Katherine McDonald

Age-related differences in postsynaptic increases in sweating and skin blood flow postexercise

The influence of peripheral factors on the control of heat loss responses (i.e., sweating and skin blood flow) in the postexercise period remains unknown in young and older adults. Therefore, in eight young (22 ± 3 years) and eight older (65 ± 3 years) males, we examined dose‐dependent responses to the administration of acetylcholine (ACh) and methacholine (MCh) for sweating (ventilated capsule), as well as to ACh and sodium nitroprusside (SNP) for cutaneous vascular conductance (CVC, laser‐Doppler flowmetry, % of max). In order to assess if peripheral factors are involved in the modulation of thermoeffector activity postexercise, pharmacological agonists were perfused via intradermal microdialysis on two separate days: (1) at rest (DOSE) and (2) following a 30‐min bout of exercise (Ex+DOSE). No differences in sweat rate between the DOSE and Ex+DOSE conditions at either ACh or MCh were observed for the young (ACh: P = 0.992 and MCh: P = 0.710) or older (ACh: P = 0.775 and MCh: P = 0.738) adults. Similarly, CVC was not different between the DOSE and Ex+DOSE conditions for the young (ACh: P = 0.123 and SNP: P = 0.893) or older (ACh: P = 0.113 and SNP: P = 0.068) adults. Older adults had a lower sweating response for both the DOSE (ACh: P = 0.049 and MCh: P = 0.006) and Ex+DOSE (ACh: P = 0.050 and MCh: P = 0.029) conditions compared to their younger counterparts. These findings suggest that peripheral factors do not modulate postexercise sweating and skin blood flow in both young and older adults. Additionally, sweat gland function is impaired in older adults, albeit the impairments were not exacerbated during postexercise recovery.

Hair pull test: Evidence-based update and revision of guidelines

Background: The hair pull test lacks validation and has unclear pretest guidelines. Objective: We sought to quantify normal hair pull test values and elucidate the effect of pretest hair washing and brushing. The impact of hair texture and lifestyle was also examined. Methods: Participants (n = 181) completed a questionnaire recording demographics, medications, and hair health/history. A single hair pull test (scalp vertex) was performed. Results: The mean number of hairs removed per pull was 0.44 (SD 0.75). There was no significant difference in the mean number of hairs removed regardless of when participants washed (P = .20) or brushed (P = .25) their hair. Hair pull test values were similar between Caucasian‐, Asian‐, and Afro‐textured hair. There was no significant difference in hair pull values between participants taking medications affecting hair loss and participants not taking these medications (P = .33). Tight hairstyles did not influence hair pull test values. Limitations: Participant hair washing and brushing could not be controlled during the study, but this information was documented and analyzed. Conclusion: Normal values for the hair pull test should be reduced to 2 hairs or fewer (97.2% of participants). The current 5‐day restriction on pretest hair washing can be reduced and brushing be made permissible.

The PHQ-2 in Dermatology—Standardized Screening for Depression and Suicidal Ideation

