Melvin W. Chiu

Skin cancer and photoprotection in people of color: A review and recommendations for physicians and the public

Skin cancer is less prevalent in people of color than in the white population. However, when skin cancer occurs in non-whites, it often presents at a more advanced stage, and thus the prognosis is worse compared with white patients. The increased morbidity and mortality associated with skin cancer in patients of color compared with white patients may be because of the lack of awareness, diagnoses at a more advanced stage, and socioeconomic factors such as access to care barriers. Physician promotion of skin cancer prevention strategies for all patients, regardless of ethnic background and socioeconomic status, can lead to timely diagnosis and treatment. Public education campaigns should be expanded to target communities of color to promote self-skin examination and stress importance of photoprotection, avoidance of tanning bed use, and early skin cancer detection and treatment. These measures should result in reduction or earlier detection of cutaneous malignancies in all communities. Furthermore, promotion of photoprotection practices may reduce other adverse effects of ultraviolet exposure including photoaging and ultraviolet-related disorders of pigmentation.

Psoriasis and comorbidities: links and risks

Psoriasis is a chronic inflammatory skin disease affecting approximately 2% of the population worldwide. In the past decade, many studies have drawn attention to comorbid conditions in psoriasis. This literature review examines the epidemiological evidence, pathophysiological commonalities, and therapeutic implications for different comorbidities of psoriasis. Cardiovascular disease, obesity, diabetes, hypertension, dyslipidemia, metabolic syndrome, nonalcoholic fatty liver disease, cancer, anxiety and depression, and inflammatory bowel disease have been found at a higher prevalence in psoriasis patients compared to the general population. Because of the wide range of comorbid conditions associated with psoriasis, comprehensive screening and treatment must be implemented to most effectively manage psoriasis patients.

Cost, utilization, and patterns of medication use associated with chronic idiopathic urticaria

BACKGROUND The literature on chronic idiopathic urticaria (CIU) lacks large-scale population-based studies. OBJECTIVE To characterize an insured population with CIU, including their demographic characteristics and comorbidities. METHODS We conducted a cross-sectional analysis using insurance claims. We included patients with 1 outpatient claim with an International Classification of Diseases, 9(th)Edition, Clinical Modification (ICD-9-CM) code for idiopathic, other specified, or unspecified urticaria (ICD-9-CM 708.1, 708.8, or 708.9) and either (1) another of these claims 6 or more weeks later; (2) a claim for angioedema (ICD-9-CM 995.1) 6 or more weeks from the urticaria diagnosis; or (3) overlapping claims for 2 prescription medications commonly used for CIU. RESULTS We identified 6,019 patients who had claims consistent with CIU. The mean age was 36 years. Fifty-six percent of patients had primary care physicians as their usual source of care, 14% had allergists, and 5% had dermatologists. Allergic rhinitis was diagnosed in 48%, asthma in 21%, other allergy in 19%, and atopic dermatitis in 8%. Sixty-seven percent of patients used prescription antihistamines, 54% used oral corticosteroids (OCSs), 24% used montelukast, and 9% used oral doxepin. Antihistamine users received a mean of 152 days of prescription antihistamines, OCS users 30 days of OCSs, montelukast users 190 days of montelukast, and oral doxepin users 94 days of doxepin. CONCLUSIONS Primary care physicians managed most patients with CIU. Antihistamines were the most common treatment for CIU, although OCSs were frequently prescribed. Thirty days of OCS supply among users may represent multiple steroid bursts each year. Given the known risks of OCSs, identifying other CIU treatments with more favorable safety profiles may be beneficial.

The A′ and F′ Pockets of Human CD1b Are Both Required for Optimal Presentation of Lipid Antigens to T Cells

CD1 proteins are unique in their ability to present lipid Ags to T cells. Human CD1b shares significant amino acid homology with mouse CD1d1, which contains an unusual putative Ag-binding groove formed by two large hydrophobic pockets, A′ and F′. We investigated the function of the amino acid residues that line the A′ and F′ pockets of CD1b by engineering 36 alanine-substitution mutants and analyzing their ability to present mycobacterial glycolipid Ags. Two lipid Ags presented by CD1b were studied, a naturally occurring glucose monomycolate (GMM) isolated from mycobacteria, which contains two long alkyl chains (C54-C62 and C22-C24) and synthetic GMM (sGMM), which includes two short alkyl chains (C18 and C14). We identified eight residues in both the A′ and F′ pockets that were involved in the presentation of both GMM and sGMM to T cells. Interestingly, four additional residues located in the distal portion of the A′ pocket were required for the optimal presentation of GMM, but not sGMM. Conversely, nine residues located between the center of the groove and the F′ pocket were necessary for the optimal presentation of sGMM, but not GMM. These data indicate that both the A′ and F′ pockets of human CD1b are required for the presentation of lipid Ags to T cells.

Erythema multiforme during anti–tumor necrosis factor treatment for plaque psoriasis

Tumor necrosis factor alpha (TNF-alpha) inhibitors constitute a class of biologic treatments utilized in the management of psoriasis. We report a case of a patient treated for chronic plaque psoriasis with the anti-TNF-alpha monoclonal antibody adalimumab, who developed erythema multiforme (EM). The patient had previously developed EM on two occasions while taking the TNF-alpha inhibitor etanercept. EM has previously been reported in connection with other TNF-alpha inhibitors, including etanercept and infliximab. To our knowledge, this is the first case reported in the literature documenting EM occurring subsequent to adalimumab treatment for psoriasis. The recurrent development of EM in our patient while being treated with distinct TNF-alpha inhibitors may suggest that EM is the consequence of a class effect with TNF-alpha inhibitors.

