Secukinumab emerges as a rapidly effective therapy for pityriasis rubra pilaris.

Refractory pityriasis rubra pilaris (PRP) often is treated off-label with the same biologic therapies that are approved for the treatment of psoriasis, most commonly tumor necrosis factor (TNF) α antagonists and ustekinumab; however, the IL-17A antagonist secukinumab also has shown efficacy in the treatment of PRP. We report 2 new cases of severe refractory PRP that responded rapidly to treatment with secukinumab.

Unique clinical presentations of pityriasis rosea: aphthous ulcers, vesicles and inverse distribution of lesions.

Pityriasis Rosea (PR) is a common skin disorderencountered in daily practice. Although its etiologyhas not been established, there has been widespreadresearch into possibilities. The lack of its characteristicmanifestations, specifically the herald patch andtruncal involvement, can lead to pitfalls in diagnosis.Whereas other conditions in the differential diagnosisshould be considered, PR can at times also manifest inan atypical manner. We wish to illustrate three casesof PR including those that presented with aphthousulcers, vesicles, and an inverse pattern.

The use of an imagery mnemonic to teach the Krebs cycle.

The Krebs Cycle is a highly taught biochemical pathway that is traditionally difficult to learn. Twenty-seven undergraduate students were randomized to a rote memorization arm or to a mnemonic arm. They were given a pre-test, then shown a lecture corresponding to their assigned method, and then given an immediate Week 0 post-test and a Week 4 post-test. Groups scored comparably low on the pre-test (p = 0.7113). Students in the mnemonic arm performed better on the Week 0 post-test than those using rote (p = 0.0055). By Week 4, there was evidence of knowledge decay, with both arms' having comparably low scores (mnemonic vs. rote, p = 0.3739). The mnemonic assists in rapid acquisition of knowledge but probably has to be reviewed iteratively over time to demonstrate its full potential over rote memorization. A limited number of students from only one school was used. © 2016 by The International Union of Biochemistry and Molecular Biology, 44:224-229, 2016.

Understanding the logic of common suturing techniques in dermatologic surgery.

Although most trainees in dermatology learn that different suturing techniques are designated for a specific purpose (i.e., certain functional and cosmetic outcomes), students often have a difficult time visualizing how a given suture functions in its designated capacity. In this article, we address the logic behind the most common suturing techniques in dermatologic surgery, including the direction and magnitude of their pulling force with respect to the wound edges and the ensuing displacement of dermal and epidermal structures. To aid better understanding, we diagram the vectors of suture force with each of the techniques discussed.

Long-term durability and dose escalation patterns in infliximab therapy for psoriasis.

BACKGROUND: Infliximab often requires dose escalation to maintain response. Studies regarding long-term durability and dose escalation patterns for psoriasis are few. OBJECTIVE: We sought to evaluate dose escalation patterns in psoriatic patients to identify factors of lack of optimal response to infliximab. METHODS: A retrospective cohort study included 93 patients (216.3 patient-years) treated with infliximab for psoriasis. Kaplan-Meier analysis assessed drug durability. RESULTS: A median infliximab dose of 5.42 mg/kg/mo (range: 2.71-10.83) for a mean of 28 months was administered. Two thirds of patients received a dose escalation. Concurrent methotrexate extended duration of therapy (by a mean ± SD of 19.5 ± 8.1 months, P = .034), including time until first dose escalation (by a mean ± SD of 12.0 ± 6.1 months, P = .037), and failure (by a mean ± SD of 20.7 ± 6.7 months, P = .034). Patients who increased the infusion frequency before increasing the dose remained on infliximab 8.4 months longer than those who first increased the dose (P = .045). Four patients experienced adverse events; 2 required discontinuation. LIMITATIONS: Psoriasis Area and Severity Index, infliximab levels, and antibody titers were not measured. CONCLUSIONS: Dose escalation optimizes durability of infliximab. The probability of maintaining response is enhanced by concomitant methotrexate and increasing the infusion frequency before increasing the dose.

Combination use of ustekinumab with other systemic therapies: a retrospective study in a tertiary referral center.

BACKGROUND: Patients with moderate to severe psoriasis may not respond adequately to single systemic agent and may require combination systemic therapy. OBJECTIVE: To evaluate the prevalence, indications, and response to combination systemic therapy with ustekinumab for psoriasis in a tertiary referral center. METHODS: This retrospective study comprised 102 psoriasis patients treated with ustekinumab at a single tertiary care center. Data was collected pertaining to history of psoriasis, past and current therapies including use of concomitant psoriasis agents, response to therapy, and side effects while on ustekinumab. RESULTS: Twenty-two of 102 (22%) patients were identified as receiving combination systemic treatment involving ustekinumab and at least one additional agent. The most common indication for combination therapy was psoriatic arthritis (35%), followed by bridging therapy (26%), inadequate psoriasis control (13%), prevention of non-melanoma skin cancers (17%), and control of palmoplantar disease (9%). Methotrexate was the additional agent in 12 patients, cyclosporine in 7 patients, acitretin in 5 patients, and 1 patient received a second biologic agent, first etanercept and then adalimumab. Overall, the reduction in body surface area (BSA) was 80% for patients on combination therapy. For those patients on combination therapy for psoriatic arthritis, 75% had resolution or stabilization of their symptoms. Only one patient, receiving cyclosporine, discontinued combination therapy due to adverse side effects. CONCLUSION: Combination systemic therapy with ustekinumab can be effective and well tolerated for patients who cannot be adequately treated with ustekinumab alone.

Acquired perforating dermatosis: a clinical and dermatoscopic correlation.

