Sunscreens in the United States: Current Status and Future Outlook.

Incidence rates of nonmelanoma skin cancer and melanoma have been on the rise in the USA for the past 25 years. UV radiation (UVR) exposure remains the most preventable environmental risk factor for these cancers. Aside from sun avoidance, sunscreens continue to provide the best alternative protection. UVR directly damages DNA and causes indirect cellular damage through the creation of reactive oxygen species, the sum of which leads to cutaneous immunosuppression and a tumorigenic milieu. The current generation of sunscreens protect from UVR through two main mechanisms: absorption and deflection. In the USA, the Food and Drug Association (FDA) regulates sunscreen products which are considered over-the-counter drugs. With the release of new FDA testing and labeling requirements in 2011 and the enactment of the Sunscreen Innovation Act in 2014, sunscreen manufacturers are now required to evaluate their products not only on the sun protection factor (SPF) but also on broad-spectrum UVA protection. The American Academy of Dermatology Association and the American Academy of Pediatrics have provided specific recommendations for proper sun protection and sunscreen usage with the continual goal of increasing public awareness and compliance with appropriate sun protective measures. Antioxidants, photolyases, and plant polyphenols remain an interesting avenue of research as additives to sunscreens or stand-alone topical or oral products that appear to modulate the immunosuppressive effects of UVR on the skin. Additionally, although UVR induces endogenous cutaneous production of vitamin D, its damaging effects overshadow this positive benefit, especially in light of the ease of achieving recommended amounts of vitamin D through diet and supplementation.

Pyoderma Gangrenosum: A Review for the Gastroenterologist.

Pyoderma gangrenosum (PG) is a rare ulcerative skin disease of unknown etiology often associated with systemic inflammatory conditions, most commonly inflammatory bowel disease (IBD). The most common presentation of PG is spontaneous rapid formation of an extremely painful ulcer on the extremities, associated with significant morbidity and mortality. Rarely, PG can also occur as a chronic peristomal complication or as an acute postoperative complication of a surgical wound. The clinical course is unpredictable; it may not correlate with IBD activity and may even precede a diagnosis of IBD. Pyoderma gangrenosum is a diagnosis of exclusion. Treatment is challenging, often involving a variety of immunosuppressive therapies. This review aims to provide an update for the gastroenterologist on the pathogenesis, presentation, diagnosis, and management of PG, a rare complication of IBD.

Bedbugs: Helping your patient through an infestation.

Bedbugs--hematophagous parasitic arthropods of the genus Cimex--have been unwelcome bedfellows for humans for thousands of years. With increases in population density, ease of travel, and insecticide resistance, bedbugs have reemerged. As a result, physicians are often at the forefront in the diagnosis and treatment of bedbug infestation. This review summarizes the biology and epidemiology of bedbugs and provides details on the diagnosis and treatment of bedbug infestation.

Got the Travel Bug? A Review of Common Infections, Infestations, Bites, and Stings Among Returning Travelers.

The popularity of international travel continues to increase among Americans, even though they often experience subsequent illness on return from their journey. The pathogens responsible are not necessarily endemic to the destination itself but are often the result of poor sanitary conditions or activities engaged in while away. Skin disease ranks third among all medical concerns in returning travelers. This review addresses the pathogenesis, epidemiology, clinical presentation, and treatment of the most common skin diseases in returning travelers: insect bites and bedbugs, cutaneous larva migrans, scabies, tungiasis, myiasis, leishmaniasis, viral exanthems, and marine envenomation. Primary care physicians and dermatologists should be familiar with these illnesses and a general approach to their evaluation and management.

Granulomatous disease associated with NOD2 sequence variants and familial camptodactyly: An intermediate form of NOD2-associated diseases?

OBJECTIVE: Nucleotide-binding oligomerization domain-containing protein-2 (NOD2)-associated diseases may be a spectrum of disease. We report two families who exhibited an intermediate form of Blau syndrome and NOD2-associated autoinflammatory disease (NAID). METHODS: We identified two families with granulomatous disease. The clinical phenotypes and genotypes of these two families were reviewed and analyzed. RESULTS: The proband in family 1 was a white 57-year-old woman, with camptodactyly (age 6 years), inflammatory polyarthritis and dermatitis (age of 30 years), and cough, dyspnea, dry eyes, parotid gland enlargement, and fever. A computerized tomography showed mediastinal lymphadenopathy without hilar involvement, and a mediastinal lymph node biopsy revealed non-caseating granuloma. Pedigree analysis suggested autosomal dominant inheritance, and genetic testing identified a NOD2 sequence variant IVS8(+158). The proband in family 2 was a white 50-year-old woman with inflammatory polyarthritis and periarticular subcutaneous nodules. Skin biopsy showed non-necrotizing granuloma. There was a family history of camptodactyly, and genetic testing identified a NOD2 sequence variant R703C. CONCLUSIONS: Both probands had granulomatous disease and autosomal dominant phenotype of familial camptodactyly coupled with the presence of the NOD2 sequence variants, IVS8(+158), and R703C. Granulomatous disease associated with NOD2 variants may be an intermediate form between Blau syndrome and NAID.

