Long-Term Efficacy of Dupilumab in Alopecia Areata.

BACKGROUND Dupilumab is a relatively new immune-modulating drug that has transformed the way clinicians treat common immunologic conditions, including atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis. Blocking signaling molecules involved within the Th2 immune response, dupilumab is a proven effective treatment for moderate to severe atopic dermatitis - a condition whose disease pathogenesis is heavily linked to the dysregulation of this immunologic pathway. Interestingly, dupilumab has found broader clinical utility, showing efficacy in treating other distinct dermatologic diseases, including alopecia areata. CASE REPORT A 16-year-old White male with a past medical history of moderate atopic dermatitis presented to our clinic with complete scalp hair, eyebrow, and eyelash loss. At this time, the patient was given a clinical diagnosis of alopecia totalis. Understanding that dupilumab has been previously used for treatment in adults of this specific autoimmune condition, we started this adolescent patient on dupilumab to concomitantly treat his atopic dermatitis and alopecia areata. The patient gradually experienced complete regrowth of his hair and almost complete resolution of his atopic dermatitis. Three years after starting dupilumab, the patient remains without signs of alopecia totalis. CONCLUSIONS This case report demonstrates the long-term efficacy of dupilumab use in alopecia areata. More investigation is required to understand dupilumab's broadening clinical indications. Additionally, this case highlights the complex relationship between dysregulation of the Th2 response and autoimmunity. Crosstalk between immune pathways within the disease spectrum of alopecia areata may explain why dupilumab has been reported to both treat and exacerbate alopecia areata.

Mucinous carcinoma: a translucent blue papule on an 89-year-old man.

An 89-year-old man with no significant medical history presented with a slow-growing, asymptomatic translucent blue mass noticed 1 year prior to evaluation. Review of symptoms was negative for constitutional symptoms, gastrointestinal (GI) disturbance, and visual complaints. Physical evaluation revealed a 4-mm firm light blue translucent papule on the left medial canthus (Figure 1). No cervical or axillary adenopathy was present. No further lesions were identified during full body skin examination, including chest wall masses. A diagnostic study was performed and stained with hematoxylin-eosin (Figure 2) and periodic acid-Schiff (Figure 3).

Multiples in dermatology: markers for special considerations in diagnosis, therapy, and prognosis.

Multiples of certain cutaneous lesions should alert the clinician to a wider differential diagnosis and possible systemic associations although the individual skin lesion is often benign in nature and banal in appearance. This article focuses on such findings in selected multiple cutaneous lesions that may be classified according to the primary cutaneous feature as vascular, pigmentary, nevoid hamartomas, and tumors/neoplastic conditions. The clinical presentation of each entity and its significance, appropriate diagnostic evaluation, therapeutic and prognostic considerations and pertinent differential diagnoses will be reviewed.

Palmar erythema.

Palmar erythema (PE), an often overlooked physical finding, is due to several physiologic or systemic pathologic states. PE can exist as a primary physiologic finding or as a secondary marker of systemic pathology. Primary or physiologic PE can be due to heredity, occurs in at least 30% of pregnant women as a result of associated alterations in the function of the skin and its microvasculature, or may be a diagnosis of exclusion (i.e. idiopathic PE). Secondary PE from systemic pathology encompasses a wide range of disease states. Twenty-three percent of patients with liver cirrhosis, from varying causes, can manifest PE as a result of abnormal serum estradiol levels. Patients with a rare neonatal liver disease such as Wilson disease and hereditary hemochromatosis may exhibit PE along with the other systemic manifestations of the genodermatoses. PE has been reported to occur in >60% of patients with rheumatoid arthritis and is associated with a favorable prognosis. Up to 18% of patients with thyrotoxicosis and 4.1% of patients with diabetes mellitus can have PE. This cutaneous manifestation of diabetes occurs more often than the more classic diseases such as necrobiosis lipoidica diabeticorum (0.6%). PE can be seen in early gestational syphilis and among patients with human T-lymphotrophic virus-1-associated myelopathy. Drug-induced PE with hepatic damage has been documented with use of amiodarone, gemfibrozil, and cholestyramine, while topiramate and albuterol (salbutamol) have been reported to cause PE in the setting of normal liver function. Fifteen percent of patients with both metastatic and primary brain neoplasms may have PE. Increased levels of angiogenic factors and estrogens from solid tumors have been postulated as the cause of PE in such cases. Erythema ab igne can mimic PE, and patients with atopic diathesis are more likely to have PE than matched control subjects. Smoking and chronic mercury poisoning are environmental causes of PE.No treatment of primary PE is indicated. If medication is the cause of PE, the drug responsible should be discontinued if possible. Identification of PE related to underlying disorders should be followed by treatment of the underlying condition. In light of the numerous etiologies of PE, this article reviews the current literature and provides a framework to help guide the clinician in determining the cause of PE in patients presenting with this finding.