Olabola Awosika

Profile of dupilumab and its potential in the treatment of inadequately controlled moderate-to-severe atopic dermatitis.

Atopic dermatitis (AD) is a common inflammatory skin disorder that manifests as eczematous lesions, often associated with allergic rhinitis and asthma. Historically, moderate-to-severe disease has been managed with systemic immunosuppression, such as oral corticosteroids, which result in relapse and limiting side effects. Due to recent advancements in the identification of interleukin (IL)-4 and IL-13 as key mediators in AD, new biological agents have been developed for treatment. Dupilumab is a recently approved monoclonal antibody that targets the alpha subunit of the IL-4 receptor and, thus, downregulates activity of IL-4 and IL-13. This review discusses the profile of dupilumab and its potential for efficacy and safety in treating moderate-to-severe AD by reviewing data from Phase I–III clinical trials. Results suggest that dupilumab shows great therapeutic promise for AD. Further studies investigating extended use of dupilumab and dupilumab in comparison to other agents are needed to establish long-term efficacy and safety.

Review of Applications of Microneedling in Dermatology.

Microneedling (MN) is a novel therapeutic modality in dermatology. Through physical trauma from needle penetration, MN induces a wound healing cascade with minimal damage to the epidermis. This allows for enhancement in the absorption of mainstay topical therapies across the thick stratum corneum. MN has become increasingly utilized over the last several years as it is a relatively simple procedure that is cost-effective, well tolerated, and offers both cosmetic and therapeutic benefits. The ability to treat localized areas of disease has led to numerous studies gauging its potential in focal diseases of inflammation, dyschromia, and photodamage. This review discusses the principles and evidence behind the expanding applications of MN. It has shown promising results as an adjuvant therapy for enhanced drug delivery in the treatment of atrophic scars, alopecia, actinic keratoses, and disorders of pigmentation such as melasma. The efficacy in treatment of vitiligo remains limited. Overall, the procedure has few adverse sequelae compared to other therapies, is highly efficacious, and is a viable resurfacing option for skin of color. Future research is needed to determine the frequency, interval, and specific device settings that foster optimal results. Additionally, large controlled trials are needed to shed light on the utility of MN as an evidence-based regimen for the treatment of various dermatologic conditions.

Angioedema, Urticaria, and Stomatitis Caused by Contact Allergy to Invisalign.

A 23-year-old healthy white woman was referred to our dermatology clinic for patch testing. One month before presentation, the patient developed intermittent urticaria on her extremities and flanks 2 days after application of Invisalign clear aligners (Align Technology, Santa Clara, CA). Subsequent development of facial and periorbital swelling and redness with burning/stinging of the lips and oral mucosa prompted the patient to present to an urgent care facility. She was treated with oral prednisone and advised to remove her aligners, leading to resolution of her symptoms. The patient’s medical history was significant for allergy to penicillin and amoxicillin and a family history of asthma. Patch testing was performed with the North American Contact Dermatitis Group standard tray, dental screening series, and isocyanate series (Chemotechnique MBDiagnostics AB, Vellinge, Sweden), and Invisalign clear aligners (Fig. 1). At 96 hours, strong positive reactions (2+) to Invisalign (Figs. 2A,B) andquestionable reactions (+/j) to formaldehyde, cobalt, copper sulfate, diaminodiphenylmethane (MDA), and hexamethylene diisocyanate (HDI) were observed. These findings were consistent with contact sensitization to Invisalign and concerning for sensitivity to isocyanates. Isocyanates are highly reactive, lowYmolecular-weight compounds that react exothermically with hydroxyl groups to form polyurethane products. Isocyanates are a known culprit in occupational contact dermatitis, particularly for workers in the polyurethane industry. Similar to our observation, Lammintausta and Liippo reported a man who developed periorbital and lip dermatitis and was patch tested positive for MDA from occupational isocyanate exposure. Our patient was highly sensitive to Invisalign clear aligners and questionably sensitive to MDA and HDI. Invisalign is composed of polyurethane from 4,4¶-methylene diphenyl diisocyanate (4,4¶-MDI) and 1,6-hexanediol precursors (including HDI). However, patients have been shown to test positive for MDAwithout reacting to 4¶4MDI. This discrepancy is thought to be due to exclusive sensitization to 4,4¶-MDIYderived MDA after contact with water. Invisalign wraps around the teeth and is worn continuously throughout the day. When isocyanates come into contact with mucosal tissues, they bind to proteins forming immunogenic haptens that enter the epithelium and may lead to systemic or localized sensitization. Leaching of isocyanates from clear aligners may lead to systemic exposure through ingestion and mucosal absorption inducing type 1 hypersensitivity, which may manifest as angioedema and urticaria as seen in our patient. Interestingly, Premaraj et al demonstrated increased membrane permeability and decreased adhesion of gingival epithelial cells after exposure to Invisalign plastic that was reversible upon removal. However, saliva was found to confer a protective effect against isocyanates by maintaining epithelial cell integrity and neutralizing potential adverse effects of wearing Invisalign. Reported adverse events associated with clear aligners include angioedema, acute urticaria on the neck and face, and ulcerations of the oral mucosa, equivalent to the hypersensitivity observed in

