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Immunology and Allergy Clinics of North... Aug 2023Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides... (Review)
Review
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
Topics: Humans; Drug Hypersensitivity; Stevens-Johnson Syndrome; Skin; Acute Generalized Exanthematous Pustulosis; Hypersensitivity, Delayed
PubMed: 37394254
DOI: 10.1016/j.iac.2022.10.005 -
Journal of the American Academy of... Mar 2024Seborrheic dermatitis (SD) is a common skin disease with signs and symptoms that may vary by skin color, associated medical conditions, environmental factors, and... (Review)
Review
Seborrheic dermatitis (SD) is a common skin disease with signs and symptoms that may vary by skin color, associated medical conditions, environmental factors, and vehicle preference. Diagnosis of SD is based on presence of flaky, "greasy" patches, and/or thin plaques accompanied by erythema of the scalp, face, ears, chest, and groin and is associated with pruritus in many patients. The presentation may vary in different skin types and hyper- or hypopigmentation may occur, with or without erythema and minimal or no scaling. While the pathogenesis is not certain, 3 key factors generally agreed upon include lipid secretion by sebaceous glands, Malassezia spp. colonization, and some form of immunologic dysregulation that predisposes the patient to SD. Treatment involves reducing proliferation of, and inflammatory response to, Malassezia spp. Topical therapies, including antifungal agents and low potency corticosteroids, are the mainstay of treatment but may be limited by efficacy and side effects. Few novel treatments for SD are currently being studied; however, clinical trials assessing the use of topical phosphodiesterase-4 inhibitors have been completed. Improving outcomes in SD requires recognizing patient-specific manifestations/locations of the disease, including increased awareness of how it affects people of all skin types.
Topics: Humans; Dermatitis, Seborrheic; Antifungal Agents; Adrenal Cortex Hormones; Erythema; Malassezia
PubMed: 36538948
DOI: 10.1016/j.jaad.2022.12.017 -
Clinical and Experimental Dermatology Aug 2023Topical steroid withdrawal (TSW) is a newly described disease characterized by erythema and burning following discontinuation of prolonged use of mid- to high-potency...
BACKGROUND
Topical steroid withdrawal (TSW) is a newly described disease characterized by erythema and burning following discontinuation of prolonged use of mid- to high-potency topical corticosteroids. No consensus diagnostic criterion exists. TSW is frequently interpreted as flaring of the underlying disorder or contact allergy to topical treatment.
OBJECTIVES
To better characterize TSW symptomatology, detail our experience with management and assess the proportion of patients who pursue nonconventional management.
METHODS
A retrospective review of case notes collected from our multidisciplinary service between January 2019 and June 2021 was carried out to identify patients presenting with TSW.
RESULTS
Nineteen cases of TSW were identified, 15 in females and 4 in males. The majority were < 35 years old. Eighteen had atopic dermatitis. The most frequently reported features were redness, skin pain (typically 'burning'), skin sensitivity, excessive skin flaking, insomnia and severe itching. There was a high burden of anxiety and depression, with three patients expressing suicidal thoughts. Nonconventional treatments were pursued by approximately half the cohort, some of whom sought private consultation with international dermatologists. Improvements were noted in the context of open psychodermatology consultations with an earlier introduction of conventional management options.
CONCLUSIONS
Many patients report dismissal by dermatology healthcare professionals, often driving them to seek help from unregulated online sources, heightening the burden of mental, social and physical morbidity. Dermatology healthcare professionals need to be aware of TSW and offer support with shared decision-making when considering treatments.
Topics: Male; Female; Humans; Adult; Dermatologic Agents; Dermatitis, Atopic; Erythema; Pruritus; Steroids
PubMed: 37119282
DOI: 10.1093/ced/llad161 -
Journal of the American Academy of... Mar 2024Erythromelalgia is a rare pain disorder that is underrecognized and difficult-to-treat. It is characterized by episodes of extremity erythema and pain that can be... (Review)
Review
Erythromelalgia is a rare pain disorder that is underrecognized and difficult-to-treat. It is characterized by episodes of extremity erythema and pain that can be disabling; it may be genetic, related to an underlying systemic disease, or idiopathic. Considering the prominent cutaneous features characteristic of the condition, dermatologists can play an important role in early recognition and limitation of morbidity. The first article in this 2-part continuing medical education series reviews the epidemiology, pathogenesis, clinical manifestations, evaluation, and complications.
