Jenny E. Murase

Safety of dermatologic medications in pregnancy and lactation: Part I. Pregnancy

Dermatologists are frequently faced with questions about the safety of commonly prescribed topical and systemic medications during pregnancy and lactation from women of childbearing age who are pregnant, considering pregnancy, or breastfeeding. Safety data, particularly regarding medications that are unique to dermatology, can be difficult to locate and are not consolidated in a single reference guide for clinicians. Parts I and II of this continuing medical education article provide a capsule summary of key points for the most commonly prescribed dermatologic medications to facilitate patient medication risk counseling in pregnancy. A summary table details safety classification data for 3 primary international classification systems: the US Food and Drug Administration, the Swedish Catalogue of Approved Drugs, and the Australian Drug Evaluation Committee. In addition, this table includes an alternative pregnancy classification system developed by a consortium of active members of teratology societies in the US and Europe detailed in Drugs during Pregnancy and Lactation: Treatment Options and Risk Assessment and a safety classification system developed for breastfeeding mothers detailed in Medications and Mothers Milk.

Effect of ethnicity on the risk of developing nonmelanoma skin cancer following long-term PUVA therapy.

Background  Research demonstrating an increased incidence of skin cancer with psoralen plus ultraviolet A (PUVA) therapy has reflected the Caucasian experience. Our objective was to review the literature on skin cancer risk associated with long‐term PUVA therapy in non‐Caucasians.

Erosive pustular dermatosis of the scalp: A review with a focus on dapsone therapy

BACKGROUND Erosive pustular dermatosis of the scalp (EPDS) is an inflammatory disorder of unknown origin characterized by pustules, erosions, and crusting in areas of alopecia that tend to be atrophic, actinically damaged, or both. The most common treatments reported include antibiotics and topical anti-inflammatories, which can be ineffective. In the search for effective treatment for EPDS, we share our experience with topical dapsone 5% gel. OBSERVATIONS We present 4 patients with EPDS, all with classic clinical presentations and histologic findings of EPDS, who had failed a variety of treatments including oral, intralesional, or topical steroids, tacrolimus, and antibiotics. All patients demonstrated rapid improvement or resolution with topical dapsone 5% gel. LIMITATIONS Our experience and success with topical dapsone for EPDS is observational and not the result of a randomized controlled trial. CONCLUSION Our observations demonstrate topical dapsone 5% gel to be a novel, safe, and efficacious therapeutic alternative for mild to moderate EPDS.

Safety of dermatologic medications in pregnancy and lactation: Part II. Lactation

Dermatologists are frequently faced with questions from women who are breastfeeding about the safety of commonly prescribed topical and systemic medications during lactation. Safety data in lactation, particularly regarding medications that are unique to dermatology, are limited and can be difficult to locate. We have consolidated the available safety data in a single reference guide for clinicians. We review literature pertaining to the safety of common dermatologic therapies in lactation and offer recommendations based on the available evidence.

An updated review of acitretin – a systemic retinoid for the treatment of psoriasis

Background: Acitretin is a systemic retinoid used for psoriasis. It normalizes cellular differentiation and maturation and is also used as a chemopreventive agent against cutaneous malignancies. However, it is not used frequently because of its side-effect profile. Objective: Safety and efficacy of acitretin was evaluated as monotherapy, as well as in combination with other systemic agents. Methods: Medical literature from 2005 to 2008 was reviewed. The most scientifically rigorous clinical trials were selected for Psoriasis Area and Severity Index. Articles were limited to case reports or clinical trials, human subjects and English language journals. Results/conclusion: Acitretin is effective as monotherapy for pustular and erythrodermic psoriasis and for plaque psoriasis (with other systemic agents). Side effects of acitretin use occur more commonly with high doses. Hence, acitretin is safe and effective for psoriasis.

Delusional infestations: clinical presentation, diagnosis and treatment

Patients with delusional infestations (DI), previously named delusions of parasitosis, have a fixed, false belief that they are infested with living or non‐living pathogens. Patients have abnormal cutaneous symptoms such as itching, biting, or crawling sensations. They often demonstrate self‐destructive behavior in an effort to rid the pathogens from under their skin, leading to excoriations, ulcerations, and serious secondary infections. This review article aims to provide an overview of DI including its clinical presentation, diagnosis, and treatment. Strategies on how to establish a strong therapeutic alliance with DI patients are discussed. In addition, antipsychotic medications used in the treatment of DI are described.

