Diane L. Whitaker-Worth

Mucocutaneous reactions to chemotherapy

UNLABELLED Chemotherapeutic agents are a widely used treatment modality. Side effects range from common to unusual and may be confused with other cutaneous sequelae of oncologic treatment. The goal of this communication is to elaborate on previous descriptions of the cutaneous manifestations of chemotherapeutic treatment and to discuss more recent findings. LEARNING OBJECTIVE At the conclusion of this learning activity, participants should be able to generate a differential diagnosis of possible etiologies for varying patterns of cutaneous involvement in patients receiving chemotherapy and identify the various cutaneous side effects of chemotherapeutic treatment. In addition, they should be able to distinguish life-threatening side effects that require immediate management from more benign manifestations of chemotherapeutic treatment.

Atopic dermatitis and nutrition

Atopic dermatitis, a chronic disease with no cure, currently affects almost one-fifth of the population of industrialized nations. Treatment can be challenging for physicians and patients alike. Children are commonly affected, making it even more difficult to find safe therapeutic options, especially in severe disease. Interest in diet and nutrition has increased during the last few years. Nutritional interventions are both intriguing and accessible for many patients. Given the recent expansion of the field of nutrition in the realm of medicine and in popular culture, it is important for the dermatologist to be knowledgeable about the risks and benefits of nutritional interventions. This contribution reviews the current literature on the role of nutrition in atopic dermatitis, from dietary restriction to dietary supplementation, from traditional interventions such as vitamins and minerals to the emerging fields of probiotics and essential fatty acids, and from the prenatal period through infancy and adulthood.

The role of nutrition in dermatologic diseases: Facts and controversies

Many dermatologic diseases are chronic with no definitive cure. For some diseases, the etiology is not completely understood, with treatment being difficult and associated with side effects. In such cases, patients may try alternative treatments to prevent onset, reduce symptom severity, or prevent reoccurrence of a disease. Dietary modification, through supplementation and exclusion, is an extremely popular treatment modality for patients with dermatologic conditions. It is, therefore, important for dermatologists to be aware of the growing body of literature pertaining to nutrition and skin disease to appropriately inform patients on benefits and harms of specific dietary interventions. We address the role of nutrition in psoriasis, atopic dermatitis, urticaria, and bullous diseases and specific dietary modifications as an adjunct or alternative to conventional therapy.

The economics of topical immunomodulators for the treatment of atopic dermatitis

Atopic dermatitis is a common, chronic, relapsing inflammatory skin disease frequently affecting infants and children. The worldwide prevalence of atopic dermatitis is estimated to be 5–20% of the paediatric population. First-line therapy has generally consisted of dry skin care, avoidance of triggers, application of topical corticosteroids, and administration of antihistamines and oral antibacterials. Topical corticosteroids improve the lesions of atopic dermatitis; however, concern on the part of physicians and patients regarding adverse effects has led to reluctance to utilise topical corticosteroids early and especially for prolonged periods. Topical immunomodulators (TIMs), including tacrolimus ointment and pimecrolimus cream, were recently introduced for the treatment of atopic dermatitis.Clinical data show that TIMs are effective in atopic dermatitis, yet do not cause the significant adverse effects associated with topical corticosteroids. Questions remain regarding the place of TIMs as a treatment for atopic dermatitis and how to use them most effectively, from both therapeutic and pharmacoeconomic standpoints. Specifically, two major issues remain unresolved: (i) how TIMs measure up to other therapies, especially topical corticosteroids; and (ii) how members of the TIM drug class compare against each other.Previous research has established that atopic dermatitis has a significant impact on quality of life (QOL) and carries a substantial economic burden. Some studies have also measured the utility of various atopic dermatitis disease states. While there is a need for further research, early economic studies provide evidence that TIMs positively affect the QOL of patients and families. In certain patients, TIMs may be cost effective and have an acceptable incremental cost utility compared with topical corticosteroids.Making cost-effectiveness comparisons between tacrolimus and pimecrolimus is challenging because there are limited head-to-head comparative data. Given currently available efficacy data, the results of one study suggest that tacrolimus may be more cost effective than pimecrolimus in paediatric patients with moderate atopic dermatitis.The full economic and QOL benefits of both agents are yet to be completely understood. The studies reviewed herein are the first to delineate the pharmacoeconomic benefits of TIMs in atopic dermatitis, and lay the foundation for future analyses. TIMs represent an exciting advance in the treatment of atopic dermatitis. Additional research will help determine the proper place of TIMs among the current array of therapeutic options for atopic dermatitis.

Diabetes but not psoriasis.