Topics: Humans; Erythromelalgia; Pain; Erythema; Skin
PubMed: 37364617
DOI: 10.1016/j.jaad.2023.02.071 -
Ophthalmology Oct 2023To evaluate the safety and efficacy of lotilaner ophthalmic solution 0.25% compared with vehicle for the treatment of Demodex blepharitis. (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
To evaluate the safety and efficacy of lotilaner ophthalmic solution 0.25% compared with vehicle for the treatment of Demodex blepharitis.
DESIGN
Prospective, randomized, double-masked, vehicle-controlled, multicenter, phase 3 clinical trial.
PARTICIPANTS
Four hundred twelve patients with Demodex blepharitis were assigned randomly in a 1:1 ratio to receive either lotilaner ophthalmic solution 0.25% (study group) or vehicle without lotilaner (control group).
METHODS
Patients with Demodex blepharitis treated at 21 United States clinical sites were assigned either to the study group (n = 203) to receive lotilaner ophthalmic solution 0.25% or to the control group (n = 209) to receive vehicle without lotilaner bilaterally twice daily for 6 weeks. Collarettes and erythema were graded for each eyelid at screening and at all visits after baseline. At screening and on days 15, 22, and 43, 4 or more eyelashes were epilated from each eye, and the number of Demodex mites present on the lashes was counted with a microscope. Mite density was calculated as the number of mites per lash.
MAIN OUTCOME MEASURES
Outcome measures included collarette cure (collarette grade 0), clinically meaningful collarette reduction to 10 collarettes or fewer (grade 0 or 1), mite eradication (0 mites/lash), erythema cure (grade 0), composite cure (grade 0 for collarettes as well as erythema), compliance with the drop regimen, drop comfort, and adverse events.
RESULTS
At day 43, the study group achieved a statistically significant (P < 0.0001) higher proportion of patients with collarette cure (56.0% vs. 12.5%), clinically meaningful collarette reduction to 10 collarettes or fewer (89.1% vs. 33.0%), mite eradication (51.8% vs. 14.6%), erythema cure (31.1% vs. 9.0%), and composite cure (19.2% vs. 4.0%) than the control group. High compliance with the drop regimen (mean ± standard deviation, 98.7 ± 5.3%) in the study group was observed, and 90.7% of patients found the drops to be neutral to very comfortable.
CONCLUSIONS
Twice-daily treatment with lotilaner ophthalmic solution 0.25% for 6 weeks generally was safe and well tolerated and met the primary end point and all secondary end points for the treatment of Demodex blepharitis compared with vehicle control.
FINANCIAL DISCLOSURE(S)
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Topics: Animals; Humans; Mite Infestations; Prospective Studies; Ophthalmic Solutions; Blepharitis; Mites; Eyelashes; Erythema; Eye Infections, Parasitic
PubMed: 37285925
DOI: 10.1016/j.ophtha.2023.05.030 -
Journal of Drugs in Dermatology : JDD Nov 2023Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare and dangerous dermatologic emergency. It can have different presentations, especially in patients... (Review)
Review
INTRODUCTION
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare and dangerous dermatologic emergency. It can have different presentations, especially in patients with multiple drug causes, and definitive management of SJS/TEN in these presentations remains unclear. Systemic corticosteroids, TNF inhibitors, and cyclosporine A are promising therapies.
CASE REPORT
In this case report, we present a 55-year-old man who developed SJS/TEN while on pembrolizumab and lamotrigine. The patient was treated with corticosteroids and a single dose of etanercept. After a one-week follow-up, the patient’s SJS/TEN had no new activity.
DISCUSSION
This literature review highlights how SJS/TEN may present differently in patients on immune checkpoint inhibitors. Treatments in these cases may vary from those with classic SJS/TEN. Specifically, etanercept given days late into the disease course is effective in speeding re-epithelialization and tapering of already given corticosteroids in classic SJS/TEN. J Drugs Dermatol. 2023;22(11):e24-e28 doi:10.36849/JDD.6999e.