A Case–Control Study to Evaluate Serum Lipoprotein Levels and Other Biomarkers of Cardiovascular Disease in Patients With Psoriasis

Background: Studies investigating lipid abnormalities associated with psoriasis have reported conflicting results. The purpose of this study is to evaluate differences in serum lipoprotein levels among patients with psoriasis compared to controls via the use of the Vertical Auto Profile (VAP) test, which directly measures the cholesterol concentrations of all 5 lipoprotein classes and their subclasses. We also assess other cardiovascular biomarkers, including highly sensitive C-reactive protein (hs-CRP), lipoprotein-associated phospholipase A2 (Lp-PLA2), and homocysteine. Methods: In this 6-year case–control study, 210 patients (110 patients with psoriasis and 100 controls) elected to participate in VAP testing between November 2009 and April 2016 at The George Washington Medical Faculty Associates dermatology clinic. All psoriatic cases were age-, sex-, and body mass index–matched to control patients. Data were analyzed in June 2016. We evaluated cardiovascular biomarkers in patients with psoriasis versus control patients and whether an association exists between the presence of psoriasis and the level of cardiovascular dysfunction. Results: Compared to the control group, patients with psoriasis had significantly lower high-density lipoprotein (HDL) (P = .007), HDL2 (P = .013), and HDL3 cholesterol (P = .015) as well as higher low-density lipoprotein (LDL) pattern B (P= .032), LDL3 (P = .030), and LDL4 cholesterol (P = .003). Patients with psoriasis also had lower apolipoprotein A1 (P = .011), lower Lp-PLA2 (P = .037), and higher hs-CRP (P = .048). Conclusion: Our findings suggest an increased risk of cardiovascular biomarker dysfunction in patients with psoriasis compared to their matched controls. Serum biomarkers such as high LDL pattern B, LDL3, and LDL4 as well as lower HDL2, HDL3, and total HDL were found to have a higher association with psoriatic disease.

A case of eosinophilic annular erythema as a presenting sign for autoimmune hepatitis

REPORT OF A CASE A 22-year-old man with history of acne was referred to our dermatology department for possible patch testing and evaluation of his widespread rash. Three months before referral, the patient had an eruption of well-demarcated plaques on his scalp, face, neck, and extremities, associated with pruritus. The patient’s eruption was refractory to topical corticosteroids (desoximetasone, clobetasol, and triamcinolone). The patient denied similar eruption in family members or close contacts. Additional medical history, including newmedications, changes in personal products, and new sexual contacts, was noncontributory, and detailed review of systems was found to be negative. Physical examination found annular erythematous plaques with central clearing on the trunk and extremities, including the palms of both hands (Fig 1). The face, scalp, and inguinal area were spared. Results of laboratory tests, which included