Audrey S. Wang

Corticosteroids and wound healing: clinical considerations in the perioperative period

BACKGROUND Determining whether systemic corticosteroids impair wound healing is a clinically relevant topic that has important management implications. METHODS We reviewed literature on the effects of corticosteroids on wound healing from animal and human studies searching MEDLINE from 1949 to 2011. RESULTS Some animal studies show a 30% reduction in wound tensile strength with perioperative corticosteroids at 15 to 40 mg/kg/day. The preponderance of human literature found that high-dose corticosteroid administration for <10 days has no clinically important effect on wound healing. In patients taking chronic corticosteroids for at least 30 days before surgery, their rates of wound complications may be increased 2 to 5 times compared with those not taking corticosteroids. Complication rates may vary depending on dose and duration of steroid use, comorbidities, and types of surgery. CONCLUSIONS Acute, high-dose systemic corticosteroid use likely has no clinically significant effect on wound healing, whereas chronic systemic steroids may impair wound healing in susceptible individuals.

Pediatric Psoriasis Comorbidity Screening Guidelines

Importance Psoriasis is a complex inflammatory skin condition associated with serious medical comorbidities in adults, including obesity, hypertension, dyslipidemia, type 2 diabetes mellitus, psoriatic arthritis, nonalcoholic fatty liver disease, depression, anxiety, and decreased quality of life. Because psoriasis begins in childhood in almost one-third of patients, early identification of risk may be critical to minimizing effects on future health. Objective To develop the first set of guidelines for comorbidity screening for patients with pediatric psoriasis based on current evidence. Evidence Review A literature review was performed using PubMed from January 1999 through December 2015. Limiting the search to human studies published in English and removing reviews and editorials produced 153 relevant manuscripts. An expert panel in psoriasis, pediatric dermatology, pediatric rheumatology, pediatric gastroenterology, pediatric endocrinology, and adult and pediatric cardiology used the patient-centered Strength of Recommendation Taxonomy (SORT) method to evaluate and grade the quality of evidence. Findings Because of the limited number of pediatric studies published on these topics, the strength of the panel’s recommendations is classified as SORT level C expert consensus recommendations. The majority of recommendations coincide with those endorsed by the American Academy of Pediatrics for the general pediatric patient but with added attention to signs and symptoms of arthritis, depression, and anxiety. The panel also identified key areas for further investigation. Conclusions and Relevance Patients with pediatric psoriasis should receive routine screening and identification of risk factors for associated comorbidities. These guidelines are relevant for all health care providers caring for patients with pediatric psoriasis, including primary care clinicians, dermatologists, and pediatric specialists. Because these are the first pediatric guidelines, re-review and refinement will be necessary as studies further detail, and possibly stratify, risk in affected children.

Effect of Automated Online Counseling on Clinical Outcomes and Quality of Life Among Adolescents With Acne Vulgaris: A Randomized Clinical Trial

IMPORTANCE Effective patient education is necessary for treating patients with acne vulgaris. Automated online counseling simulates face-to-face encounters and may be a useful tool to deliver education. OBJECTIVE To compare the effectiveness of a standard educational website with that of an automated-counseling website in improving clinical outcomes and quality of life among adolescents with acne. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted between March 27, 2014, and June 27, 2014, including a 12-week follow-up in a local inner-city high school. Ninety-eight students aged at least 13 years with mild to moderate acne were eligible for participation. A per-protocol analysis of the evaluable population was conducted on clinical outcome data. INTERVENTIONS Participants viewed either a standard educational website or an automated-counseling website. MAIN OUTCOMES AND MEASURES The primary outcome was the total acne lesion count. Secondary measures included the Childrens Dermatology Life Quality Index (CDLQI) scores and general skin care behavior. RESULTS Forty-nine participants were randomized to each group. At baseline, the mean (SD) total acne lesion count was not significantly different between the standard-website group and the automated-counseling-website group (21.33 [10.81] vs 25.33 [12.45]; P = .10). Improvement in the mean (SD) acne lesion count was not significantly different between the standard-website group and the automated-counseling-website group (0.20 [9.26] vs 3.90 [12.19]; P = .10). The mean (SD) improvement in CDLQI score for the standard-website group was not significantly different from that of the automated-counseling-website group (0.17 [2.64] vs 0.39 [2.94]; P = .71). After 12 weeks, a greater proportion of participants in the automated-counseling-website group maintained or adopted a recommended anti-acne skin care routine compared with the standard-website group (43% vs 22%; P = .03). CONCLUSIONS AND RELEVANCE Internet-based acne education using automated counseling was not superior to standard-website education in improving acne severity and quality of life. However, a greater proportion of participants who viewed the automated-counseling website reported having maintained or adopted a recommended anti-acne skin care regimen. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02031718.

