Hardening of the skin of the trunk and upper extremities without Raynaud’s phenomenon — a quiz

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Pokrzywkowe zapalenie naczyń z hipokomplementemią — opis przypadku

Hypocomplementemic urticarial vasculitis syndrome (HUVS) is an uncommon small-vessel vasculitis presenting as a chronic urticaria with hypocomplementemia and the presence of anti-C1q autoantibodies. In most patients it is accompanied by a wide variety of extracutaneous manifestations such as arthritis, glomerulonephritis, ocular inflammation and pulmonary disease. We present a case of 49-year-old male with a 3-year history of recurrent urticaria accompanied by arthralgia, myalgia and gastrointestinal symptoms. The additional laboratory assessments revealed the presence of circulating anti-C1q autoantibodies in high titer. Histology of the lesional skin biopsy was consistent with leukocytoclastic vasculitis. The diagnosis of HUVS was confirmed in accordance to the currently adopted criteria. The described case emphasizes the necessity of high clinical suspicion when caring for patients with chronic urticaria and concomitant systemic symptoms.Pokrzywkowe zapalenie naczyń z hipokomplementemią (HUVS, hypocomplementemic urticarial vasculitis syndrome) to rzadko występujące zapalenie drobnych naczyń krwionośnych, którego objawami są przewlekła pokrzywka z hipokomplementemią oraz obecność przeciwciał anty-C1q. U większości chorych występuje również wiele objawów pozaskórnych, takich jak zapalenie stawów, kłębuszkowe zapalenie nerek, zmiany zapalne w obrębie oka i choroby płuc. W pracy przedstawiono przypadek 49-letniego pacjenta, u którego od 3 lat występowały nawracające epizody pokrzywki, którym towarzyszyły bóle stawów i mięśni oraz objawy żołądkowo-jelitowe. W badaniach laboratoryjnychwykazano wysokie miano krążących przeciwciał anty-C1q. Obraz histologiczny bioptatu skóry pobranego w obrębie zmian odpowiadał leukocytoklastycznemu zapaleniu naczyń. Rozpoznanie HUVS potwierdzono na podstawie obowiązujących obecnie kryteriów. Opisany przypadek zwraca uwagę, że przewlekła pokrzywka z objawami ogólnoustrojowymi powinna się wiązać z istotnym podejrzeniem klinicznym

A review of topical corticosteroid sprays for the treatment of inflammatory dermatoses

Background: Topical corticosteroids are available in many vehicles. However, patients' preference for vehicles are variable and could be tailored to maximize patient adherence. Spray vehicles may offer, convenience, and strong efficacy. Methods: A literature review was conducted using keywords: clobetasol, desoximetasone, betamethasone, triamcinolone, corticosteroid, topical, spray, vehicles, treatment, and clinical trial. Results: For moderate-to-severe plaque psoriasis, 87% of subjects achieved an Overall Disease Severity (ODS) Score ≤2 at week two and 78% achieved an ODS ≤1 after four weeks with clobetasol propionate (CP) 0.05% spray compared to 17% and 3% in the control group, respectively (P<0.001). For desoximetasone 0.25% spray, 31%-53% with moderate-to-severe psoriasis achieve Physician's Global Assessment (PGA) score ≤1 at day 28 versus 5%-18% in the vehicle spray group (P<0.01). For betamethasone dipropionate 0.05% spray, 19% with mild-to-moderate plaque psoriasis achieved an Investigator's Global Assessment (IGA) score ≤1 or a 2-grade reduction in IGA versus 2.3% in vehicle group (P≤0.001). For mild-to-severe steroid responsive inflammatory dermatoses, 64% using triamcinolone acetonide 0.2% spray achieved clear or almost clear skin at day 14 (no P value reported). Adverse events including burning, irritation, and dryness were similar across all corticosteroids

Discontinuation of Transmission Precautions for COVID-19 Patients: Polymerase Chain Reaction Diagnostics, Patient Delays, and Cycle Threshold Values

BACKGROUND: The decision of when it is safe to discontinue transmission-based precautions for SARS-CoV-2 coronavirus disease 2019 (COVID-19) hospitalized patients has been controversial. The Centers for Disease Control and Prevention offered reverse transcriptase polymerase chain reaction (PCR) diagnostic test- or symptom-based guidelines. METHODS: A retrospective chart review of Vidant Health system, Eastern North Carolina, was conducted. Length of stay, days in isolation unit, and date appropriate for discharge or isolation discontinuation based on the symptom-based strategy were recorded. RESULTS: Of 196 COVID hospitalized patients, 34 had repeated COVID PCR tests 3 or more days from their first positive test result. Half of these patients experienced delays in release from transmission-based precautions because of repeated positive PCR test results and use of the test-based approach. This resulted in an additional 166 days of hospitalization, costing an estimated $415,000. Furthermore, 2 subjects had a combined 16-day delay in necessary medical procedures. Most of the COVID PCR platforms yield quantitative results in the form of cycle threshold (Ct) values, the number of cycles needed to detect the genome. These values have also been used to assess whether patients are likely to remain contagious. None of our patients who met the criteria for symptom-based strategy for transmission-based precaution discontinuation had positive PCR test results with Ct values lower than 25, but 4 had Ct values lower than 30. CONCLUSIONS: Concerns surround immunocompromised patients and those treated with steroids who might be delayed or incapable of stopping viral replication and thus remain contagious. Our results suggest that clinicians use all available data including Ct values to evaluate the safety of discontinuation of transmission precautions

