Jacob Levitt

Therapy for head lice based on life cycle, resistance, and safety considerations

The timing of head lice maturation most favorable to their survival in the presence of anti-lice agents is the maximum time as an ovum (12 days) and the shortest possible time of maturing from newly hatched nymph to egg-laying adult (8.5 days). Pediculicides that are not reliably ovicidal (pyrethroids and lindane) require 2 to 3 treatment cycles to eradicate lice. Ovicidal therapies (malathion) require 1 to 2 treatments. Treatment with an agent to which there is genetic resistance is unproductive. In the United States, lice have become increasingly resistant to pyrethroids and lindane but not to malathion. Treatment with malathion has favorable efficacy and safety profiles and enables the immediate, safe return to school. Nit combing can be performed adjunctively. No-nit policies should be rendered obsolete.

Practical aspects in the management of hypokalemic periodic paralysis

Management considerations in hypokalemic periodic paralysis include accurate diagnosis, potassium dosage for acute attacks, choice of diuretic for prophylaxis, identification of triggers, creating a safe physical environment, peri-operative measures, and issues in pregnancy. A positive genetic test in the context of symptoms is the gold standard for diagnosis. Potassium chloride is the favored potassium salt given at 0.5–1.0 mEq/kg for acute attacks. The oral route is favored, but if necessary, a mannitol solvent can be used for intravenous administration. Avoidance of or potassium prophylaxis for common triggers, such as rest after exercise, high carbohydrate meals, and sodium, can prevent attacks. Chronically, acetazolamide, dichlorphenamide, or potassium-sparing diuretics decrease attack frequency and severity but are of little value acutely. Potassium, water, and a telephone should always be at a patients bedside, regardless of the presence of weakness. Perioperatively, the patients clinical status should be checked frequently. Firm data on the management of periodic paralysis during pregnancy is lacking. Patient support can be found at http://www.periodicparalysis.org.

The sensitivity and specificity of potassium hydroxide smear and fungal culture relative to clinical assessment in the evaluation of tinea pedis: a pooled analysis.

Background. There are relatively few studies published examining the sensitivity and specificity of potassium hydroxide (KOH) smear and fungal culture examination of tinea pedis. Objective. To evaluate the sensitivity and specificity of KOH smear and fungal culture for diagnosing tinea pedis. Methods. A pooled analysis of data from five similarly conducted bioequivalence trials for antifungal drugs was performed. Data from 460 patients enrolled in the vehicle arms of these studies with clinical diagnosis of tinea pedis supported by positive fungal culture were analyzed 6 weeks after initiation of the study to determine the sensitivity and specificity of KOH smear and fungal culture. Results. Using clinical assessment as the gold standard, the sensitivities for KOH smear and culture were 73.3% (95% CI: 66.3 to 79.5%) and 41.7% (34.6 to 49.1%), respectively. The respective specificities for culture and KOH smear were 77.7% (72.2 to 82.5%) and 42.5% (36.6 to 48.6%). Conclusion. KOH smear and fungal culture are complementary diagnostic tests for tinea pedis, with the former being the more sensitive test of the two, and the latter being more specific.

Treatment of Acquired Perforating Dermatosis With Cantharidin

A 65-year-old woman presented with a 6-month history of pruritic, hyperpigmented papules with central, hyperkeratotic plugs on her bilateral lower extremities (Figure 1A). There were no papules on her trunk, head, upper extremities, volar surfaces, or mucous membranes. Her medical history was significant for chronic renal failure treated for the past 4 years with peritoneal dialysis, a 30-year history of insulin-dependent diabetes mellitus, hypercholesterolemia, hypertension, coronary artery bypass, hypothyroidism, and hyperparathyroidism. There was no family history of similar skin lesions. A biopsy specimen from a lesion on the left leg revealed keratotic plugs filled with laminated orthokeratotic and parakeratotic keratin and debris. Beneath the plug, the epidermis was thinned and the dermis showed a neutrophilic infiltrate and foci of fibrosis (Figure 2A). Trichrome stain showed rare focal collagen extruding through the base. The surrounding skin showed features of lichen simplex chronicus. The clinical and histopathologic features supported the diagnosis of an acquired perforating disorder associated with renal disease.

