Shreya Dixit

The skin microbiome: Associations between altered microbial communities and disease

A single square centimetre of the human skin can contain up to one billion microorganisms. These diverse communities of bacteria, fungi, mites and viruses can provide protection against disease, but can also exacerbate skin lesions, promote disease and delay wound healing. This review addresses the current knowledge surrounding the healthy skin microbiome and examines how different alterations to the skin microbial communities can contribute to disease. Current methodologies are considered, changes in microbial diversity and colonisation by specific microorganisms are discussed in the context of atopic dermatitis, psoriasis, acne vulgaris and chronic wounds. The recent impact of modern Westernised lifestyles on the human skin microbiome is also examined, as well as the potential benefits and pitfalls of novel therapeutic strategies. Further analysis of the human skin microbiome, and its interactions with the host immune system and other commensal microorganisms, will undoubtedly elucidate molecular mechanisms for disease and reveal gateways for novel therapeutic treatment strategies.

Vulvovaginal candidiasis as a chronic disease: diagnostic criteria and definition.

Objective Although recurrent vulvovaginal candidiasis is defined as 4 or more discrete attacks of vulvovaginal candidiasis per year, there is no diagnostic nomenclature or definition for the many women who are chronically symptomatic. This study aims to establish and propose a definition and a set of diagnostic criteria, which would enable clinicians to promptly identify and treat women with chronic vulvovaginal candidiasis (CVVC). Design Prospective cohort study. Setting Public and private vulvar dermatology outpatient clinics in Sydney, Australia. Participants Data were obtained prospectively from 50 women with presumptive CVVC and 42 controls. Historical and clinical features of CVVC identified by expert consensus were compared between the 2 groups. Diagnostic criteria were then prospectively applied to a further 163 patients to verify their accuracy. Outcome Measures Signs and symptoms diagnostic of CVVC. Results The following characteristics were found to be significantly more common in women with CVVC compared to controls (p ⩽ .001): a history of positive vaginal Candida swab, discharge, dyspareunia, soreness, swelling, cyclicity, and exacerbation of symptoms with antibiotics. Conclusions We propose that CVVC can be confidently diagnosed using the major criteria of a chronic nonspecific and nonerosive vulvovaginitis that includes at least 5 or more properties from the following criteria: soreness, dyspareunia, positive vaginal swab either at presentation or in the past, previous response to antifungal medication, exacerbation with antibiotics, cyclicity, swelling, and discharge. This condition responds reliably to oral antifungal medication.

Management of nonsexually acquired genital ulceration using oral and topical corticosteroids followed by doxycycline prophylaxis

BACKGROUND Data regarding the treatment of nonsexually acquired genital ulceration (NSAGU) are limited. OBJECTIVE We sought to provide evidence for the safety and efficacy of topical and systemic corticosteroids followed by doxycycline prophylaxis for acute and recurrent NSAGU. METHODS A retrospective chart review was conducted of patients with NSAGU treated in a private dermogynecology practice. RESULTS A total of 26 girls and women with NSAGU were identified and divided into 2 groups: group A = 17 patients with moderate to severe ulceration treated in the acute stage with oral corticosteroid; and group B = 9 patients with mild ulceration treated in the acute stage with topical corticosteroid. Patients in group A, with a mean age of 27.9 years (range, 11-62 years), were treated with oral prednisolone commencing with 15 to 50 mg per day depending on severity. Sixteen (94%) achieved rapid pain relief and complete healing of ulcers within 16 days. Eight (47%) commenced doxycycline prophylaxis. Women in group B, with a mean age of 42.5 years (range, 26-67 years) were treated with topical corticosteroids. Eight (89%) had a history of recurrent ulcers and 6 (66%) commenced doxycycline prophylaxis. Of all 14 patients on doxycycline prophylaxis, none reported any recurrences during a mean follow-up of 18.3 months. There were no adverse effects caused by prednisolone. One patient experienced mild photosensitivity from doxycycline but continued to take it. LIMITATIONS This was a retrospective case series from a single private practice-based population. CONCLUSION Topical or oral corticosteroids followed by prophylactic doxycycline can be effective in rapidly resolving acute flareups and preventing recurrences of NSAGU. All patients responded to therapy without treatment-limiting side effects.

Vulvovaginal pyoderma gangrenosum secondary to rituximab therapy.

Rituximab is being used increasingly for the treatment of B-cell malignancies and nonmalignant conditions. Pyoderma gangrenosum is a rare neutrophilic dermatosis, which can be either idiopathic or associated with underlying systemic inflammatory conditions. We present a series of 4 patients who presented with ulcerative pyoderma gangrenosum in the vulvovaginal area after treatment with rituximab.

Ustekinumab in the treatment of severe paediatric psoriasis.

