Michelle Rodrigues

Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement

Atopic eczema is a chronic inflammatory disease affecting about 30% of Australian and New Zealand children. Severe eczema costs over AUD 6000/year per child in direct medical, hospital and treatment costs as well as time off work for caregivers and untold distress for the family unit. In addition, it has a negative impact on a childs sleep, education, development and self‐esteem. The treatment of atopic eczema is complex and multifaceted but a core component of therapy is to manage the inflammation with topical corticosteroids (TCS). Despite this, TCS are often underutilised by many parents due to corticosteroid phobia and unfounded concerns about their adverse effects. This has led to extended and unnecessary exacerbations of eczema for children. Contrary to popular perceptions, (TCS) use in paediatric eczema does not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used appropriately as per guidelines. In rare cases, prolonged and excessive use of potent TCS has contributed to striae, short‐term hypothalamic‐pituitary‐adrenal axis alteration and ophthalmological disease. TCS use can also exacerbate periorificial rosacea. TCS are very effective treatments for eczema. When they are used to treat active eczema and stopped once the active inflammation has resolved, adverse effects are minimal. TCS should be the cornerstone treatment of atopic eczema in children.

Vitiligo is not a cosmetic disease

itiligo is an autoimmune disease that results VITILIGO RESULTS FROM V in prominent white patches of the skin. Vitiligo is often considered cosmetic by third-party payers in Western countries. Despite the fact that vitiligo is a well-characterized autoimmune disorder, patients often face difficulties in receiving coverage for their medical treatment because the disease is considered ‘‘cosmetic.’’ For these reasons, we provide the following evidence to support the designation of vitiligo as a medical disease, which should no longer be considered cosmetic.

New discoveries in the pathogenesis and classification of vitiligo

Vitiligo is a common autoimmune disease that progressively destroys melanocytes in the skin, resulting in the appearance of patchy depigmentation. This disfiguring condition frequently affects the face and other visible areas of the body, which can be psychologically devastating. The onset of vitiligo often occurs in younger individuals and progresses for life, resulting in a heavy burden of disease and decreased quality of life. Presentation patterns of vitiligo vary, and recognition of these patterns provides both diagnostic and prognostic clues. Recent insights into disease pathogenesis offer a better understanding of the natural history of the disease, its associations, and potential for future treatments. The first article in this continuing medical education series outlines typical and atypical presentations of vitiligo, how they reflect disease activity, prognosis, and response to treatment. Finally, we discuss disease associations, risk factors, and our current understanding of disease pathogenesis.

Current and emerging treatments for vitiligo

Clinicians should be aware that vitiligo is not merely a cosmetic disease and that there are safe and effective treatments available for vitiligo. It is important to recognize common and uncommon presentations and those with active disease, as well as their implications for clinical management; these were discussed in the first article in this continuing medical education series. Existing treatments include topical and systemic immunosuppressants, phototherapy, and surgical techniques, which together may serve to halt disease progression, stabilize depigmented lesions, and encourage repigmentation. We discuss how to optimize the currently available treatments and highlight emerging treatments that may improve treatment efficacy in the future.

Skin Cancer Risk (Nonmelanoma Skin Cancers/Melanoma) in Vitiligo Patients

The relative genetic and immune protection against melanoma and nonmelanoma skin cancers in those with vitiligo is reassuring. The results of recent studies allow us to be cautiously optimistic when discussing the risk of skin cancer caused by therapeutic exposure to narrow-band ultraviolet B light. However, we should continue to recommend sun protection at all other times to avoid burning in vitiliginous skin and to decrease incidental ultraviolet exposure. It is also important to perform full skin checks regularly in light of the prolonged courses of phototherapy required to repigment vitiliginous skin and maintain repigmentation thereafter.

Treatment of Minocycline-Induced Cutaneous Pigmentation With the Picosecond Alexandrite (755-nm) Laser.

Minocycline hydrochloride (minocycline)-induced pigmentation (MIP) is a rare but well-recognized adverse effect of the long-term use of doses above 100 mg daily, especially in those with advancing age. Pigmentationmay takemonths or years to resolve, but resolution may never be complete. Three types ofMIP have been reported (Table 1). The exact mechanism of laser-mediated pigment resolution is not completely understood. It is theorized that laser surgery may fragment the intracellular and extracellular pigment complexes trapped within the dermis, which are then cleared by macrophages.

Randomized, placebo-controlled, double-blind study of oral tranexamic acid in the treatment of moderate-to-severe melasma

Background Melasma is a common pigmentary disorder that is often difficult to treat. Tranexamic acid (TA) has emerged as a promising treatment for melasma; however, few controlled studies exist. Objective To determine the efficacy of oral TA in patients with moderate‐to‐severe melasma. Methods Patients with moderate‐to‐severe melasma were treated with 250 mg of TA or placebo capsules twice daily for 3 months and sunscreen followed by 3 months of treatment with sunscreen only. The primary outcome measure was the modified Melasma Area and Severity Index (mMASI) score. Results A total of 44 patients were enrolled and 39 completed the study. At 3 months, there was a 49% reduction in mMASI score in the TA group versus 18% in the control group. Patients with severe melasma improved more than those with moderate melasma. Three months after treatment was stopped, there was a 26% reduction in mMASI score in the TA group compared with the baseline visit versus a 19% reduction in the placebo arm. No serious adverse events were noted in either group. Limitations Single‐center study enrolling predominantly Hispanic women. Conclusions Oral TA appears to be an effective treatment for moderate‐to‐severe melasma with minimal side effects.

Interpretability of the Modified Melasma Area and Severity Index (mMASI).

Author Contributions: Drs Bernet and Fiorentino had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Bernet, Lewis, Fiorentino. Acquisition, analysis, or interpretation of data: Bernet, Lewis, Rieger, Casciola-Rosen, Fiorentino. Drafting of the manuscript: Bernet. Critical revision of the manuscript for important intellectual content: Bernet, Lewis, Rieger, Casciola-Rosen, Fiorentino. Statistical analysis: Bernet, Fiorentino. Administrative, technical, or material support: Lewis, Rieger, Casciola-Rosen. Study supervision: Lewis, Fiorentino.

Australian dermatologists' perspective on skin of colour: Results of a national survey.

This study documents the perspectives of Australian dermatologists on the adequacy of teaching and training in skin of colour (SOC), and their confidence in diagnosing and treating common medical, surgical and cosmetic issues in SOC and to gauge their desire for further training in this area.

Post-inflammatory Hyperpigmentation

Post-inflammatory hyperpigmentation (PIH) is a common dermatosis most often seen in those with skin of color. PIH results when cutaneous inflammation or injury promotes activation of cytokines that induce melanin production and dispersion in the epidermis. Damage to the basement membrane results in pigment incontinence and eventual phagocytosis by melanophages in the upper dermis. The most common causes of PIH include acne, lichen planus, contact dermatitis, mechanical trauma, and skin-directed physical therapy such as dermabrasion, chemical peels, and laser surgery. PIH is a clinical diagnosis with light–dark brown macules or patches at the site of inflammation or trauma. Prevention is critical given the well-documented adverse effects on quality of life as well as the management challenge that it presents. PIH can take months to years to fade away. Diverse treatment modalities have been documented with variable success and include topical preparations, chemical peels, and laser therapy. Currently, the gold-standard treatment for PIH is 4% hydroquinone in combination with photoprotection.