Pyoderma gangrenosum: A review

BACKGROUND: Pyoderma gangrenosum (PG) is an uncommon neutrophilic dermatosis typically characterized by painful cutaneous ulceration's with hermorrhagic and purulent crust. PG has several different variants that often delay correct diagnosis. Clinical appearance and histopathology should suggest the diagnosis and exclude other diseases with similar ulceration's. The course of the disease is variable, often chronic, and occasionally severe and progressive. PG is frequently associated with other inflammatory diseases, most often inflammatory bowel disease and rheumatoid arthritis. Management can be challenging, with immunosuppression as the mainstay of treatment.

Sunscreens in the United States: current status and future outlook.

Incidence rates of nonmelanoma skin cancer and melanoma has been on the rise in the United States for the past 20 years. UV radiation (UVR) exposure remains the most preventable environmental risk factor for these cancers. Aside from sun avoidance, sunscreens remain our best protection. UVR directly damages DNA and cause indirect cellular damage through the creation of reactive oxygen species, the sum of which leads to cutaneous immunosuppression and a tumorigenic milieu. The current generation of sunscreens protect from UVR through two main mechanisms: absorption and deflection. In the US, new Food and Drug Association rules require sunscreen manufacturers to evaluate their products not only on sun protection factor but also on broad spectrum UVA protection by the end of 2013. New labeling requirements will also be instituted. The American Academy of Dermatology and the American Academy of Pediatrics have provided specific recommendations for proper sun protection and sunscreen usage. Plant polyphenols such as those isolated from green tea, pomegranate, and grape seed remain an interesting avenue of research as additives to sunscreens or stand-alone products that appear to modulate the immunosuppressive effects of UVR on the skin. Additionally, although UVR induces endogenous cutaneous production of vitamin D, its damaging effects overshadow this positive benefit, especially in light of the ease of achieving recommended amounts of vitamin D through diet and supplementation.

Tropical dermatology: cutaneous larva migrans, gnathostomiasis, cutaneous amebiasis and trombiculiasis.

In today's world, many people can travel easily and quickly around the globe. Most travel travel-related illnesses include fever, diarrhea, and skin disease, which are relatively uncommon in returning travelers. We review four of the most common emerging infestations and skin infections in the Americas, which are important to the clinical dermatologist, focusing on the clinical presentation and treatment of cutaneous larva migrans, gnathostomiasis, cutaneous amebiasis, and trombiculiasis.

Selected skin diseases with systemic involvement.

The skin is often a window to systemic disease that is available to the trained eye of the dermatologist. Herein, we focus on four dermatoses with associated systemic conditions of interest: scleromyxedema and monoclonal gammopathy, nephrogenic systemic fibrosis in the setting of renal insufficiency, dermatitis herpetiformis and celiac disease, and psoriasis as a risk factor for cardiovascular disease. Dermatologists can play a crucial role in recognizing the cutaneous manifestations linked with these conditions. Identifying the related underlying disorder will contribute to appropriate diagnosis and improved management.

Dermatitis as a characteristic phenotype of a new autoinflammatory disease associated with NOD2 mutations.

OBJECTIVES: We sought to characterize a new category of autoinflammatory disease associated with nucleotide-binding oligomerization domain 2 (NOD2) gene mutations. METHODS: A total of 22 patients were identified, inclusive of those reported previously. All had autoinflammatory phenotypes and NOD2 gene mutations that were prospectively studied between January 2009 and February 2012. RESULTS: All 22 patients were non-Jewish whites (13 women and 9 men). The mean age at diagnosis was 40.1 years (range 17-72), with a mean disease duration of 4.7 years (range 1-13). Three female patients were siblings. Common clinical features were weight loss (13/22), episodic self-limiting fever (13/22), dermatitis (19/22), and inflammatory polyarthritis/polyarthralgia (20/22). Gastrointestinal symptoms occurred in 13 patients, sicca-like symptoms in 9, and recurrent chest pain in 5. All patients carried the NOD2 gene mutations, with the intervening sequence 8(+158) variant in 21 and the R702W variant in 8. LIMITATIONS: The NOD2 allelic frequency may need to be examined in a larger population with systemic autoimmune diseases. CONCLUSIONS: The characteristic clinical phenotype, notably dermatitis, coupled with certain NOD2 variants constitutes a new autoinflammatory disease entity, which we have named as NOD2-associated autoinflammatory disease.