Psoriasis is a chronic skin condition with a prevalence in Australia of approximately 2 per cent. Approximately 30–45 per cent of those affected have had symptoms since childhood or adolescence. Given the chronicity of the condition, it is important to find therapies that can safely be used for extended periods of time in these patients, with the aim of reducing psychological morbidity as well as preventing systemic complications associated with psoriasis. Ustekinumab is an interleukin 12/23 monoclonal antibody, which is effective in the treatment of adults with moderate to severe chronic plaque psoriasis. There are no published reports describing the treatment of paediatric psoriasis with ustekinumab. We here report the case of a 16-year-old boy who obtained 100 per cent improvement in his psoriasis area and severity index (PASI 100) after treatment with ustekinumab. Our patient was first seen by a paediatric dermatologist when he was 9-years old. On initial review, he had hyperkeratotic plaques on his elbows and knees and smaller plaques on the trunk, legs and arms. He also had eyelid and genital psoriasis. He was commenced on multiple topical therapies, which initially kept his psoriasis controlled. At the age of 11 he was referred for phototherapy and, for the first time, he had almost complete clearance of his psoriasis. By the time he reached the age of 13, the phototherapy was having less effect, so he was started on acitretin. After 2 years his psoriasis flared and he was switched to methotrexate 10 mg weekly, which resulted in an almost 90 per cent improvement in his psoriasis, but after 9 months this, too, became less efficacious. His appearance was limiting his social life and his parents reported his mood was increasingly depressed. He had gained a significant amount of weight and was morbidly obese with a body mass index of 50 at the age of 16. As he had failed three systemic treatments he was referred to the public hospital for an assessment of a biological treatment. None of the biological agents at that time were approved or subsidised for the treatment of psoriasis in the under-18 age group, so the manufacturer kindly provided a compassionate supply of ustekinumab. His initial PASI was 21.2 and his weight was 145 kg. He was commenced on 90 mg at weeks 0 and 4 before ongoing 12-weekly dosing. At the week 8 review he had complete clearance of his psoriasis with a PASI score of 0, which he has maintained for 18 months. He has suffered no side effects, and has lost 10 kg. Psoriasis in children has significant physical and psychological morbidity. Kimball and colleagues conducted a retrospective study evaluating the risk of developing psychiatric disorders in paediatric patients with psoriasis. They found that children with psoriasis were significantly more at risk of developing psychiatric disorders, especially depression and anxiety. Patients with psoriasis have also been found to have a higher risk for diabetes mellitus and cardiovascular disease, possibly secondary to effects of chronic inflammatory changes, particularly the secretion of pro-inflammatory cytokines. It can thus be hypothesized that treating children with psoriasis with systemic therapy will result in a reduced risk of late-term cardiovascular complications. Paller and colleagues assessed the safety and efficacy of etanercept in children and adolescents with moderate to severe plaque psoriasis. They found that at week 12, 57 per cent of patients receiving etanercept achieved a PASI 75, 27 per cent had PASI 90 and 53 per cent had a physician’s global assessment of clear or almost clear. We have found ustekinumab to be effective and well tolerated in our paediatric patient with chronic severe plaque psoriasis. We believe this emphasises the need for further large-scale trials to demonstrate the safety and efficacy of this agent for use in children with psoriasis.

Ice anaesthesia in procedural dermatology.

This article presents findings from a survey of Australian dermatologists who were questioned about their preferred pain control methods when carrying out injectable procedures. We also present, what is to the best of our knowledge, the first proof‐of‐concept experiment exploring the relationship between ice‐to‐skin contact time and skin surface temperature, using both ice wrapped in latex and ice wrapped in aluminium foil. Of 79 dermatologists 32 responded to the survey (41% response rate): 31 (97%) injected botulinum toxin type A (BTA) for dynamic lines, 26 (81%) injected BTA for hyperhidrosis, and 24 (75%) injected skin fillers. Ice anaesthesia was the most common method of pain control (75%) followed by use of topical anaesthesia (50%) such as EMLA, compound agents and lignocaine 4%. Ice wrapped in latex or latex‐like material was the most common ice packaging used by those surveyed and the median ice‐to‐skin contact time was 10 s. The ice experiment results indicated that ice wrapped with aluminium foil was equivalent to ice wrapped in latex for short contact times (< 20 s), but more effective at reducing skin temperature with longer contact times (> 20 s). These findings will be of relevance to cosmetic and paediatric dermatologists or any area of procedural medicine where effective non‐injectable pain control is required.

Role of nanocrystalline silver dressings in the management of toxic epidermal necrolysis (TEN) and TEN/Stevens-Johnson syndrome overlap.

Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are severe mucocutaneous eruptions. There is currently no defined optimal approach to wound care. The objective of this study was to evaluate silver dressings in the wound‐care management of TEN and SJS/TEN syndrome overlap with a retrospective case review of nine patients with TEN and SJS/TEN overlap presenting to our institution. Nanocrystalline silver dressings appear to be useful in the rapid commencement of healing in these patients. TEN and SJS/TEN overlap are rare conditions. This contributed to a relatively small number of cases included in the study. The ease of application, antimicrobial properties and low frequency of change make nanocrystalline silver dressings ideal in TEN/SJS.

A case series of 11 patients with hormone-responsive sebaceous adenitis of the labia minora

Sebaceous adenitis, an idiopathic inflammation of the sebaceous gland, is a condition that is well described in animals but has been reported only thrice previously in humans. We present a series of 11 cases of sebaceous adenitis that presented as tender nodular lesions clinically similar to hidradenitis suppurativa, but was confined to the labia minora. All cases responded to tetracyclines and anti‐androgen therapy.

Assessment of attitudes towards sun-protective behaviour in Australians: A cross-sectional study

To assess the knowledge, attitudes and behaviour towards sun protection measures in a sample of Australian adults.

Haemorrhagic purpura in an elderly man

You are asked to review an 85 year old man with bullous lesions on the torso and limbs (as shown), which developed after treatment with low‐molecular weight heparin (LMWH), unfractionated heparin (UFH), and furosemide. Based on the given history and the clinical and histological images, what is your diagnosis?