by their dermatologist [1, 2].