Cory A. Dunnick

Acne Vulgaris: Pathogenesis, Treatment, and Needs Assessment

Acne vulgaris is a common skin condition with substantial cutaneous and psychologic disease burden. Studies suggest that the emotional impact of acne is comparable to that experienced by patients with systemic diseases, like diabetes and epilepsy. In conjunction with the considerable personal burden experienced by patients with acne, acne vulgaris also accounts for substantial societal and health care burden. The pathogenesis and existing treatment strategies for acne are complex. This article discusses the epidemiology, pathogenesis, and treatment of acne vulgaris. The burden of disease in the United States and future directions in the management of acne are also addressed.

The epidemiology of acne vulgaris in late adolescence

Importance Acne vulgaris is the most common skin condition affecting late adolescents across the globe. Although prior studies have evaluated epidemiologic patterns of acne vulgaris in various ethnicities and regions, adequate understanding of the worldwide burden of the disease associated with patients in their late adolescence (15–19-year olds) remains lacking. Objective To assess the global burden of the disease associated with acne vulgaris for late adolescents (15–19-year olds) and provide an overview of the epidemiology, pathophysiology, and treatment options for acne in this population. Design Database summary study. Setting Global Burden of Disease Study 2010 database. Participants Global Burden of Disease regions comprised countries with prevalence of acne vulgaris between the ages of 15 and 19 years. Main outcomes and measures Geographic region-level disability-adjusted life year rates (per 100,000 persons) associated with acne vulgaris in years 1990 through 2010. Median percentage change in disability-adjusted life year rates was estimated for each region across the specified study period. Conclusion and relevance Acne vulgaris-associated disease burden exhibits global distribution and has continued to grow in prevalence over time within this population. This continued growth suggests an unmet dermatologic need worldwide for this disorder and potential opportunities for improved access and delivery of dermatologic care. Our analysis of the literature reveals numerous opportunities for enhanced patient care. To that end, we highlight some of the effective and promising treatments currently available and address important factors, such as sex, nationality, genetics, pathophysiology, and diet, as they relate to acne vulgaris in late adolescence.

The global burden of psoriatic skin disease

DEAR EDITOR, Psoriasis is a common chronic inflammatory disorder of the skin frequently characterized by relapsing thick scaling plaques, with or without nail and joint involvement. While not life-threatening, psoriasis may cause substantial disability subsequent to both physical discomfort (e.g. pruritus, arthralgias, etc.) and psychosocial harm. Although prior research has evaluated the prevalence of psoriasis in various regions and countries, adequate understanding of geographical variation in psoriasis epidemiology has been hindered by variability in study design, outcome measures, population sampling techniques and, importantly, lack of emphasis on psoriasis-associated disease burden. However, a recent enterprise has attempted to provide new insights into global disease burden resulting from psoriasis and other dermatological disorders. The Global Burden of Disease Study (GBD) 2010 is a comprehensive database of worldwide epidemiological information regarding diseasespecific burden stratified by age, sex, geography and time. GBD 2010 provides disability estimates for 291 diseases and injuries, along with 67 risk factors, from 1990 to 2010. Given this novel resource, we sought to evaluate temporal trends and geographical variation in psoriasis-associated disease burden in order to narrow an important knowledge gap concerning the consequences of this disorder across time, diverse world regions and sociodemographic populations. We used GBD 2010 to conduct a cross-sectional study of geographical regions with prevalent psoriasis (Table S1; see Supporting Information). A detailed description of GBD 2010 development, design and implementation has been described previously. The primary outcome was regional burden of disease associated with psoriasis, as measured by disabilityadjusted life years (DALYs). This metric combines years lost to disability (a morbidity component) with years of life lost (a mortality component), such that one DALY is equivalent to 1 year of healthy life lost. The DALY metric includes a constant value disability weight, which ranges from 0 to 1 and is derived from an analysis of the comparative impact of itch and disfigurement against other conditions by international volunteer panels. The disability weight for psoriasis was 0 054. The following metrics were obtained for psoriasis in 21 geographical regions (Table S1; see Supporting Information): age-adjusted DALY rates per 100 000 persons and associated 95% confidence intervals (CIs), median percentage change in psoriasis-associated DALY rates from 1990 to 2010 and percentage of total global DALYs (across all conditions and regions). These data are available for public access at GBD websites. Geographical differences in psoriasis-associated DALY rates were compared using standard Z-scores. The equality of psoriasis disease burden distribution across geographical regions was evaluated using the Lorenz curve and associated Gini coefficient (range 0–1, where values closer to 1 indicate greater inequality in disease burden distribution). All analyses were performed using Excel 2013 (Microsoft, Redmond, WA, U.S.A.) and Stata SE 13.1 (StataCorp, College Station, TX, U.S.A.), and all statistical tests were two-tailed with a = 0 05.