Alopecia areata after dupilumab for atopic dermatitis

AA: alopecia areata AD: atopic dermatitis IL: interleukin Th: T helper INTRODUCTION Dupilumab is the first targeted biologic therapy approved for the treatment of atopic dermatitis (AD). More than 1,000 adult patient exposures formed the basis of its approval in March 2017 for the treatment of moderate-to-severe AD not well controlled with topical therapies or when other therapies are inadvisable. A reassuring safety profile was established, with conjunctivitis being the most significant safety signal.We describe our experience in a patient treated with dupilumab for AD that developed alopecia areata (AA) within 5 weeks of first exposure (3 doses). corticosteroids 7/18/2016e7/26/2016 Cyclosporine Before first appointmente 11/22/2016 Prednisone

The use of an imagery mnemonic to teach the Krebs cycle.

The Krebs Cycle is a highly taught biochemical pathway that is traditionally difficult to learn. Twenty‐seven undergraduate students were randomized to a rote memorization arm or to a mnemonic arm. They were given a pre‐test, then shown a lecture corresponding to their assigned method, and then given an immediate Week 0 post‐test and a Week 4 post‐test. Groups scored comparably low on the pre‐test (pu2009=u20090.7113). Students in the mnemonic arm performed better on the Week 0 post‐test than those using rote (pu2009=u20090.0055). By Week 4, there was evidence of knowledge decay, with both arms having comparably low scores (mnemonic vs. rote, pu2009=u20090.3739). The mnemonic assists in rapid acquisition of knowledge but probably has to be reviewed iteratively over time to demonstrate its full potential over rote memorization. A limited number of students from only one school was used.

“Correction: Practical aspects in the management of hypokalemic periodic paralysis”

After the publication of this work, we noticed and error in Table 1. The dosage of potassium citrate monohydrate should be 1622mg, not 540mg as originally stated. The corrected table is included below.

“Correction: Practical aspects in the management of hypokalemic periodicparalysis”

After the publication of this work, we noticed and error in Table 1. The dosage of potassium citrate monohydrate should be 1622mg, not 540mg as originally stated. The corrected table is included below.

Erratum to: “Correction: Practical aspects in the management of hypokalemic periodic paralysis”

After the publication of this work, we noticed and error in Table 1. The dosage of potassium citrate monohydrate should be 1622mg, not 540mg as originally stated. The corrected table is included below.

Ophthalmic cyclosporine for the treatment of psoriatic conjunctivitis

To the Editor: A 54-year-old woman with a history of moderate to severe psoriasis and psoriatic arthritis presented with red scaly plaques on her knees, elbows, and trunk affecting 8% of her total body surface area. She reported contemporaneous onset of her psoriasis and conjunctivitis. Bilateral conjunctival injection was noted with no exudates, photophobia, miosis, or eyelid edema (Fig 1). Physical exam was otherwise normal. Past medical history included hypertension, diabetes, and depression. Medications included metformin, enalapril, and amlodipine. The patient had failed treatment with etanercept and adalimumab in the past. She was started on a regimen of 5to 10-mg/kg infliximab intravenous (IV) infusion every 4 to 6 weeks. After 5 rounds of treatment, her conjunctival erythema had cleared completely and her psoriasis had improved. The infliximab was discontinued prematurely due to a lapse in her insurance coverage. After 2 months without systemic treatment, the conjunctival injection recurred bilaterally, at which time she was started on cyclosporine ophthalmic emulsion 0.05%, 1 drop in each eye twice daily, and methotrexate 20 mg/week. On follow-up at 11 days, the conjunctivitis had completely resolved (Fig 2). Ocular involvement occurs in approximately 10% of psoriasis patients and commonly includes conjunctivitis, keratoconjunctivitis sicca, and uveitis. An ophthalmology referral at initial presentation is suggested to assess the degree of ocular involvement and for ongoing monitoring. The prevalence of conjunctivitis in psoriasis patients has been reported to be as high as 64.5%. Karabulut et al found that the conjunctival epithelial cells of psoriasis patients lacking clinical ocular disease demonstrated increased rates of squamous metaplasia compared with controls, with no correlation between the presence of squamous metaplasia and duration of skin disease. They also found increased rates of neutrophil clumping in the conjunctival tissue of these patients, reminiscent of the epidermal microabscesses pathognomonic of psoriasis. Their findings suggest a common underlying disease process, as in our patient, whose conjunctivitis responded independently to both IV infliximab and ophthalmic cyclosporine. Her rapid response to treatment after relapse is most likely attributable to treatment with cyclosporine, which has a faster onset