Distinguishing cellulitis from its mimics.

Distinguishing true cellulitis from its many imitators is challenging but critical if we are to avoid unnecessary use of antibiotics and delays in treatment. Common imitators of cellulitis are stasis dermatitis, lipodermatosclerosis, contact dermatitis, lymphedema, eosinophilic cellulitis, and papular urticaria. Specific criteria do not exist for the diagnosis of cellulitis, but the alert physician can find clues in the history and physical examination that point toward cellulitis.

UV protection and sunscreens: what to tell patients.

Ultraviolet (UV) radiation is the major environmental risk factor for nonmelanoma skin cancer and is a suspected risk factor for melanoma. Avoiding overexposure to direct sunlight during the peak daylight hours, wearing protective clothing, and applying sunscreen are ways to protect the skin. To provide clinicians with the tools to advise patients and to answer their inquiries, including which sunscreen to use, we review UV radiation's effect on the skin, how sunscreens block UV light, current recommendations on sunscreen use, and new sunscreen labeling requirements.

Novel systemic antibiotics in dermatology.

The treatment of bacterial skin infections has become challenging with the evolution of resistant species. As common antibiotics are losing efficacy, there is a pressing need for the discovery of new antibacterial agents. Only several systemic antibiotics have been approved for the treatment of skin infections in recent years. The expanding repertoire includes novel compounds structurally based on existing antibiotic classes, such as the glycopeptides, cephalosporins, and glycylcyclines. Antibiotics with completely unique mechanisms of action are being developed as members of the lipoprotein, oxazolidonone, and streptogramin classes. Most of these drugs require intravenous administration that limits their use. Future development should focus on more accessible routes of antibiotic administration, including oral, inhaled, or transdermal formulations.

Tumor necrosis factor receptor associated periodic fever syndrome with photographic evidence of various skin disease and unusual phenotypes: case report and literature review.

OBJECTIVES: To report a case of tumor necrosis factor receptor associated periodic fever syndrome (TRAPS) with unusual clinical phenotypes and a systematic review. METHODS: The relevant English literature of TRAPS was searched using the keywords TRAPS, autoinflammatory disease, and gene mutation. Original and review articles were reviewed and the clinical scenarios were exemplified with a case report. RESULTS: A 58-year-old Jewish woman with Eastern European Ashkenazic background presented with photographic evidence of various skin disease, including previously unreported vesicles and alopecia, as well as other systemic manifestations. The complaints of urinary foreign bodies prompted a discovery of ureteral strictures with atypia perhaps from autoinflammation. A R92Q gene mutation of TNFRSFA1 was detected. The clinical manifestations of this disease are protean and its pathogenesis is complex, involving the interaction of wild-type and mutated gene products, innate immune system, and proinflammatory cytokines. Glucocorticoid and anticytokine therapy is generally efficacious but some cases remain refractory to the current treatment. CONCLUSIONS: TRAPS is a systemic autoinflammatory disease with variable clinical phenotypes associated with gene mutations. Recognition of the unusual phenotypes may enhance early accurate diagnosis.

Coexistent tumor necrosis factor receptor-associated periodic fever syndrome and Ehlers-Danlos syndrome.

A 32-year-old Caucasian woman had periodic fevers, skin disease, polyarthralgia and hypermobile joints that were consistent with tumor necrosis factor receptor-associated periodic fever syndrome confirmed with a finding of R92Q missense mutation of the TNFRSFA1 gene with Ehlers-Danlos hypermobility type syndrome. They are both autosomal dominant disorders, and their coexistence suggests that they could share some phenotypic features that may require special consideration in management. Conceivably, they could share common gene mutations although no such data are available.

Cutaneous infections and infestations: new therapies.

Directed and preventive therapies for cutaneous infectious disease and infestation continue to evolve, providing physicians with new options for care. Common infectious diseases (e.g., genital herpes, herpes zoster, and head lice) occur in the outpatient and inpatient setting. This review of the literature highlights new therapies, including those still in development, such as novel drugs and vaccines, all of which should help to decrease the frequency and severity of common infectious diseases of the skin and subcutaneous tissues.

Innovative management of recurrent furunculosis.

One of the most common bacterial infections of the skin and soft tissue is furunculosis (boil), an inflammatory nodule that involves the hair follicle, with small abscess formation extending through the dermis into the subcutaneous layers. Treatment of recurrent furunculosis is a difficult and challenging process. The mainstay of therapy is incision and drainage of a furuncle coupled with bacterial culture. Affected patients and their family members must practice good hygiene, predicated with regular hand washing, fomite cleaning, and avoiding contact with contaminated skin.