Rebecca Tung

Tumour necrosis factor-α inhibition can stabilize disease in progressive vitiligo

Tumour necrosis factor (TNF)‐α, a proinflammatory cytokine central to many autoimmune diseases, has been implicated in the depigmentation process in vitiligo. We review its role in vitiligo by exploring its pro‐ and anti‐inflammatory properties and examine the effects of blocking its actions with TNF‐α antagonist therapeutics in reports available in the literature. We found that TNF‐α inhibition halts disease progression in patients with progressive vitiligo but that, paradoxically, treatment can be associated with de novo vitiligo development in some patients when used for other autoimmune conditions, particularly when using adalimumab and infliximab. These studies reinforce the importance of stating appropriate outcomes measures, as most pilot trials propose to measure repigmentation, whereas halting depigmentation is commonly overlooked as a measure of success. We conclude that TNF‐α inhibition has proven useful for patients with progressive vitiligo, where TNF‐α inhibition is able to quash cytotoxic T‐cell‐mediated melanocyte destruction. However, a lingering concern for initiating de novo disease will likely prevent more widespread application of TNF inhibitors to treat vitiligo.

Treatment of forehead/glabellar rhytide complex with combination botulinum toxin a and hyaluronic acid versus botulinum toxin a injection alone: a split‐face, rater‐blinded, randomized control trial

Forehead and glabella rhytides are treated mostly with neurotoxins, although some practitioners prefer the concurrent use of fillers. It has been suggested that combination treatments can result in a better overall improvement.

Preferential secretion of inducible HSP70 by vitiligo melanocytes under stress

Inducible HSP70 (HSP70i) chaperones peptides from stressed cells, protecting them from apoptosis. Upon extracellular release, HSP70i serves an adjuvant function, enhancing immune responses to bound peptides. We questioned whether HSP70i differentially protects control and vitiligo melanocytes from stress and subsequent immune responses. We compared expression of HSP70i in skin samples, evaluated the viability of primary vitiligo and control melanocytes exposed to bleaching phenols, and measured secreted HSP70i. We determined whether HSP70i traffics to melanosomes to contact immunogenic proteins by cell fractionation, western blotting, electron microscopy, and confocal microscopy. Viability of vitiligo and control melanocytes was equally affected under stress. However, vitiligo melanocytes secreted increased amounts of HSP70i in response to MBEH, corroborating with aberrant HSP70i expression in patient skin. Intracellular HSP70i colocalized with melanosomes, and more so in response to MBEH in vitiligo melanocytes. Thus, whereas either agent is cytotoxic to melanocytes, MBEH preferentially induces immune responses to melanocytes.

Oral Glycopyrrolate for the Treatment of Hailey-Hailey Disease

Hailey-Hailey disease is an autosomal dominant blistering dermatosis due to a mutation in the ATP2C1 gene (OMIM 604384). This gene encodes a calcium ATPase present on the Golgi apparatus contributing to the formation of intercellular adhesions. Disruption of this enzyme results in acantholysis, which is most clinically pronounced in intertriginous areas that are subject to heat, friction, sweating, and bacterial colonization.1 Hailey-Hailey disease can have spontaneous periods of clinical improvement; however, the disease often has a long-term course and treatment can be challenging. Because there is currently no cure for this condition, most therapies aim to minimize the influence of exacerbating factors.

Effect of Needle Size on Pain Perception in Patients Treated With Botulinum Toxin Type A Injections: A Randomized Clinical Trial

IMPORTANCE Transcutaneous injection through smaller hollow-bore needles may decrease patient discomfort, but current evidence is equivocal. OBJECTIVE To compare injection discomfort in patients treated with botulinum toxin type A with 30- and 32-gauge needles. DESIGN, SETTING, AND PARTICIPANTS Split-face, patient- and injector-blinded randomized clinical trial at the dermatology service of an urban university medical center. The 20 participants were women aged 25 to 70 years in good health and with moderate dynamic forehead and glabellar wrinkles. Data were collected from November 20, 2013, through January 16, 2014. Follow-up was complete on January 16, 2014. Data from the per-protocol population were analyzed from July 1 to July 31, 2014. INTERVENTIONS One side of each patientsforehead received botulinum toxin type A in saline injected with a 32-gauge needle; the other side received the same treatment injected with a 30-gauge needle. In addition, each patient received randomized injections of saline only to both upper inner arms with the same types of needles. MAIN OUTCOMES AND MEASURES Primary outcomes included the patient-reported pain rating on a visual analog scale (VAS) on either side of the face and arms and the proportion of patients whose VAS ratings corresponded with more than moderate (ie, clinically significant) pain. The secondary outcome consisted of patient-reported information about the character of the pain at both sites using the expanded and revised version of the Short-Form McGill Pain Questionnaire. RESULTS All 20 patients completed the study. Overall, facial and arm injections were nominally but not significantly more painful with 30-gauge needles (mean [SD] VAS ratings for the face, 4.16 [2.55] vs 3.41 [2.31], P = .34; for the arm, 1.66 [2.07] vs 1.21 [1.65], P = .45). For facial injections, the likelihood of clinically significant pain (VAS rating, ≥5.4) was significantly greater with 30-gauge needles, which were associated with such pain in 8 patients (40%) compared with the 32-gauge needles, which were associated with such pain in 3 patients (15%) (odds ratio, 3.80 [95% CI, 1.05-13.78]; P = .04). No difference was found in the character of pain associated with needle bore (P > .05 for all comparisons). CONCLUSIONS AND RELEVANCE For facial injections of neurotoxin in saline, 30-gauge needles were associated with greater incidence of clinically significant pain than 32-gauge needles. For patients prone to experience clinically significant pain with facial injections, use of 32-gauge needles may minimize this discomfort. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01981174.

