Long-Term Efficacy of Tildrakizumab in the Treatment of Psoriasis.

The pathogenesis of psoriasis has been linked to autoimmune and autoinflammatory traits that result in atypical cytokine and keratinocyte activation and proliferation. Many cytokine pathways are involved in the development of inflammation with interleukin-23 (IL-23) playing a significant role in plaque-type psoriasis. Biologic agents that target specific cytokines have shown to be effective therapies in the treatment of plaque-type psoriasis over other conventional treatments such as systemic retinoids. Tildrakizumab is an immunoglobulin G1-kappa monoclonal antibody that inhibits the IL-23/IL-17 pathway and has demonstrated through two three-part randomized Phase 3 clinical trials (reSURFACE 1 and reSURFACE 2) and their extension trials to be an efficacious and safe therapy for the targeted treatment of moderate-to-severe plaque-type psoriasis.

The Use of Silver Oxynitrate Wound Dressings in the Treatment of Chronic Wounds: A Feasibility Pilot Study.

OBJECTIVE: To evaluate the feasibility and effectiveness of a silver oxynitrate (Ag 7 NO 11 ) dressing on wound healing in patients with stalled chronic wounds. METHODS: A prospective pilot study was conducted to determine the feasibility and effect of using silver oxynitrate dressings within an outpatient setting in Alberta, Canada. A total of 23 patients (12 women and 11 men; mean age, 66.1 ± 13.8 years) with a chronic wound that failed to heal with conventional treatment were included in the study. Wound assessments including the Bates-Jensen Wound Assessment Tool, wound-related pain, wound size, and patient quality of life (QoL) were conducted at baseline, after dressing application for 1 and 2 weeks, and during 4- and 12-week follow-ups. RESULTS: Dressing application at 1 and 2 weeks improved patients' wound healing progression as measured through significantly decreased Bates-Jensen Wound Assessment Tool scores with a more than 10% decrease at 4- and 12-week follow-up ( P < .001). Pain ( P = .004), and QoL psyche subscore ( P = .008) significantly improved at 4-week follow-ups, although wound area, perimeter, and QoL body and everyday subscores were not significantly affected. Wound size was not significantly affected. CONCLUSIONS: The silver oxynitrate dressing may improve healing progression in patients with chronic wounds, enhance patient experience by reducing wound-related pain, and improve patients' mental well-being. Further studies are warranted to elucidate the effect of silver oxynitrate dressings on wound area, perimeter, and volume measurements.

Dupilumab for the Treatment of Prurigo Nodularis.

Prurigo nodularis (PN) is a chronic inflammatory skin condition characterized by the presence of pruritic nodules. Dupilumab was approved by the US Food and Drug Administration in September 2022 and Health Canada in July 2023 for the treatment of PN. Dupilumab is a human monoclonal immunoglobulin G4 antibody that binds the interleukin (IL)-4 receptor alpha subunit, blocking intercellular signalling of IL-4 and IL-13. Inhibition of these cytokines downregulates the inflammatory response and improves disease severity and pruritus. Two randomized controlled trials have shown dupilumab to be effective in reducing pruritus and lesion count in patients with PN. The approval of dupilumab for PN represents the first approved therapy for PN and may indicate a paradigm shift in the way this condition is treated.

Mitigating diagnostic performance bias in a skin-tone balanced dermatology curriculum.