Prevention of Nickel Allergy: The Case for Regulation?

Nickel is the most common allergen detected in patch-tested patients. Nickel allergy is highest among females and patients under the age of 18, affecting 35.8% of patients patch-tested in this demographic. Nickel allergic contact dermatitis is a T-cell-mediated immune reaction which most commonly presents as a skin rash in areas exposed to nickel; however, more serious reactions to nickel in medical devices and more widespread eruptions to dietary nickel can occur. In contrast to Europe, where regulations have resulted in a decreasing prevalence of nickel allergy, the incidence of nickel allergic contact dermatitis in North America is increasing. This article summarizes primary prevention strategies as well as management of patients already sensitized to nickel.

Global mortality from conditions with skin manifestations

BACKGROUND Global Burden of Disease Study is a research database containing systematically compiled information from vital statistics and epidemiologic literature to inform research, public policy, and resource allocation. OBJECTIVE We sought to compare mortality among conditions with skin manifestations in 50 developed and 137 developing countries from 1990 to 2010. METHODS This was a cross-sectional study to calculate mean age-standardized mortality (per 100,000 persons) across countries for 10 disease categories with skin manifestations. We compared differences in mortality from these disorders by time period (year 1990 vs year 2010) and by developing versus developed country status. RESULTS Melanoma death rates were 5.6 and 4.7 times greater in developed compared with developing countries in 1990 and 2010, respectively. Measles death rates in 1990 and 2010 were 345 and 197 times greater in developing countries, and corresponding syphilis death rates were 33 and 45 times greater. LIMITATIONS Inability to adjust for patient-, provider-, and geographic-level confounders may limit the accuracy and generalizability of these results. CONCLUSION The mortality burden from skin-related conditions differs between developing and developed countries, with the greatest differences observed for melanoma, measles, and syphilis. These results may help prioritize and optimize efforts to prevent and treat these disorders.

Pediatric Contact Dermatitis Registry Inaugural Case Data

BackgroundLittle is known about the epidemiology of allergic contact dermatitis (ACD) in US children. More widespread diagnostic confirmation through epicutaneous patch testing is needed. ObjectiveThe aim was to quantify patch test results from providers evaluating US children. MethodsThe study is a retrospective analysis of deidentified patch test results of children aged 18 years or younger, entered by participating providers in the Pediatric Contact Dermatitis Registry, during the first year of data collection (2015–2016). ResultsOne thousand one hundred forty-two cases from 34 US states, entered by 84 providers, were analyzed. Sixty-five percent of cases had one or more positive patch test (PPT), with 48% of cases having 1 or more relevant positive patch test (RPPT). The most common PPT allergens were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), propylene glycol (6.8%), cocamidopropyl betaine (6.4%), bacitracin (6.2%), formaldehyde (5.7%), and gold (5.7%). ConclusionsThis US database provides multidisciplinary information on pediatric ACD, rates of PPT, and relevant RPPT reactions, validating the high rates of pediatric ACD previously reported in the literature. The registry database is the largest comprehensive collection of US-only pediatric patch test cases on which future research can be built. Continued collaboration between patients, health care providers, manufacturers, and policy makers is needed to decrease the most common allergens in pediatric consumer products.