Disseminated superficial actinic porokeratosis co-existing with linear and verrucous porokeratosis in an elderly woman: Update on the genetics and clinical expression of porokeratosis

Disseminated superficial actinic porokeratosis (DSAP) is the most common form of porokeratosis, occurring mainly in women on the extremities as atrophic patches rimmed by a ridge of keratin (the cornoid lamella that is diagnostic of porokeratosis histologically and is thought to be a clonal keratinocyte proliferation). DSAP can sometimes coexist with other forms of porokeratosis (Mibelli, linear porokeratosis, porokeratosis palmaris et plantaris disseminata, and punctate porokeratosis). Rare variants of linear porokeratosis are the hyperkeratotic and verrucous forms which usually occur on the buttocks or perianal area. We present clinical and histopathologic findings from biopsy specimens of a 73-year-old woman with DSAP on the distal extremities, linear/segmental porokeratosis on thighs, and verrucous porokeratosis on buttocks and mons pubis. The verrucous lesions had been present for 30+ years, the DSAP and linear lesions for 10+ years. Biopsy specimens from distal extremity showed classic features of DSAP with infrequent cornoid lamellae separated by atrophic epidermis. Biopsy specimens from the mons pubis and thigh showed epidermal hyperplasia with multiple, almost contiguous, broad cornoid lamellae. Coexisting variants of porokeratosis are rare and our conclusions are drawn from a few cases in the literature. The rare variants of porokeratosis are of interest because the clinical morphology correlates with the histopathology.

Dermatoses of the breast in lactation.

Dermatoses of the breast during lactation can be difficult to diagnose because of their overlapping clinical appearances. It is important to properly diagnose and treat nipple dermatitis since it can be a significant source of pain when nursing. Poorly controlled nipple pain in nursing mothers is one of the primary reasons for breastfeeding to be discontinued earlier than is recommended. Therefore, it is relevant for practicing dermatologists to be aware of certain facts in a patients history, specific physical exam findings, and the most appropriate laboratory tests used to diagnose these conditions. In addition, the therapeutic approach should be effective and safe for the mother and infant. This review article provides dermatologists with a detailed discussion on the clinical features and management of various breast dermatoses seen in lactation, including atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, psoriasis, bacterial infections, yeast infections and herpes simplex virus infections.

Chronically painful right thumb with pustules and onycholysis

A 67-year-old woman presented with a 5-year history of a chronically tender right distal thumb with pustules and nail dystrophy. She described recurrent episodes of pain and purulent discharge of her thumb and occasionally other digits. For years, these periods of discomfort had resolved with use of topical steroids, but most recently, the eruption on her thumb had been prolonged, and treatment with azithromycin and topical steroids had not improved her condition. She had no history of other skin disorders. On examination, the right distal thumb was found to be tender to palpation. The nail bed and surrounding tissue were erythematous and oedematous, with extensive onycholysis. A well-circumscribed erythematous plaque with scale, fissures, lakes of pus and clear exudate extended beneath the lytic nail. The patient had no other skin lesions (Fig. 1).

Caring for new mothers: diagnosis, management and treatment of nipple dermatitis in breastfeeding mothers

Breastfeeding is thought to be the most optimal form of infant nutrition. Nursing mothers are generally advised to continue breastfeeding until the infant is two years of age or beyond. Unfortunately, however, a majority of nursing mothers will discontinue breastfeeding much earlier than recommended. The most common reason for early discontinuation of breastfeeding is nipple pain. It is, therefore, essential that dermatologists know how to appropriately diagnose and effectively treat nipple pain associated with nipple dermatitis among nursing mothers. This review article provides a detailed discussion on the clinical features and management of various causes of nipple dermatitis during lactation, including problems with infant latch‐on, congenital oral anomalies, plugged lactiferous ducts, atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, yeast infections, bacterial infections, herpes simplex virus, and Raynaud’s phenomenon of the nipple.