Melissa Danesh

The role of the dermatologist in detecting elder abuse and neglect

The National Research Council of the National Academies defines elder mistreatment as: (1) intentional actions that cause harm or create serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder; or (2) failure by a caregiver to satisfy the elders basic needs or to protect the elder from harm. Estimates of the prevalence of elder abuse have ranged from 2.2% to 18.4%. Dermatologists are uniquely positioned to identify and manage suspected cases of elder abuse given their expertise in distinguishing skin lesions of abuse from organic medical disease and their patient populations with strong elderly representation. This article discusses aspects of both the screening and management of elder abuse with particular relevance to dermatologists. Like physicians across medical specialties, dermatologists must be familiar with those aspects of elder abuse in screening, diagnosis, management, and reporting that are unique to their field and to those aspects that are applicable to all health care providers.

The psychosocial impact of acne, vitiligo, and psoriasis: a review

Introduction Chronic skin conditions have been well reported to affect a patient’s quality of life on multiple dimensions, including the psychosocial domain. Psychosocial is defined as the interrelation of social factors with an individual’s thoughts and behavior. The assessment of the psychosocial impact of skin disease on a patient can help direct the dermatologists’ treatment goals. To evaluate the psychosocial impact of skin disease, we conducted a review of the literature on three skin conditions with onsets at various stages of life: acne, vitiligo, and psoriasis. Methods A PubMed search was conducted in March 2015 using the terms “psychosocial” AND “acne”, “psychosocial” AND “vitiligo”, and “psychosocial” AND “psoriasis”. The results were limited to articles published in English in the past 5 years studying patients of all ages. Results and their references were evaluated for relevance according to their discussion of psychosocial qualities in their patients and the validity of psychosocial assessments. The search for acne yielded 51 results, and eleven were found to be relevant; vitiligo yielded 30 results with ten found to be relevant; and psoriasis yielded 70 results with seven found to be relevant. Results According to the articles evaluated, 19.2% of adolescent patients with acne were affected in their personal and social lives. Social phobia was present in 45% of patients with acne compared to 18% of control subjects. Race and sex played a role in self-consciousness and social perceptions of the disease. Vitiligo negatively affected marriage potential and caused relationship problems in >50% of patients. Psoriasis negatively affected multiple domains of life, including work, relationships, and social activities. Anxiety and depression affected not only psoriasis patients but also their cohabitants; up to 88% of cohabitants had an impaired quality of life. Conclusion Though all three skin conditions resulted in an increase in anxiety and depression among their patient populations, the psychosocial focus varied slightly for each disease. Overall, acne, vitiligo, and psoriasis can have negative psychosocial impact in different stages of life development.

Increasing utility of finasteride for frontal fibrosing alopecia

SOLUTION Off-label use of finasteride may represent a safe and effective alternative for frontal fibrosing alopecia. Finasteride, a type 2 5a-reductase inhibitor, is commonly used in men. However, this agent has shown increasing efficacy for frontal fibrosing alopecia in women: 2.5 to 5 mg/d in a study involving 102 patients showed improvement in 48 (47%) and stabilization in 54 (53%) patients. A combination strategy using finasteride (2.5 mg/d) and minoxidil (2% twice per day) in 8 patients halted progression of disease in 4 (50%) patients after 12 to 18 months. We recommend starting finasteride at 2.5 mg daily. If there are signs of activity in the biopsy specimen such as perifollicular erythema or follicular hyperkeratosis and the patient has not advanced to the fibrosing stage of disease, add intralesional corticosteroids (almost 60% response rate). After 6months, evaluate for arrest or regrowth of hair at the hairline. If there is no improvement, increase the dose of finasteride to 5 mg/d and consider adding minoxidil 2% to 5%. The possible side effects in women include depression, headache, nausea, and hot flashes. Finasteride is also highly teratogenic (Pregnancy Category X). However, most patients with frontal fibrosing alopecia are postmenopausal. If the patient is premenopausal, accompany the use of finasteride with strict birth control methods to prevent ambiguous genitalia in the male fetus.