INTRODUCTION: Individuals with skin of colour (SoC) have delayed diagnosis and poorer outcomes when presenting with some dermatologic conditions when compared to individuals with light skin (LS). The objective of this study was to determine if diagnostic performance bias can be mitigated by a skin-tone balanced dermatology curriculum. METHODOLOGY: A prospective randomised intervention study occurred over 2 weeks in 2020 at a Canadian medical school. A convenience sample of all first-year medical students (n = 167) was chosen. In week 1, all participants had access to dermatology podcasts and were randomly allocated to receive non-analytic training (NAT; online patient 'cards') on either SoC cases or LS cases. In week 2, all participants received combined training (CT; NAT and analytic training through workshops on how to apply dermatology diagnostic rules for all skin tones). Participating students completed two formative assessments after weeks 1 and 2. RESULTS: Ninety-two students participated in the study. After week 1, both groups had a lower diagnostic performance on SoC (p = 0.0002 and p = 0.002 for students who trained on LS 'cards' and SoC 'cards', respectively). There was a significant decrease in mean skin tone difference in both groups after week 2 (initial training on SoC: 5.8% (SD 12.2) pre, -1.4% (14.7) post, p = 0.007; initial training on LS: 7.8% (15.4) pre, -4.0% (11.8%) post, p = 0.0001). Five students participated in a post-study survey in 2023, and all found the curriculum enhanced their diagnostic skills in SoC. CONCLUSIONS: SoC performance biases of medical students disappeared after CT in a skin tone-balanced dermatology curriculum.

Painless ulceration due to digital hypoperfusion ischaemic syndrome: case report and literature review.

Digital hypoperfusion ischaemic syndrome (DHIS), also known as steal syndrome, is a well recognised serious complication of haemodialysis (HD) access creation. The clinical presentation varies from cyanosis to tissue loss due to necrosis or gangrene. In this article, we present a case of painless digital ulceration due to DHIS and provide a review of the literature. A 40-year-old-female presented with multiple painless digital ulcerations of the left hand. Her medical profile included atherosclerotic disease, hypertension, hyperparathyroidism and type I diabetes causing retinopathy, peripheral neuropathy, gastroparesis and end-stage renal disease (ESRD). Her ESRD required HD with the construction of a left-arm basilic vein transposition arteriovenous fistula (AVF). A year later, she developed intermittent, painless ulcerations of the left hand. A Doppler ultrasound confirmed the diagnosis of DHIS. The patient was treated with AVF ligation surgery. At six months postoperatively, she had near complete re-epithelialisation of her ulcers. This case is unique in that the patient did not have preceding pain, likely due to her underlying diabetic neuropathy. While DHIS in haemodialysis patients with AVF is well documented in literature, digital ulceration in this context is an advanced form of this condition. Early recognition of digital ulceration as a complication of DHIS may enable early intervention and prevent permanent damage.

What Is the Role of Allergic Contact Dermatitis in Patients with Lower Leg Ulcers?

GENERAL PURPOSE: To analyze the relationship between contact dermatitis and delayed wound healing, discuss the diagnosis and treatment of lower leg contact dermatitis, and provide an algorithm for the patient with a red leg and delayed wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Describe the nature of contact dermatitis.2. Distinguish between allergic and irritant contact dermatitis and the other major differential diagnoses of delayed wound healing in this clinical scenario.3. Outline the steps in the diagnosis of allergic contact dermatitis and irritant contact dermatitis and identify common haptens responsible for allergic contact dermatitis in patients with venous leg ulcers.4. Apply the algorithm for delayed wound healing on a background of lower leg dermatitis.

Lower leg ulcers are a common clinical presentation to wound care clinics. They are often associated with the presence of dermatitis on the periwound skin, which can be a factor in delayed wound healing. Correctly diagnosing the underlying etiology is critical to reversing the breakdown in the skin barrier function. The author discusses allergic contact dermatitis as an etiology and describes the most common allergens, fragrances, and preservatives identified from a limited literature review. Patch testing is the criterion standard for the diagnosis of allergic contact dermatitis and is the most appropriate means of identifying causative allergens. An algorithm for the identification and treatment of lower leg dermatitis is provided to simplify the process.

Topical Clascoterone for Acne Vulgaris.

The pathogenesis of acne is multifactorial and involves inflammation, bacterial dysbiosis, and androgen stimulation. Existing systemic therapies target hormonal pathways to mitigate acne lesions; however, their use is limited to the female population and associated with systemic adverse effects. Clascoterone is the first topical therapy to target the hormonal pathogenesis of acne approved to treat acne vulgaris. In two identical phase 3 trials, clascoterone showed favorable efficacy over placebo in treating acne, with higher treatment success and a greater reduction in acne lesions. Large scale trials are required to assess the efficacy of clascoterone against its comparators and in combination with existing acne therapies; however, results from the current phase 3 trials support the therapeutic value of clascoterone, suggesting that this novel topical androgen inhibitor represents a valuable addition to the catalogue of acne therapy.