Comparing cutaneous research funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases with 2010 Global Burden of Disease results.

Importance Disease burden data helps guide research prioritization. Objective To determine the extent to which grants issued by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) reflect disease burden, measured by disability-adjusted life years (DALYs) from Global Burden of Disease (GBD) 2010 project. Design Two investigators independently assessed 15 skin conditions studied by GBD 2010 in the NIAMS database for grants issued in 2013. The 15 skin diseases were matched to their respective DALYs from GBD 2010. Setting The United States NIAMS database and GBD 2010 skin condition disability data. Main Outcome(s) and Measure(s) Relationship of NIAMS grant database topic funding with percent total GBD 2010 DALY and DALY rank for 15 skin conditions. Results During fiscal year 2013, 1,443 NIAMS grants were issued at a total value of

The role of cannabinoids in dermatology

424 million. Of these grants, 17.7% covered skin topics. Of the total skin disease funding, 82% (91 grants) were categorized as “general cutaneous research.” Psoriasis, leprosy, and “other skin and subcutaneous diseases” (ie; immunobullous disorders, vitiligo, and hidradenitis suppurativa) were over-represented when funding was compared with disability. Conversely, cellulitis, decubitus ulcer, urticaria, acne vulgaris, viral skin diseases, fungal skin diseases, scabies, and melanoma were under-represented. Conditions for which disability and funding appeared well-matched were dermatitis, squamous and basal cell carcinoma, pruritus, bacterial skin diseases, and alopecia areata. Conclusions and Relevance Degree of representation in NIAMS is partly correlated with DALY metrics. Grant funding was well-matched with disability metrics for five of the 15 studied skin diseases, while two skin diseases were over-represented and seven were under-represented. Global burden estimates provide increasingly transparent and important information for investigating and prioritizing national research funding allocations.

American Contact Dermatitis Society Core Allergen Series: 2017 Update

CB1: cannabinoid 1 CB2: cannabinoid 2 PEA: palmitoylethanolamide THC: tetrahydrocannabinol T wenty-eight states currently allow for comprehensive public medical cannabis programs, and this number continues to grow. Approximately 1 in 10 adult cannabis users in the United States use it for medical purposes. Numerous studies have investigated its uses for chronic pain, spasticity, anorexia, and nausea. In recent years, researchers have also investigated its use for the treatment of dermatologic conditions including pruritus, inflammatory skin disease, and skin cancer. Perhaps the most promising role for cannabinoids is in the treatment of itch. In a study of patients with uremic pruritus on maintenance hemodialysis, topical application of a cream with structured physiologic lipids (derma membrane structure) and endogenous cannabinoids applied twice daily for 3 weeks completely eliminated pruritus in 8 of 21 patients (38%). The authors suggested that the welltolerated product might work by reducing xerosis. Stander et al further studied 22 patients with prurigo, lichen simplex, and pruritus who applied an emollient cream with palmitoylethanolamide (PEA). PEA, which stimulates anandamide (endocannabinoid) activation of cannabinoid 1 (CB1) receptors, reduced itch by 86.4% and was well tolerated by patients. Most recently, WIN 55,212-2, a cannabinoid agonist, was found to reduce serotonin-induced itching in a dose-dependent manner through intraperitoneal administration in mice. When the investigators used neurotoxins to deplete serotonin in the spinal cord, they reported no change in these results. Thus, they suggested that the cannabinoids may

Dermatology information on the Internet: An appraisal by dermatologists and dermatology residents

The American Contact Dermatitis Society Core Allergen Series was introduced in 2012. After 4 years of use, changes in our recommended allergens are necessary. For the updated series, we have reordered the first 4 panels to approximately mirror the current TRUE Test and removed parthenolide, triclosan, glutaraldehyde, and jasmine. Polymyxin B, lavender, sodium benzoate, ethylhexylglycerin, and benzoic acid are new additions to the American Contact Dermatitis Society series.