A 74-year-old man was admitted to hospital in February, 1999, with a presumed flare of psoriasis. He had lost his appetite, was weak, confused, and had lost weight over the past 5 months. He also had a diffuse erythematous desquamating rash which had recently become more extensive. He had had this rash for 4 years. It was thought to be atypical psoriasis. Biopsy specimens showed several findings ranging from spongiotic to psoriaform dermatitis. He had recently noticed a painful tongue that made swallowing difficult. He had had diabetes requiring insulin for 15 years. His father had had diabetes mellitus but no skin rash. There were large annular and confluent areas of erythematous erosive plaques with desquamation over his abdomen, shoulders, buttocks, groin, lower back, the backs of his thighs, and his perineum (figure). No blisters or pustules were noted though many areas were tender. He also had mucositis, beefy red glossitis, cheilitis, and inflammation of perineum and perianal area. His chest, heart, and abdomen were normal on examination. His minimental scale score was 21/30. He was anaemic (haemtocrit 31%), his white cell count was 11·2 10/L), and a ferrokinetic profile was consistent with anaemia of chronic disease (reduced total serum iron, reduced total iron binding capacity, and borderline increased ferritin). Red blood cell folate, serum vitamin B12, and mean corpuscular haemoglobin were all normal. He also had hypocholesterolaemia (2·7 mmol/L).

Parenting and female dermatologists’ perceptions of work-life balance

Background Women in medicine may feel pressure to choose between the competing demands of career goals and being a dedicated spouse and parent. Objective The purpose of this survey study is to report on the current opinions of female dermatologists with regard to family planning, maternity leave, and career success. Methods We surveyed 183 members of the Women’s Dermatologic Society using a 13-question survey that was approved for distribution by the institutional review board committee of the University of Connecticut Health Center. Results We found that women were most likely to have children while they were residents (51%), despite the fact that residents were more likely to report barriers to childbearing at this career stage. These barriers included length of maternity leave, appearing less committed to residency responsibilities compared with peers, and inadequate time and privacy to breast feed. Strategies to achieve a work-life balance included hiring in-home help and working part-time. Of note, many women commented on the need for more family planning resources at work. Conclusion Thought should be given to future administrative strategies that can lessen the burden of parents who are dermatologists and have academic ambitions.

Acne: Kids are not just little people

Acne vulgaris is a common inflammatory disease of the pilosebaceous follicles that affects patients of all ages, from neonates to adults. We have compared and contrasted the clinical presentation of acne in neonates, infants, children, teenagers, and young adults and review the scenarios in which further systemic endocrine or hormonal tests are indicated. We also discuss age-dependent treatment considerations, including appropriate oral antimicrobial regimens and the proper dosing of isotretinoin in young children versus teenagers and adults.

The ethical controversies of office-based dispensing in academic health centers

Office dispensing of cosmecuticals has become a widespread practice in private dermatology offices and even has begun to appear in academic dermatology settings. Proponents of the practice state that in-office dispensing is beneficial for the patient and the physician and can be ethically accomplished with the patient remaining the primary concern of the care provider. This requires the maintenance of professionalism and the sale of efficacious, reasonably priced products that are not misrepresented. Opponents believe that in-office dispensing undermines the physician- patient relationship and may produce an inherent conflict of interest. In academia, additional concerns include how students and residents perceive this activity. Does selling products negatively affect professionalism in an academic environment? In an academic teaching environment there is a paramount need to model ethical behavior to medical students and residents. We will discuss the opposition and rationalization for the practice of in-office dispensing in academic teaching settings.

Differences in dermatology training abroad: A comparative analysis of dermatology training in the United States and in India

Dermatology residency training is not standardized internationally, and each country dictates how training is conducted within its own borders. This article highlights the types of variability in training that can occur from country to country by comparing dermatology residency training programs in the United States and India. This article specifically analyzes the differences that pertain to application and selection, residency program structure, and post-residency opportunities.

Cutaneous adverse drug reactions: Kids are not just little people

Cutaneous adverse drug reactions are a common complication of drug therapy and affect patients of all ages. Despite the daunting frequency at which these reactions occur, there are no scientific contributions comparing cutaneous adverse drug reactions in adults to those occurring in children. Literature delineating such differences is important given that there are significant age-related differences in the pharmacokinetics of many drugs and that most of the package-insert data on adverse drug reactions are based on preclinical trials that do not include children as participants. This contribution attempts to bridge the literature gap by examining five cutaneous adverse drug reactions that occur in both adults and children, highlighting the many types of age-related differences, with a special emphasis on comparisons of (1) epidemiology, (2) etiology, (3) clinical presentation, (4) workup, and (5) treatment.