Compounding crises of social reproduction: Microfinance, over-indebtedness and the COVID-19 pandemic.

The COVID-19 pandemic has hit at a time when microfinance is at its historical peak, with an estimated 139 million microfinance customers globally. Cambodia's microfinance sector is one of the fastest growing, and like others in the Global South has moved from offering entrepreneurial capital to everyday liquidity, and even disaster relief. In this Viewpoint, however, we argue that the promotion of microfinance as market-based relief and recovery from the pandemic should be a source of concern, not comfort. We firstly suggest that as a result of the health and economic impacts associated with COVID-19, credit-taking is likely to escalate further in terms of the number of borrowers and loan amounts. Second, we contend that a growing reliance on MFIs will leave households undernourished, and further vulnerable to its disciplining and extractive impulses. Third, we argue that the interplay between over-indebtedness, pre-existing malnutrition challenges, and the global public health crisis of COVID-19 represents a major challenge to gender equality and sustainable development. Coordination between the Cambodian government, microfinance lenders, international investors, and development partners is vital to offer debt relief. Furthermore, to reverse the reliance of so many households on the microfinance industry for survival, inclusive socio-economic policies and public welfare services must be prioritised.

Dermatologic Training and Practice in Canada: An In-Depth Review [Formula: see text].

As part of an in-depth review of the specialty for the Royal College of Physicians and Surgeons of Canada (RCPSC), the Dermatology Working Group (DWG) was tasked with leading a comprehensive and objective analysis of the current state of Dermatology practice and training patterns in Canada. Preliminary research for the report was conducted in 3 areas: a jurisdictional analysis, a literature review, and a landscape overview. The results of this research were published in the spring 2019 edition of the Journal of Cutaneous Medicine and Surgery. Various factors impacting the discipline were explored, including trends in the workforce, population needs, accessibility, and wait times, as well as issues in undergraduate and postgraduate medical education. The DWG, supported by the RCPSC's Office of Specialty Education, used information gained from the reviews, a national survey, and stakeholder perspectives to develop recommendations that address the current challenges and build upon opportunities for advancement in the specialty.

Effectively Communicating Climate Science beyond Academia: Harnessing the Heterogeneity of Climate Knowledge.

Approaches to communicating climate science beyond academia are necessary for enhancing salience, understanding, and engagement and accelerating action. This Primer discusses the heterogeneous manner in which climate change messaging is received by different audiences, how social scientific approaches could help to better tailor climate change messaging to this varied landscape, and how attempts to close this gap must consider the emotional and affective dimensions of climate messaging. We explore how the use of narratives can enhance effective climate science communication and emphasize the importance of evidence-based advocacy in the current era of global challenges, uncertainty, and post-truth.

Scratching the Surface: A Review of Dermatitis.

GENERAL PURPOSE: To present a case-based review illustrating atopic and contact dermatitis, including management of these conditions using topical and systemic therapies. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Review the prevalence, etiology, and consequences of the various types of dermatitis.2. Describe the clinical manifestations and differential diagnosis of the various types of dermatitis.3. Outline the treatment options for the various types of dermatitis. ABSTRACT: Eczematous reactions such as atopic dermatitis and contact dermatitis are prevalent worldwide. Despite contrasting pathophysiology, the diagnosis and management of these dermatitides can be challenging for healthcare providers. Differences in the distribution of the affected areas, duration of onset, and associated symptoms may help to distinguish these conditions. Diagnosis of the respective conditions is useful in developing appropriate management plans. Herein, the authors present a case-based review illustrating these different disease entities. Management of these conditions, including the use of topical and systemic therapies, is discussed.

Does self-modulated learning vs. algorithm-regulated learning of dermatology morphology affect learning efficiency of medical students?