Perceptions of Aesthetic Outcome of Linear vs Multiple Z-Plasty Scars in a National Survey

IMPORTANCE The process of Z-plasty scar revision breaks up a linear scar into multiple parts with the purpose of camouflage and improvement of the cosmetic appearance of surgical scars. Although this postulation guides the practices of many reconstructive surgeons, few studies support improved aesthetic outcomes. OBJECTIVE To compare the perceived cosmetic appearance of linear scars vs zigzag scars by the general public. DESIGN, SETTING, AND PARTICIPANTS A computer-generated image of a mature scar was designed in linear and zigzag configurations and overlaid on the faces of standardized headshots of 4 white individuals. Twelve sets of images of linear vs zigzag scars were arranged in side-by-side comparisons in an Internet-based national survey. Respondents rated each scar on the 10-point Patient and Observer Scar Assessment Scale, where a lower score indicated likeness with normal skin and a higher score, the worst scar imaginable. Data were collected from May 1 through June 30, 2013, and analyzed from July 31 to September 1, 2013. MAIN OUTCOMES AND MEASURES Aesthetic rating of scars by the survey respondents. RESULTS Eight hundred seventy-six participants responded to the survey (24.5% response rate); of these, 810 completed the survey (379 men [46.1%] and 443 women [53.9%]; 148 [18.0%] were 18 to 29 years, 171 [20.8%] were 30 to 44 years, 290 [35.3%] were 45 to 60 years, and 213 [25.9%] were older than 60 years). Significantly lower scores and better perceived cosmetic outcomes were found for linear scars compared with zigzag scars in every assessed group of images on the Patient and Observer Scar Assessment Scale (mean [SD] scores, 2.9 [1.6] vs 4.5 [2.2], respectively; P < .001). CONCLUSIONS AND RELEVANCE The lay public has a significantly better perception of the appearance of linear scars compared with zigzag scars in 3 facial locations (temple, cheek, and forehead) of white patients in various age groups. LEVEL OF EVIDENCE NA.

Effectiveness of a novel interactive health care education tool on clinical outcomes and quality of life in acne patients: A randomized controlled pilot study

Abstract Background: We developed an Internet-based education tool (My Personalized Application for health Care Education, MyPACE) to promote patient comprehension about acne. Objective: To determine if MyPACE improves clinical outcomes and quality of life in acne patients. Methods: Modeling the spaced education approach, 50 participants received weekly multiple-choice questions for 12 weeks. Those randomized to the intervention group received acne-related questions, while those in the control group received non-dermatologic health-related questions. Acne lesion counts and Dermatology Life Quality Index (DLQI) scores were recorded at initial enrollment and at 12 weeks. Results: Within-group analysis for the intervention group showed a significant mean change in inflammatory and non-inflammatory acne lesions per person (−3.2 ± 1.3, p = 0.0219; −4.4 ± 1.8, p = 0.0267, respectively). The control group only demonstrated a significant mean change in inflammatory lesions (−2.8 ± 0.80, p = 0.0040). Both groups had statistically significant improvement in DLQI score. Compared with participants in the control group, those receiving acne-related questions experienced greater improvement in clinical outcomes and quality of life. Limitations: The small sample size limited our ability to detect statistically significant differences. Conclusion: Internet-based, disease-specific, spaced education tools may be more effective than non-targeted tools for improving clinical outcomes and quality of life.

Multiple Firm Nodules and Tender, Indurated Plaques

Aman in his 30swith a history of multiple medical conditions, includinghypertension, congestiveheart failure (receiving chronicdiuretic therapy), chronic renal insufficiency, andpulmonaryembolus (receiving warfarin therapy), presented with multiple firm nodules that extruded a thin, white, milky fluid within tender, hyperpigmented, induratedplaquesonthe lowerabdomen(Figure,A).Healso hadnumerous smallernondraining, yellow-whitenodulesonanerythematous to hyperpigmented base on the bilateral medial thighs (Figure, B). A few scattered firm, yellow-white subcutaneous nodules were also seen on the extensor upper extremities. The lesions appeared approximately 1 year prior to our evaluation of his lower abdomen, where he had injected enoxaparin sodium subcutaneously for4days. Sixmonths later, similar lesionsappearedonhismedial thighs and upper extremities without prior trauma or injection. The patient reported no fevers, chills, joint pain, or swelling. He admitted to social alcohol use. A punch biopsywas obtained of a nondraining yellow-white nodule on the left upper arm (Figure, C). What is your diagnosis?

Reply to: “Wound edge eversion: Tradition or science?”

To the Editor: We are honored by Dr Dzubow’s interest in our studies and would like to address his questions. He understandably wonders, if our study regarding wound edge eversion showed no difference between planar closures and everted ones, why perform a study on different everting techniques? Although these 2 studies were published simultaneously, our study on the set-back versus buried vertical mattress suture was performed first. In this study, we found increased wound eversion with the set-back suture technique as well as statistically significant better cosmetic outcomes. We hypothesized that enhanced wound eversion may have contributed to the superior cosmetic outcomes of the scar when compared with the side closed with the buried vertical mattress suture technique. This prompted further investigation into whether wound eversion itself, regardless of the technique used to achieve it, affected cosmetic outcome. Interestingly, our second study failed to show any cosmetic benefit associated with wound edge eversion. So what explains these findings? Drs Trufant and Leach astutely noted differences in both surgical location and experience level ( fellow vs attending performed closures) between the 2 studies. Dr Dzubow notes that the method of eversion was not standardized in the second study. We sought a mix of techniques so that results would reflect the effects of eversion and not necessarily subcutaneous closure technique. It should also be noted that wounds closed with set-back sutures result in deeper suture material