Approximately 30% of all dermatology patients experience a psychiatric disorder or some form of notable psychosocial morbidity.1 When the psychiatric concern is related to skin disease, dermatologists are in a unique position to identify the problem and help patients seek treatment. Psychodermatology is a growing field that includes both primary and secondary psychiatric conditions. Primary psychiatric conditions associated with skin findings include disorders where self-induced skin lesions result from an emotional disturbance (eg, acne excoriée).2 In contrast, secondary psychiatric disorders involve emotional disturbances that manifest in response to the psychologic stress caused by the skin condition (eg, major depression induced by severe psoriasis).2 This article will focus on these secondary conditions. We do not know how often dermatologists screen for secondary psychiatric concerns in at-risk patients. Dermatologists do have difficulty perceiving psychological distress in patients3 and some may feel uncertain about the diagnosis of psychiatric conditions secondary to skin disease.4 Patients may not volunteer mental health information, and dermatologists do not always pursue further action even when mental health problems are identified in a consultation.3 It is unclear if this is owing to lack of clear guidelines, lack of time in busy clinics, or the perception that secondary psychiatric disorders fall outside of the dermatology domain. Taken together, these studies3,4 suggest that both dermatologists and patients may benefit from a simple and quick screening tool to identify patients experiencing secondary emotional distress. This article aims to provide a simple approach for dermatologists to screen and refer patients with psychiatric conditions secondary to skin disease. It is not suggested that dermatologists manage psychiatric conditions. However, it is important to screen dermatology patients for mental health concerns because conditions with high disease burden such as psoriasis (particularly with comorbidities), severe atopic dermatitis, and hidradenitis suppurativa, which are associated with increased suicidal ideation.4 Patients with chronic facial lesions or facial scarring secondary to a dermatologic conditions are also at higher risk of depression and suicide, particularly when the lesions develop early in life.5 This is especially true of severe acne vulgaris in adolescence.5 Regardless of the specific diagnosis, depression is often related to the patient’s experience of the skin disease rather than the objective disease severity. Dermatologic conditions and any secondary scars can impact socialization, leading to isolation and depression. Less obvious symptoms, such as pruritus, can cause insomnia. Insomnia is an independent suicide risk factor and pruritic severity is directly correlated with degree of depression.6 A broader list of risk factors for depression and suicidal ideation is provided in the Figure. When these dermatologic-specific risk factors are paired with additional high-risk features, depression and suicidal ideation screening become increasingly necessary. A patient’s degree of suffering is subjective; therefore, objective documentation of skin disease severity and negative psychiatric history is insufficient. Moreover, dermatologic conditions can trigger new psychiatric illness, so a negative history does not preclude a patient from risk of depression and suicide. Although quality-of-life assessments are useful, depression and suicide screens are a separate entity. Based on standard psychiatric screening in a clinical setting when the risk of depression and/or suicide is suspected, we suggest that dermatologists ask the following 2 questions (Patient Health Questionnaire-2 [PHQ-2])7: Over the past 2 weeks, how often have you been bothered by either of the following problems? • Little interest or pleasure in doing things. • Feeling down, depressed, or hopeless. The patient’s answers should be documented in their medical record. Each question should be scored 0 if not at all; 1, several days; 2, more than half the days; 3, nearly every day. The total score ranges from 0 to 6, with 3 or greater considered positive and requiring follow-up.7 If the PHQ-2 is positive, dermatologists should ask the following 2 questions while the patient is still in their office to gain an idea of urgency for follow-up: • Do you ever think about ending your own life? • (If the answer to 1 is “yes”) Do you currently have a plan to commit suicide? If the patient screens negative for the 2 follow-up questions or screens positive for suicidal ideation but does not have a plan, dermatologists should refer the patient to his or her primary care physician by an urgent referral letter or a call to directly address the concern for depression. Dermatologists can provide the patient with resources such as the US National Suicide Prevention Lifeline (1-800-273-8255) or the Canadian Association for Suicide Prevention website that lists provincespecific crisis lines (https://suicideprevention.ca/needhelp/). If the patient screens positive for question 1 and 2, an additional urgent referral should be made to psychiatric emergency department for further assessment (Figure). The discussion with the patient and the referral recommendation should be documented. The PHQ-2 and brief follow-up screen may help catch the unrecognized patients who fall between the dermatology and psychiatry domains. The simplicity and brevity of the PHQ-2 makes it an appropriate option for VIEWPOINT

A Systematic Review on Oral Isotretinoin Therapy and Clinically Observable Wound Healing in Acne Patients

The association between isotretinoin and atypical wound healing remains controversial. It is common practice to delay elective procedures for 6 to 24 months after oral isotretinoin therapy. The studies supporting common practices (SCP) recommend extending this period to include the 6 to 24 months preceding treatment. The opposing studies (challenging common practices; CCP) state that the rate of scarring in isotretinoin patients is low and that delaying elective procedures is unnecessary. These practices impact a large number of dermatology patients undergoing acne treatment. This systematic review compiled articles obtained from online databases and examined data from both SCP and CCP studies. The inconsistencies in the reported data and the methodological flaws in the literature preclude any firm conclusions that can resolve the controversy. As such, this review demonstrates that there is insufficient evidence to either corroborate or refute delaying elective procedures in isotretinoin acne patients. Although the recent literature trends toward removing the procedural delay, we advocate for clinicians to consider the research presented in this review in the context of their own clinical experience and each individual patient’s situation. The possible negative procedural outcomes must be weighed against the severity of the patient’s acne scarring and the psychosocial impact of this scarring on the patient.

A Case of Amoxicillin-Induced Acute Generalized Exanthematous Pustulosis Presenting as Septic Shock

This case report demonstrates the challenges of diagnosing and managing acute generalized exanthematous pustulosis (AGEP) presenting as septic shock. The disseminated, erythematous, pustular rash is a common feature. However, extensive organ involvement and life-threatening hypotension are unusual. The constellation of signs has not previously been documented following amoxicillin therapy. Toxic epidermal necrolysis (TEN) and toxic shock syndrome (TSS) were considered in addition to AGEP because of the systemic presentation. AGEP was diagnosed following histopathology (TEN was ruled out based on limited necrotic keratinocytes and lack of epidermal necrosis) and a negative antistreptolysin O titer (eliminated TSS). Antibiotic therapy for septic shock was provided before the diagnosis was confirmed as AGEP. Upon confirmation of the AGEP diagnosis, antibiotics were discontinued and a 5-day course of oral prednisone (40 mg/d) was initiated in addition to topical half-strength (0.05%) betamethasone valerate. The patient rapidly improved and was discharged. Outpatient patch testing confirmed amoxicillin as the culprit drug. In conclusion, it is critical to realize that AGEP cannot be ruled out with a septic shock presentation. Recent drug history is critical in recognizing an adverse drug reaction, and patch testing is useful for determining the culpable drug when the diagnosis is AGEP.