BACKGROUND: Deliberate practice is an important method of skill acquisition and is under-utilized in dermatology training. We delivered a dermatologic morphology training module with immediate feedback for first year medical students. Our goal was to determine whether there are differences in accuracy and learning efficiency between self- regulated and algorithm-regulated groups. METHODS: First year medical students at the University of Calgary completed a dermatologic morphology module. We randomly assigned them to either a self-regulated arm (students removed cases from the practice pool at their discretion) or an algorithm-regulated arm (an algorithm determined when a case would be removed). We then administered a pre-survey, pre-test, post-test, and post-survey. Data collected included mean diagnostic accuracy of the practice sessions and tests, and the time spent practicing. The surveys assessed demographic data and student satisfaction. RESULTS: Students in the algorithm-regulated arm completed more cases than the self-regulated arm (52.9 vs. 29.3, p<0.001) and spent twice as much time completing the module than the self-regulated participants (34.3 vs. 17.0 min., p<0.001). Mean scores were equivalent between the algorithm- and self-regulated groups for the pre-test (63% vs. 66%, n = 54) and post-test (90% vs. 86%, n = 10), respectively. Both arms demonstrated statistically significant improvement in the post-test. CONCLUSION: Both the self-regulated and algorithm-regulated arms improved at post-test. Students spent significantly less time practicing in the self-directed arm, suggesting it was more efficient.

Diagnosis and Management of Cutaneous Tinea Infections.

GENERAL PURPOSE: To provide information about the epidemiology, clinical features, and management of cutaneous tinea infections. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to:1. Summarize the epidemiology related to cutaneous tinea infections.2. Describe the clinical features of cutaneous tinea infections.3. Identify features related to the diagnosis and management of cutaneous tinea infections. ABSTRACT: Dermatophyte or tinea infection refers to a group of superficial fungal infections of the hair, skin, and nails. Tinea infections are most commonly caused by fungi of the genus Trichophyton, Microsporum, or Epidermophyton. Cutaneous manifestations of tinea infections are seen worldwide and classified based on the affected body site. The diagnosis of these conditions is complicated by morphologic variations in presentation and overlap with other common infectious and noninfectious entities. As a result, diagnosis and appropriate management of these conditions are essential to avoid patient morbidity. This case-based review summarizes the epidemiology, relevant clinical features, microbiology, and management considerations for commonly encountered tinea infections.

Dermatologic Training and Practice in Canada: A Historical Overview.

The specialty of dermatology is constantly changing to meet the medical needs of our society. The discipline is in flux because of a variety of factors such as growing population needs, technological advancements, fiscal restraint, and demographic changes. As part of an in-depth review of the specialty, the Dermatology Working Group (DWG) for the Royal College of Physicians and Surgeons of Canada sought to determine whether the current training configuration is suitably preparing graduates to meet the societal health needs of dermatology patients. In this first of a 2-part series, the authors conducted comprehensive literature and historical reviews and a jurisdictional analysis to understand the current state of dermatology practice in Canada. Herein, they explore trends in the dermatology workforce, population needs, accessibility, and wait times, as well as issues in undergraduate and postgraduate medical education. In a subsequent publication, the DWG will utilize information gained from this historical analysis and jurisdictional review, stakeholder perspectives, and a national survey to shape the future of dermatology training in Canada.

Assessment of a Bidirectional Association Between Major Depressive Disorder and Alopecia Areata.