Topics: Male; Humans; Middle Aged; Stevens-Johnson Syndrome; Etanercept; Cyclosporine; Disease Progression; Adrenal Cortex Hormones
PubMed: 37943271
DOI: 10.36849/JDD.6999 -
Nature Reviews. Disease Primers Apr 2024Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms... (Review)
Review
Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (also known as drug-induced hypersensitivity syndrome), acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption, are life-threatening conditions. The pathogenesis of SCARs involves T cell receptors recognizing drug antigens presented by human leukocyte antigens, triggering the activation of distinct T cell subsets. These cells interact with keratinocytes and various immune cells, orchestrating cutaneous lesions and systemic manifestations. Genetic predisposition, impaired drug metabolism, viral reactivation or infections, and heterologous immunity influence SCAR development and clinical presentation. Specific genetic associations with distinct SCAR phenotypes have been identified, leading to the implementation of genetic screening before prescription in various countries to prevent SCARs. Whilst systemic corticosteroids and conventional immunomodulators have been the primary therapeutic agents, evolving strategies, including biologics and small molecules targeting tumour necrosis factor, different cytokines, or Janus kinase signalling pathways, signify a shift towards a precision management paradigm that considers individual clinical presentations.
Topics: Humans; Stevens-Johnson Syndrome; Drug Hypersensitivity Syndrome; Drug Eruptions; Acute Generalized Exanthematous Pustulosis
PubMed: 38664435
DOI: 10.1038/s41572-024-00514-0 -
Journal of Cosmetic Dermatology Oct 2023Topical azelaic acid (AA) is indicated for acne and rosacea, but there is some evidence for its use for other dermatological conditions. (Review)
Review
BACKGROUND
Topical azelaic acid (AA) is indicated for acne and rosacea, but there is some evidence for its use for other dermatological conditions.
AIMS
To assess the effectiveness and safety of topical AA for acne vulgaris, rosacea, hyperpigmentation/melasma, and skin aging.
METHODS
RCTs of at least 6 weeks' treatment duration were eligible for inclusion. Databases including MEDLINE, Embase, CINAHL, and ClinicalTrials.gov were searched up to December 2022. Two reviewers were involved in all stages of the systematic review process.
RESULTS
Forty-three RCTs met the inclusion criteria. Meta-analyses within 20 rosacea studies demonstrated that erythema severity, inflammatory lesion counts, overall improvement, and treatment success (achieving skin clarity) were significantly improved with AA compared with vehicle after 12 weeks. AA was more effective than metronidazole 0.75% for improved erythema severity, overall improvement, and inflammatory lesion counts. Sixteen acne studies suggest that AA is more effective than vehicle for improving global assessments and reducing acne severity. AA 20% also significantly reduced more lesions than erythromycin gel. Within seven melasma studies, AA 20% was significantly better than vehicle for both severity and global improvement. AA 20% demonstrated significantly better results compared with hydroquinone 2% for global improvement. Very few significant differences between AA and comparators were observed for commonly reported adverse events. No eligible RCTs were found that evaluated skin aging.
CONCLUSIONS
AA is more effective than vehicle for rosacea, acne and melasma. Comparisons between AA and other treatments were often equivalent. Where there is equivalence, AA may be a good option for some clinical situations. RCT evidence is needed to evaluate the effectiveness of AA on skin aging.
Topics: Humans; Skin Aging; Acne Vulgaris; Rosacea; Erythema; Treatment Outcome; Melanosis; Dermatologic Agents
PubMed: 37550898
DOI: 10.1111/jocd.15923 -
Dermatology Online Journal Dec 2023Lupus erythematosus (LE)-specific bullous lesions are often difficult to distinguish from other bullous diseases presenting in patients with systemic lupus...
Lupus erythematosus (LE)-specific bullous lesions are often difficult to distinguish from other bullous diseases presenting in patients with systemic lupus erythematosus. Herein, we describe a 49-year-old woman with systemic lupus erythematosus with recurrent tense bullae on the forearms. Clinical, histopathologic, and serologic findings led to the diagnosis of LE-specific bullous lesions. We also summarize the diagnostic clues for distinguishing LE-specific bullous lesions, bullous systemic lupus erythematosus, and erythema multiforme-like lesions in LE (Rowell syndrome).
Topics: Female; Humans; Middle Aged; Blister; Lupus Erythematosus, Systemic; Erythema Multiforme; Skin Diseases, Vesiculobullous; Lupus Erythematosus, Cutaneous
PubMed: 38478668
DOI: 10.5070/D329662997 -
Drug and Therapeutics Bulletin Sep 2023Lee EY, Knox C, Phillips EJ. Worldwide prevalence of antibiotic-associated Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and...
Lee EY, Knox C, Phillips EJ. Worldwide prevalence of antibiotic-associated Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis. JAMA Dermatol 2023;159:384-392.
Topics: Humans; Anti-Bacterial Agents; Stevens-Johnson Syndrome
PubMed: 37536751
DOI: 10.1136/dtb.2023.000041