Acquired Perforating Dermatosis (APD) is a perforating disease characterized by transepidermal elimination of dermal material [1,2]. This disease usually develops in adulthood. APD has been reported to occur in association with various diseases, but is most commonly associated with dialysis-dependent chronic renal failure (CRF) or diabetes mellitus (DM) [1,2,3,4]. Morton et al found that APD occurs in up to 10% of patients undergoing hemodialysis [5]. Additionally, Saray et al found that sixteen of twenty-two cases with APD were associated with CRF [3].

False-negative anti-treponemal immunohistochemistry in secondary syphilis.

BACKGROUND: While serological studies are the primary tool used to confirm the diagnosis of secondary syphilis, skin biopsies are often performed to control for potential false positives and negatives. Immunohistochemistry using anti-T. pallidum specific antibodies has proven to have a very high sensitivity and specificity for identification of spirochetes in biopsy specimens, but can occasionally fail to identify organisms in clinically and serologically confirmed cases. METHODS: We report two cases of apparently negative biopsy specimens in which rare organisms were subsequently identified by detailed study of multiple additional sections. RESULTS: Our experience suggests that the sensitivity of immunohistochemistry for syphilitic spirochetes may be improved by repeat immunostaining.

Organizing a dermatology service mission.

BACKGROUND: There are few published guidelines that describe the forethought and logistical considerations needed to create a dermatology-specific medical mission. OBJECTIVE: To report the experience of planning and executing a successful medical mission to an underserved community in Puerto Rico. METHODS: We identified an area of need and projected the volume of patients and diseases to be treated. After recruiting medical staff, pharmaceutical and surgical supplies were collected. Important concerns included establishing the scope of medical and educational services to be rendered, advertising the clinic, arranging for biopsy processing, ensuring follow-up, and selecting a method for medical documentation. We tracked the number of patients seen, diagnoses made, and materials used to prepare for future missions. RESULTS: We recruited 12 physicians and 25 ancillary (i.e. nonlicensed physician) staff members, including: six dermatologists, four internists, one pathologist, one psychiatrist, 23 medical students, and two medical assistants. We secured 12 examination rooms in an existing medical facility. Two pharmaceutical companies and two pathology companies provided the medications and surgical supplies with the remainder coming from the volunteer physicians' offices. Three thousand dollars were raised and used toward purchasing additional supplies. Advertising via public announcements resulted in the attendance of 166 patients during the 1-day clinic. A total of 41 procedures were performed, including 14 biopsies, five excisions, three incisions and drainage, and 19 electrodessications and curettage. CONCLUSION: Proper planning is critical in creating a successful dermatology mission. Documenting the care given and supplies used helps to identify needs and optimize limited resources for future missions. The goal of a self-sustaining public health service starts with patient education and coordination with the local healthcare providers.

Scabies: a review of diagnosis and management based on mite biology.

Scabies is a contagious parasitic dermatitis that is a significant cause of morbidity, especially outside of the United States. Scabies is diagnosed most often by correlating clinical suspicion with the identification of a burrow. Although scabies should be on the differential for any patient who presents with a pruritic dermatosis, clinicians must consider a wide range of diagnostic possibilities. This approach will help make scabies simultaneously less over- and underdiagnosed by clinicians in the community. Atypical or otherwise complex presentations may necessitate the use of more definitive diagnostic modalities, such as microscopic examination of KOH prepared skin scrapings, high-resolution digital photography, dermoscopy, or biopsy. Scabies therapy involves making the correct diagnosis, recognizing the correct clinical context to guide treatment of contacts and fomites, choosing the most effective medication, understanding how to use the agent properly, and following a rational basis for when to use and reuse that agent. Although the development of new therapeutic agents is always welcome, tried and true treatments are still effective today. Permethrin is the gold standard therapy, with malathion being an excellent topical alternative. Ivermectin is an effective oral alternative that is especially useful in crusted scabies, patients who are bed ridden, and in institutional outbreaks. Despite the availability of effective therapeutics, treatment failures still occur, mostly secondary to application error (ie, failure to treat the face and scalp or close contacts, failure to reapply medication) or failure to decontaminate fomites. Because increasing resistance to scabies treatments may be on the horizon, we propose that standard of care for scabies treatment should involve routine treatment of the scalp and face and re-treating patients at day 4 on the basis of the scabies life cycle to ensure more efficient mite eradication. Practitioners should attempt to treat all close contacts simultaneously with the source patient. To eradicate mites, all fomites should be placed in a dryer for 10 minutes on a high setting, furniture and carpets vacuumed, and nonlaunderables isolated for a minimum of 2 days, or, for those who wish to be rigorous, 3 weeks.

Practical aspects in the management of hypokalemic periodic paralysis.

Management considerations in hypokalemic periodic paralysis include accurate diagnosis, potassium dosage for acute attacks, choice of diuretic for prophylaxis, identification of triggers, creating a safe physical environment, peri-operative measures, and issues in pregnancy. A positive genetic test in the context of symptoms is the gold standard for diagnosis. Potassium chloride is the favored potassium salt given at 0.5-1.0 mEq/kg for acute attacks. The oral route is favored, but if necessary, a mannitol solvent can be used for intravenous administration. Avoidance of or potassium prophylaxis for common triggers, such as rest after exercise, high carbohydrate meals, and sodium, can prevent attacks. Chronically, acetazolamide, dichlorphenamide, or potassium-sparing diuretics decrease attack frequency and severity but are of little value acutely. Potassium, water, and a telephone should always be at a patient's bedside, regardless of the presence of weakness. Perioperatively, the patient's clinical status should be checked frequently. Firm data on the management of periodic paralysis during pregnancy is lacking. Patient support can be found at http://www.periodicparalysis.org.