Importance: Alopecia areata (AA) is an autoimmune disease characterized by hair loss that can impose a substantial psychological burden on patients, including major depressive disorder (MDD), yet many patients report mental health symptoms prior to the onset of AA. As such, there may be an association between MDD and AA that acts in both directions. Objective: To assess the bidirectional association between MDD and AA. Design, Setting, and Participants: This population-based retrospective cohort study included patients 10 to 90 years of age registered with The Health Improvement Network in general practices in the United Kingdom between January 1, 1986, and May 16, 2012. Statistical analysis was conducted from August 17, 2017, to April 23, 2018. To assess the risk of AA, the following 2 cohorts were defined: patients with an incident diagnosis of MDD (exposure) and a reference general population cohort. To assess the risk of MDD, the following 2 cohorts were defined: patients with an incident diagnosis of AA (exposure) and a reference general population cohort. Person-time was partitioned into unexposed and exposed time in the exposure cohorts. Main Outcomes and Measures: In the analysis of the risk of AA, development of incident AA during follow-up was considered the main outcome measure. In the analysis of the risk of MDD, development of incident MDD during follow-up was considered the primary outcome measure. Results: In the analysis of the risk of AA, 405 339 patients who developed MDD (263 916 women and 141 423 men; median age, 36.7 years [interquartile range, 26.6-50.5 years]) and 5 738 596 patients who did not develop MDD (2 912 201 women and 2 826 395 men; median age, 35.8 years [interquartile range, 25.3-52.6 years]) were followed up for 26 years. After adjustment for covariates, MDD was found to increase the risk of subsequently developing AA by 90% (hazard ratio, 1.90; 95% CI, 1.67-2.15; P < .001). Antidepressants demonstrated a protective effect on the risk of AA (hazard ratio, 0.57; 95% CI, 0.53-0.62; P < .001). In the analysis of the risk of MDD, 6861 patients who developed AA (3846 women and 3015 men; median age, 31.5 years [interquartile range, 18.2 years]) and 6 137 342 patients who did not develop AA (3 172 371 women and 2 964 971 men; median age, 35.9 years [interquartile range, 27.0 years]) were followed up for 26 years. After adjustment for covariates, AA was found to increase the risk of subsequently developing MDD by 34% (hazard ratio, 1.34; 95% CI, 1.23-1.46; P < .001). Conclusions and Relevance: These temporal analyses suggest that, while patients with AA are at risk for subsequently developing MDD, having MDD also appears to be a significant risk factor for development of AA, with antidepressant use confounding this risk.

Facial Involvement in Dermatitis Herpetiformis: A Case Report and Review of the Literature.

Dermatitis herpetiformis is a cutaneous manifestation of celiac disease that classically presents as a symmetric pruritic vesicular eruption on extensor surfaces. Typical locations include elbows, knees, and buttocks. Facial involvement has been reported rarely. Here, we report a case of a 44-year-old woman with dermatitis herpetiformis presenting as pruritic vesicles on the face that had previously been misdiagnosed as allergic contact dermatitis. Diagnosis was confirmed with direct immunofluorescence demonstrating granular IgA in the papillary dermis. This eruption cleared with topical dapsone 5% gel and a gluten-free diet. We report this case to raise awareness of facial involvement in dermatitis herpetiformis as well as the possibility of topical dapsone as a therapeutic option.

Vitiligo and major depressive disorder: A bidirectional population-based cohort study.

BACKGROUND: Vitiligo patients often report their mental health has an effect on their skin. However, it is unknown as to whether a common mental disorder, such as major depressive disorder (MDD), can also precipitate the onset of vitiligo. OBJECTIVE: Evaluate a bidirectional relationship between MDD and vitiligo using The Health Improvement Network database. METHODS: Incident MDD and referent cohorts were followed until the development of vitiligo. Also, incident vitiligo and referent cohorts were followed until the development of MDD. Cox proportional hazards models were used, and numerous covariates were adjusted for. RESULTS: In adjusted models, MDD patients (n = 405,397) were at a 64% increased risk for vitiligo (hazard ratio 1.64, 95% confidence interval [CI] 1.43-1.87, P < .0001) compared with the referent cohort (n = 5,739,048). This risk was decreased in patients using antidepressants. Compared with the referent cohort (n = 6,137,696), patients with vitiligo (n = 7104) that were <30 years of age at diagnosis had a higher risk of developing MDD than patients ≥30 years of age (hazard ratio 1.31, 95% CI 1.14-1.50, P < .0001 vs 1.22, 95% CI 1.08-1.37, P = .001, respectively). LIMITATIONS: This study did not evaluate the severity of MDD or vitiligo on outcome development. CONCLUSION: These results highlight the burden of depression in patients with vitiligo and support the possible existence of pathophysiological connections between these 2 conditions.