Diet and psoriasis

Background: Patients with psoriasis have a growing interest in managing their disease through diet.Objective: This review paper aims to analyze dietary interventions for psoriasis and their outcome.Methods: Terms "psoriasis AND diet" were used to search PubMed database and 63 articles describing dietary changes influencing psoriasis were selected.Results: Low calorie diet (LCD) improves Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) in conjunction with topical or systemic therapy, although LCD was unsuccessful in maintaining disease remission when patients discontinued concomitant cyclosporine or methotrexate therapy. A fish oil diet improved baseline PASI of 7.7 to 5.3 at three months and 2.6 at 6 months compared to control (PASI: 8.9, 7.8, and 7.8, respectively). A randomized, double-blind, placebo-controlled study investigating selenium supplementation in psoriasis provided no PASI improvement. Zinc supplementation with concomitant betamethasone valerate 0.0025% ointment in a randomized, double-blind, placebo-controlled study provided a mean PASI of 11.2 in the intervention group and 8.0 in the control group with no significant difference between both arms. Gluten free diet and vitamin D supplementation were also efficacious dietary changes although results were mixed.Conclusions: Dietary changes alone do not cause a large effect in psoriasis but may become an important adjunct to current first line treatments

Diet and psoriasis

Background: Patients with psoriasis have a growing interest in managing their disease through diet.Objective: This review paper aims to analyze dietary interventions for psoriasis and their outcome.Methods: Terms "psoriasis AND diet" were used to search PubMed database and 63 articles describing dietary changes influencing psoriasis were selected.Results: Low calorie diet (LCD) improves Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) in conjunction with topical or systemic therapy, although LCD was unsuccessful in maintaining disease remission when patients discontinued concomitant cyclosporine or methotrexate therapy. A fish oil diet improved baseline PASI of 7.7 to 5.3 at three months and 2.6 at 6 months compared to control (PASI: 8.9, 7.8, and 7.8, respectively). A randomized, double-blind, placebo-controlled study investigating selenium supplementation in psoriasis provided no PASI improvement. Zinc supplementation with concomitant betamethasone valerate 0.0025% ointment in a randomized, double-blind, placebo-controlled study provided a mean PASI of 11.2 in the intervention group and 8.0 in the control group with no significant difference between both arms. Gluten free diet and vitamin D supplementation were also efficacious dietary changes although results were mixed.Conclusions: Dietary changes alone do not cause a large effect in psoriasis but may become an important adjunct to current first line treatments

Review of the use of gentian violet in dermatology practice

Objective: To review the use of gentian violet in dermatology. Design: A comprehensive literature search on gentian violet in dermatology practice was performed through PubMed. Results: Gentian violet is effective in treating methicillin-resistant Staphylococcus aureus-colonized skin lesions; mean number of days for complete eradication was 9.1 days. Gentian violet is almost as effective as ketoconazole and more effective than nystatin in the treatment of oral thrush in AIDS patients. In an in vitro study on cutaneous T cell lymphoma cell lines, there was no difference between nitrogen mustard and gentian violet in stimulating apoptosis. When comparing gentian violet to silver sulfadiazine dressings in healing burn wounds, the gentian violet treatment group reported less pain, fewer febrile episodes, and decreased bacterial growth compared to control. In atopic dermatitis subjects, gentian violet decreased Staphylococcus aureus colonization and improved disease severity in lesional skin compared to non-lesional skin. Conclusion: Studies have investigated gentian violet's antibacterial, antifungal, antiviral, antiparasitic, anti-angiogenic, antitumor, and wound healing properties. Gentian violet is a low cost and well-tolerated topical agent with the potential for widespread applications in dermatology

Scented lotions may cause scaring and premature fading of tattoos

Although tattoo artists provide tattoo aftercare instructions to their clients, recommendations are often not cost-effective or supported by evidence. A 22-year-old man developed a pruritic red rash over his healing tattoo one week after receiving the tattoo. Although multiple queries were negative, the patient did note use of a scented lotion before the eruption. We determined that allergic contact dermatitis from the scented lotion caused scarring and premature fading of the new tattoo. Tattoo artists should recommend avoidance of scented lotions and instruct clients to care for their new tattoo like a wound in their aftercare instructions

The ethical foundation for honesty and the focused use of deception in dermatology

Physicians have a fiduciary duty to be honest and to act in the patients' best interest. There are times when these two duties conflict. Honesty is paramount in supporting the physician-patient relationship and loss of patient trust is devastating. Furthermore, even minor deception can suggest a return to the physician authoritarianism of the past century that has been decried by modern ethicists. Nonetheless, circumstances can arise in which good judgement may require less than complete honesty to avoid harm to the patient. If the benefit for the patient is large and the risk from deception is small, thoughtful application of minor deception could be designed to benefit patients. Of course, research is required to fully assess this strategy