Modifiable lifestyle factors associated with metabolic syndrome in patients with psoriasis

Background.  Psoriasis is a chronic inflammatory skin disease, which is associated with obesity and with cardiovascular morbidity and mortality.

UV-Based Therapy

UV phototherapy has a long history of use for the treatment of select diseases in dermatology. Its use has evolved into more effective and targeted modalities, including psoralen + UV-A photochemotherapy, narrowband UV-B, excimer laser, and UV-A1 phototherapy. With its proven record of efficacy and safety, UV phototherapy is an excellent option in the treatment of an ever-growing number of skin conditions.

Gnatophyma and Otophyma

Background: Phymas are slowly progressive, disfiguring disorders of the face and ears that represent the end stage of rosacea. The most common phyma is rhinophyma, yet similar swellings may occur on the chin (gnatophyma), forehead (metophyma), one or both ears (otophyma), and eyelids (blepharophyma). Objective: Unlike rhinophyma, otophyma is rarely seen. We report two rare phymas: a case of gnatophyma and a case of otophyma. Methods: A 56-year-old African American man presented with a history of bumps on his chin that had begun about 7 years earlier. Physical examination was remarkable for lobulated plaques on the chin, coalescing into hypertrophic nodules and dilated pores. A 73-year-old African American male presented with bilateral cauliflower-like earlobe growths for the past 17 years. Results: A skin biopsy was performed for each patient demonstrating cystic follicular dilatation with keratin plugging, dermal scarring, psoriasiform epidermal hyperplasia, and chronic inflammation of some of the follicles. Conclusion: This case report describes a relatively rare gnatophyma and otophyma. Surgical management is well accepted as the best mode of therapy to treat rhinophyma and is becoming a first-line treatment for all phymas.

Patient-reported frequency of acral surface inspection during skin examination in white and ethnic minority patients.

BACKGROUND Acral lentiginous melanomas compose a higher proportion of melanomas and have a higher mortality in ethnic minorities than in whites. Early detection by acral surface inspection during skin examinations may lead to improved acral lentiginous melanoma outcomes. OBJECTIVE This study compared patient-reported frequencies of acral skin examinations in ethnic and white populations. METHODS Written surveys were collected from 1040 dermatology clinic patients. RESULTS More whites reported performing self-skin examinations than ethnic minorities (P < .01), but there was no difference in the rates of hand (P = .7) or foot (P = .87) inspection during self-skin examination between whites and ethnic minorities. More whites (77.5%) than ethnic minorities (38.9%) reported having undergone a full-body skin examination (FBSE) from a health care provider (P < .01). During their most recent FBSE by a health care provider, more whites than ethnic minorities reported having their hands examined (P = .02), but there was no difference in reported hand inspection (P = .06) at any previous FBSE or foot inspection at any (P = .07) or the most recent (P = .59) FBSE between whites and ethnic minorities. LIMITATIONS Single-center study using a new unvalidated survey is a limitation. CONCLUSION Whites were found to more frequently report self-skin examination and FBSE than ethnic minorities, but significant differences in reported acral examinations were not detected.

Availability of sunscreen in predominantly Hispanic neighborhoods vs. adjacent predominantly non-Hispanic neighborhoods in Los Angeles

To the Editor, We read with great interest the study by Hernandez et al. describing the differences in sunscreen availability in predominantly Hispanic neighborhoods vs. predominantly non-Hispanic neighborhoods in Chicago (1). In their study, they found that Hispanic neighborhoods in Chicago were less likely to have stores that carried sunscreens than did predominantly white Chicago neighborhoods (1). This report has important implications because studies have shown that use of sunscreen by the Hispanic population is low and the incidence of sunburn among Hispanics is high (2). Furthermore, as the burden of skin cancer grows in Hispanic populations, access to appropriate sun-protective resources has become essential to stem the tide of this growing epidemic (3). This is especially true in southern California, where there is a large Hispanic population and the incidence of melanoma is increasing (3). If sunscreens are indeed less available in Hispanic neighborhoods, a possible intervention that increases access to sunscreen in Hispanic neighborhoods may lead to increased usage of sunscreens in this population. We therefore sought to investigate the availability of sunscreens in predominantly Hispanic neighborhoods vs. predominantly non-Hispanic neighborhoods in Los Angeles. The purpose of this study was to determine if there was a discrepancy in availability, as was seen in Chicago neighborhoods by Hernandez et al. (1) This study encompassed 12 adjacent census tracts in Los Angeles. These tracts were selected because they were very similar in population density and geographic location (4). Following prior studies looking at the local food environment in contiguous neighborhoods, census tracts were used as proxies for neighborhoods (5). Neighborhood ethnic composition and per capita income data were determined using 2010 US Census data (4). Census tracts with populations greater than 51% non-Hispanic or Hispanic were defined as predominantly non-Hispanic or predominantly Hispanic, respectively (Fig. 1). Information on pharmacies and beauty shops was obtained from InfoUSA (http:// www.infoUSA.com) on April 22, 2012. Use of InfoUSA to identify available stores has been described previously (5). Stores were identified by industry category, with ‘Drug Stores and Proprietary Stores’ selected in the Retail category and ‘Beauty Shops’ selected in the Personal Services category. A total of 105 stores were provided on the InfoUSA list. Stores that were classified as ‘Nail Salons’ or ‘Beauty Salons’ with no retail merchandise available were excluded. A total of 27 stores in the InfoUSA list fulfilled the inclusion criterion of being a pharmacy or beauty supply store in one of the neighborhoods of interest. Five stores were later removed from consideration, as they were no longer in business. In July 2012, trained research assistants visited each store to document number of available brands, number of sunscreen bottles of each brand, total number of sunscreen bottles, and strength of and variety in sun protection factor Photodermatology, Photoimmunology & Photomedicine