Acquired acanthosis nigricans with tripe palms in a patient with interstitial lung disease

Tripe palms [(TP); acral acanthosis nigricans (AN)], is a rare cutaneous syndrome in which the palms develop velvety thickening and rugosity that creates an exaggeration or distortion of dermatoglyphics, resembling boiled tripe. In more than 90% of patients, TP is associated with malignancy, predominantly pulmonary and gastric carcinomas.1 However, in approximately 6% to 10% of patients with TP, no associated malignancy is found.1 We report a case of TP associated only with interstitial lung disease (ILD), specifically idiopathic nonspecific interstitial pneumonia (NSIP), and no associated malignancy.

A prospective, interventional assessment of the impact of ustekinumab treatment on psoriasis-related work productivity and activity impairment

Abstract Background: The negative impact of psoriasis on quality of life is well documented. Psoriasis is also associated with impairments in work productivity and daily activities. Objectives: This study was conducted to prospectively measure the impact of ustekinumab treatment on work productivity and daily activity impairments due to psoriasis, using the Work Productivity and Activity Index: Psoriasis instrument. Methods: Thirty-two patients with moderate-to-severe plaque psoriasis received 36 weeks of ustekinumab and were followed every 4 weeks. During each visit, patients were evaluated using the Psoriasis Area Severity Index and Work Productivity and Activity Index: Psoriasis instrument. Results: Thirty-two patients completed the study. There was no change in unemployment rate after treatment. Twenty-two patients who were employed at both baseline and week 36 experienced a significant decrease in total work productivity impairment, presenteeism and a non-significant decrease in absenteeism. All patients demonstrated significant reduction in total activity impairment. Limitations: This study was limited by the lack of a placebo group and a small sample size. Conclusions: This study demonstrates the benefits of ustekinumab treatment in terms of reducing psoriasis-related work productivity and activity impairments among patients with moderate-to-severe psoriasis.

An open label pilot study of supraerythemogenic excimer laser in combination with clobetasol spray and calcitriol ointment for the treatment of generalized plaque psoriasis.

Abstract A common therapeutic modality for psoriasis includes the combination of phototherapy with topical treatments. The recent development of targeted phototherapy with the excimer laser and spray formulations for topical treatments has increased the efficacy and convenience of these combinational therapies. Herein, we aim to assess the efficacy of a novel combination of therapies using the 308 nm excimer laser, clobetasol propionate spray and calcitriol ointment for the treatment of moderate to severe generalized psoriasis. In this 12-week study, patients with moderate to severe psoriasis received twice weekly treatments with a 308-nm excimer laser combined with clobetasol proprionate twice daily for a month followed by calcitriol ointment twice daily for the next month. Of the 30 patients enrolled, 83% of patients (25/30) achieved PASI-75 [65–94%, 95% confidence interval (CI)] at week 12. For PGA, there was an estimated decrease of 3.6 points (3.1–4.1, 95% CI, p < 0.0005) by week 12. In conclusion, the combination of excimer laser with alternating clobetasol and calcitriol application has shown to be a promising combination of therapies for the treatment of moderate to severe generalized psoriasis. Further evaluation may be conducted with a larger study inclusive of control groups and head-to-head comparisons against topical steroid and UVB therapy as monotherapies.