Treatment of Acne Vulgaris With Salicylic Acid Chemical Peel and Pulsed Dye Laser: A Split Face, Rater-Blinded, Randomized Controlled Trial

INTRODUCTION Pulsed dye laser (PDL) has been used to treat acne lesions and scar erythema by interrupting superficial vasculature. Salicylic acid chemical peels are employed chiefly due to their lipophilic, comedolytic, and anti-inflammatory properties. Although studies have looked at peels and laser therapy independently in acne management, we examined these treatments in combination. Our primary objective was to evaluate the safety and efficacy of concurrent use of salicylic acid peels with PDL versus salicylic acid peels alone in the treatment of moderate to severe acne vulgaris. METHODS Adult patients with moderate to severe acne were included. Subjects received a total of 3 treatments at 3-week intervals. Per randomized split-face treatment, at week 0, one half of the subjects face was treated with PDL (595 nm) followed by whole face application of a 30% salicylic acid peel. At weeks 3 and 6, the treatments were repeated. At 0 and 9 weeks, patients were assessed with the Global Evaluation Acne (GEA) scale and Dermatology Life Quality Index (DLQI) questionnaire. RESULTS Nineteen subjects were enrolled, and 18 completed the study. Significant improvement in acne was seen in both the combined (laser and peel) and chemical peel alone treatment arms (P < .0005 and P = .001). Using the GEA scale score, compared to week 0, the mean difference in acne improvement at week 9 was -1.61 in the combination therapy group versus -1.11 in the peel only group. Based on the GEA scale scoring, a statistically significant greater difference in acne improvement was seen, from week 0 to week 9, in the combination treatment group compared with the peel only group (P = .003). CONCLUSION While acne subjects had significant benefit from the salicylic acid peel alone, they experienced greater significant benefit from PDL treatment used in conjunction with salicylic acid peels. The adjunctive utilization of PDL to salicylic acid peel therapy can lead to better outcomes in acne management.

A Novel Treatment Approach for Extensive, Eruptive, Cutaneous Squamous Cell Carcinomas in a Patient Receiving BRAF Inhibitor Therapy for Metastatic Melanoma

Vemurafenib is a potent inhibitor of BRAF with the V600E mutation and is approved for advanced cases of metastatic melanoma. Squamous cell carcinoma (SCC) has been described in patients receiving higher dosages. We present a case of a metastatic melanoma survivor who has developed 58 eruptive SCCs while taking vemurafenib that were successfully treated using an aggressive surgical and immunomodulatory approach using a combination of Mohs micrographic and excisional surgery, modified photodynamic therapy (PDT), and 5-fluorouracil (FU).

Unusual clinical presentation of cutaneous angiosarcoma masquerading as eczema: a case report and review of the literature.

An unusual case of cutaneous angiosarcoma clinically mimicking eczema is described. A 98-year-old Caucasian male presented with a 6-month history of a flesh-colored, subcutaneous nodule on his left forehead with contralateral facial erythema and scaling that had been previously diagnosed as eczema. Despite treatments with topical steroids and moisturizers, the condition did not resolve. At our clinic, excisional biopsy of the forehead lesion and scouting biopsies from the contralateral cheek were performed which revealed cutaneous angiosarcoma. The described case illustrates that dermatitis-like features should be considered as a rare clinical manifestation of cutaneous angiosarcoma. It also demonstrates that these lesions may respond well to radiotherapy as a single modality.

Cutaneous Rhodotorula Treated with Photodynamic Therapy

Rhodotorula is an emerging opportunistic fungal pathogen that is typically resistant to standard antifungal therapies. Many of the reported cases of Rhodotorula are systemic infections occurring in immunocompromised patients. The following describes the first reported case of cutaneous Rhodotorula of the scalp in the immunocompromised or immunocompetent population. Furthermore, we present a novel treatment of Rhodotorula using a combination of a superficial chemical peel and photodynamic therapy (PDT).

Blastomycosis and Pregnancy: An Unusual Postpartum Disease Course.

Blastomyces dermatitidis is responsible for systemic mycoses. It is predominantly caused by inhalation of spores and often manifests as pneumonia, which can potentially disseminate; however, direct cutaneous inoculation may also occur. Blastomycosis in the perigravid period is exceedingly rare. The partial immunosuppressive state induced by pregnancy can engender more severe infections and is associated with a risk of vertical transmission. Published cases describe postpartum symptomatic improvement accompanying immune reconstitution, even in the absence of treatment. We present a 31-year-old gravid female with multifocal cutaneous blastomycosis. After delivering a healthy full-term infant with no evidence of congenital infection, the patients cutaneous lesions continued to worsen. At 6 weeks postpartum she was treated with oral itraconazole and demonstrated clinical improvement after 5 months of therapy. This case highlights the importance of prompt disease recognition, understanding of risk factors and initiation of appropriate antifungal therapy of blastomycotic infection occurring in the unique setting of pregnancy.