Psychological Aspects of Factitious Disorder

Factitious disorder can present in multiple health care settings, with patients intentionally producing symptoms to assume the sick role. This assumption of the sick role can result in multiple hospitalizations with unnecessary diagnostic workup, as well as invasive diagnostic procedures that can lead to worrisome side effects. Differential diagnoses that should be ruled out include malingering, somatic symptom disorder, and anxiety disorders. For many providers, patients with factitious disorder can be a challenge to treat because the etiology of the disorder remains unclear. There are multiple psychological theories that attempt to explain the motivation and thought process behind the voluntary production of symptoms. Some of these theories have addressed disruptive attachments during childhood, possible intergenerational transfer of the disorder, personal identity conflicts, somatic illness as a form of masochistic activity toward oneself, and intrapsychic conflicts. Confrontation and psychotherapy with a multidisciplinary team has been proposed as a form of treatment. An understanding of the psychological factors associated with factitious disorder can help providers understand the rationale behind the patients presentation and aid in the formulation of a treatment plan.

Derivation, Evaluation, and Validation of Illustrations of Key Counselling Points for a Pediatric Eczema Action Plan

Background: Current eczema action plans (EAP) are based on written instructions without illustrations. Incorporating validated illustrations into EAPs can significantly improve comprehension and usability. Objective: To produce and validate a set of illustrations for key counselling points of a pediatric EAP. Methods: Illustrations were developed using key graphic elements and refined by subject experts. Illustrations were evaluated during one-on-one structured interviews with parents/caregivers of children ages 9 and younger, as well as with children ages 10 to 17 years between September 2015 and June 2016. The concepts of transparency, translucency, and short-term recall were assessed for validation. Results: Of 245 participants, 81.3% were parents and/or caregivers of children 0 to 9 years old, and 18.7% were children between 10 and 17 years old. A total of 15 illustrations and 2 storyboards were evaluated; 9 illustrations and 2 storyboards were redesigned to reach the preset validation targets. Overall, 13 illustrations and 2 storyboards were validated. Conclusion: A set of illustrations for use in an EAP was prospectively designed and validated, achieving acceptable transparency, translucency, and recall, with input from patients and a multidisciplinary medical team. The incorporation of validated illustrations into eczema action plans benefits patients with limited health literacy. Future studies should evaluate if illustrations improve understanding of eczema management and translate into improved clinical outcomes.

Usability, Satisfaction, and Usefulness of an Illustrated Eczema Action Plan

Background: An eczema action plan (EAP) is an individualized tool to help caregivers and patients self-manage eczema. While novel illustrated EAPs have been developed and validated, there is limited literature examining the value of EAPs from patient and caregiver perspectives. Objectives: The objective of this study was to test the usability, satisfaction, and usefulness of our validated EAP from the perspective of patients and caregivers. Methods: Consecutive patients from the pediatric dermatology clinic of a tertiary children’s hospital from July 2016 to July 2017 were offered enrolment in a prospective survey study; informed consent was obtained from participants. The illustrated EAP was explained to the participant by a trained research assistant. Participants were sent electronic postvisit surveys using Likert scale questions via REDCap on EAP usability and satisfaction (9 items) as well as on usefulness (3 items). Results: Of 233 consecutive clinic patients, 192 participants (82%) were enrolled, and 112 (58%; 85 caregivers and 22 patients) completed the postvisit surveys. Characteristics were similar between responders and nonresponders. Overall, participants rated the usability (96%), satisfaction (85%), and usefulness (78%) of the EAP positively. Education level, experience with eczema, previous dermatology consultation, and participant type (caregiver vs patient) did not significantly affect the usability or usefulness ratings. However, caregivers’ overall EAP ratings were significantly higher (P = .02) than the patients’. Conclusion: The caregivers and participants demonstrate that the EAP is a useful and highly usable tool. Future research should examine the effectiveness of EAP use on objective atopic dermatitis outcomes using a pragmatic clinical trial design.

A 2017 update: Challenging the cosmetic procedural delay following oral isotretinoin therapy

ABSTRACT For decades it has been widely accepted that elective procedures should be delayed for at least 6-months following completion of isotretinoin therapy. However, numerous 2017 publications demonstrate the need for change in best practice. The evidence has yet to be succinctly summarized in a single article or in a stand-alone quick reference algorithm for physicians. This article’s review of all 2017 publications confirms that the 6-month delay is not necessary for all procedures and provides a simple algorithmic approach to summarize the updated recommendations for procedural delay of cosmetic procedures following systemic isotretinoin therapy. This is a useful tool for clinicians and allows patients to receive the most appropriate and timely cosmetic therapy to minimize the psychosocial impact of the skin condition.