Understanding the new FDA pregnancy and lactation labeling rules

Dermatologists should be aware that the new Pregnancy and Lactation Labeling Rule (PLLR) has taken effect on June 30th, 2015. This mandate from the Federal Drug Administration (FDA) eliminated the standard pregnancy category letters for prescription medications (A, B, C, D and X). The new recommendations are now in the form of drug labeling that contains increased detail but also increased complexity. This editorial describes the newdrug-labeling rule and its potential impact in clinical dermatology. The PLLR introduced a new drug labeling schema to help physicians better communicate the risks and benefits of pharmacologic treatment to patients during pregnancy and lactation. Sandra Kweder, M.D., Deputy Director of the Office of New Drugs in the FDA’s Center for Drug Evaluation and Research, stated, “The previous letter category system was overly simplistic and was misinterpreted as a grading system, which gave an over-simplified view of the product risk.” (US Food andDrugAdministration, 2015) Consequently, the new package insert content and formatting requirements aim to provide a more consistent way of disclosing relevant information about the risks and benefits of prescription drugs and biological products used during pregnancy and breastfeeding. However, some have expressed criticism of the PLLR. Many question how labels will be revised to reflect new data as it becomes available. Drugmanufacturers face a significant challenge in condensing vast amounts of varying quality data into concise, clear paragraphs. Despite these challenges, the rule immediately applies to all drugs approved by the FDA after June 30th 2015 and requires that all labels be continually updated as new information becomes available (US Food and Drug Administration, 2015). Pregnancy labels for products approved between 2001 and June 30th 2015 will be revised using a staggered implementation schedule, and those approved before 2001 must be revised within 3 years (US Food and Drug Administration, 2015). To aid in transition, the FDA issued draft guidance to assist drug manufacturers in complying with the new labeling content and format requirements (US Food and Drug Administration, 2015). Unfortunately, labels for over-the-countermedications are not affected by the PLLR. The most notable change of the PLLR is that it will remove arbitrary and often misinterpreted pregnancy-labeling categories for pharmaceuticals (A, B, C, D, X). Instead, package inserts will now

Dermatoses of pregnancy: Nomenclature, misnomers, and myths

The most recent reclassification of dermatoses of pregnancy includes polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis; intrahepatic cholestasis of pregnancy, strictly not a dermatosis, was included in specific dermatoses of pregnancy for working purposes. Another dermatosis, pustular psoriasis of pregnancy, could be included for similar reasons. The nomenclature of these pregnancy-specific eruptions has been revised several times, generating potential confusion among practitioners. Clouding the picture further are misnomers that have been used to describe dermatoses of pregnancy. In addition, several cutaneous conditions that are associated with, but not specific to, pregnancy, have been misunderstood, which has resulted in certain myths among patients and physicians. In this contribution, we describe how the nomenclature of each dermatosis of pregnancy has evolved to fit the current classification scheme. We then identify several misnomers that have generated confusion within the scheme. Finally, we debunk several myths that have developed around cutaneous conditions outside of this scheme, in both mother and newborn.

A cross-sectional survey study to evaluate phototherapy training in dermatology residency.

Department of Dermatology, University of California, San Francisco, CA, USA. Department of Medicine, University of Arizona, Tucson, AZ, USA. Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, USA. David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. Irvine School of Medicine, University of California, Irvine, CA, USA. Department of Dermatology, University of California, Davis, CA, USA.

Diseases with Underlining Internal Conditions

The specific dermatoses of pregnancy are defined as a group of pruritic inflammatory dermatoses associated exclusively with pregnancy and/or the immediate postpartum period [1]. Classification of this disease entity remains a topic of debate. The three generally accepted dermatoses include pemphigoid gestationis (PG), polymorphic eruption of pregnancy (PEP), and intrahepatic cholestasis of pregnancy (ICP) [2]. Apart from these three, a series of clinical entities in pregnancy have been previously documented including prurigo of pregnancy, pruritic folliculitis of pregnancy, and atopic dermatitis. However, recent literature has illustrated significant overlaps in clinical presentation and histopathology between these three presentations and, therefore, they will all be categorized together under the term “atopic eruption of pregnancy” (AEP) [3]. It is important to note that two of these four dermatoses (PG and ICP) may pose significant risk for the fetus, and that early recognition and appropriate diagnostic testing are imperative. This chapter will focus on diagnosis, pathogenesis, and management of the four aforementioned dermatoses of pregnancy.