Exploring the Quality-of-Life Impact, Disease Burden, and Management Challenges of GPP: The Provider and Patient Perspective [Podcast]

Generalized pustular psoriasis (GPP) is a rare, chronic, and debilitating disease characterized by flares of widespread erythema, desquamation, and pustule formation. GPP flares can be accompanied by systemic symptoms including fever, fatigue, malaise, and skin pain; severe cases may be fatal if untreated. Although GPP may occur concurrently with plaque psoriasis, they represent two distinct inflammatory conditions. Patients with GPP experience a substantial burden of disease, and the impact of GPP on an individual's mental health and quality-of-life (QoL) goes far beyond skin pain and discomfort. The rarity of GPP may result in a misdiagnosis, as the sudden onset of skin pustules may be mistaken for a primary infection. Misdiagnosis with a subsequent delay in treatment has tremendous negative consequences for the affected patient. In September 2022, spesolimab became the first FDA-approved medication in the US for the treatment of GPP flares in adults. Spesolimab has since been approved by regulatory agencies in numerous countries, including Japan, Mainland China, and the EU. Prior to spesolimab, the clinical management of GPP relied on the off-label use of systemic or biologic therapies approved for plaque psoriasis or other inflammatory conditions. There is a need for increased education among healthcare providers regarding the clinical diagnosis, risk stratification, and therapeutic management of this rare disease, including the other novel GPP-specific therapies in development. In this podcast, two dermatologists and a patient who has plaque psoriasis and GPP discuss the clinical presentation, symptoms, disease burden, QoL impacts, diagnostic challenges, and therapeutic strategies for the management of GPP.

Impetigo herpetiformis: A rare pregnancy-specific dermatosis

Impetigo herpetiformis (IH) is a pregnancy-specific dermatosis that is currently considered a form of generalised pustular psoriasis and mainly occurs in late pregnancy during the third trimester. IH presents as erythematous patches and pustules and might have systemic involvement. The disease may be associated with severe maternal, fetal, and neonatal complications. IH treatment is very challenging, however, various therapeutic options are available and effective for disease treatment.

Monkeypox outbreak in Genoa, Italy: Clinical, laboratory, histopathologic features, management, and outcome of the infected patients

Since May 2022, multiple human Monkeypox cases were identified in nonendemic countries, mainly among men who have sex with men. We aimed to report the features, clinical course, management, and outcome of the Monkeypox cases diagnosed in the Dermatology and Infectious Disease Units of the San Martino Hospital, Genoa, Italy. We performed an observational study of the Monkeypox cases diagnosed from July 1 until August 31, 2022, collecting clinical, laboratory, and histological data. We studied 16 Monkeypox-infected men (14 homosexual, 2 bisexual) with a median age of 37 years. Three were HIV-infected. All patients reported multiple sexual partners and/or unprotected sex in the 2 weeks before the diagnosis. Most patients had prodromal signs/symptoms before the appearance of the skin/mucosal eruption, consisting of erythematous papules/vesicles/pustules in the anogenital area, which tended to erode evolving into crusts and ulcers. Lesions were often associated with local and/or systemic symptoms. Histopathology showed overlapping features in all cases: epidermal ulceration and dermal inflammatory infiltrate consisting of lymphocytes and neutrophils with an interstitial and perivascular/peri-adnexal pattern and endothelial swelling. Concomitant sexually transmitted infections (STIs) (gonococcal/nongonococcal proctitis and anal high-risk human papillomavirus [HR-HPV] infection) were frequent. Four patients were hospitalized, and one received specific treatment. The overall outcome was good. At the follow-up visit, three patients presented skin scars. Our series confirms the features of the current Monkeypox outbreak; however, different from other studies, we found a considerable rate of concomitant STIs, such as anal HR-HPV infection, that should be kept in mind because this persistent infection is the main cause of anal cancers.

Acute Localized Exanthematous Pustulosis (ALEP) Caused by Topical Application of Minoxidil

Acute Localized Exanthematous Pustulosis (ALEP) is a rare skin reaction characterized by the sudden onset of multiple, small, sterile, non-follicular pustules in an erythematous and edematous base succeeding systemic drug administration. ALEP is considered a subtype of Acute Generalized Exanthematous Pustulosis (AGEP), although the exact pathogenic mechanism of the disease remains poorly defined. Numerous drugs have been implicated in the pathogenesis of ALEP, while contact mechanisms have also been reported. Herein, we describe the first case of ALEP attributed to minoxidil in a female patient with androgenetic alopecia. The positivity of patch tests and the topical application of minoxidil proposes a contact-induced hypersensitivity reaction. Identifying new agents-including minoxidil-which serve as inducers of drug-specific T-cell-mediated responses in the clinical spectrum of ALEP, adds further value in understanding the complex, yet unknown, pathophysiological mechanisms of this rare drug hypersensitivity reaction.

Clinical features, diagnosis and management of cephalosporin-induced acute generalized exanthematous pustulosis

WHAT IS KNOWN AND OBJECTIVE

Acute generalized exanthematous pustulosis (AGEP) is a serious and rare adverse reaction of cephalosporins. We aimed to describe the clinical features of cephalosporin-induced AGEP and provide a reference for rational clinical use of cephalosporins.

METHODS

We systematically searched Chinese and English databases for cephalosporin-induced TGEP-related case reports, retrospective studies, clinical studies, and review articles published before May 2022.

RESULTS AND DISCUSSION

A total of 43 patients from 35 articles were eligible, of which 28 (65.1%) were female, with a median age of 69 years. A total of 11 cephalosporins were suspected, the most commonly involved were ceftriaxone (41.9%), cephalexin (16.3%), and cefepime (9.3%). AEGP erupted primarily within 14 days after administration, manifested as nonfollicular pustules on an erythematous base, distributed favourably to the extremities (44.2%), trunk (23.3%), face (23.3%), and could involve the oral mucosa (11.6%). During AGEP resolution, the affected area had desquamation (39.5%). The acute phase of the disease may be accompanied by fever (>38.0°C) and elevated neutrophil count (>7500/mm³ ). Histology of AGEP showed subcorneal pustules (56.3%), intraepidermal cavernous pustules (37.5%), with papillary dermal edema (37.5%), containing neutrophils and eosinophilic infiltration (71.9%). After drug discontinuation, the median time to resolution of AGEP symptoms was 10 days (range 2, 90).

WHAT IS NEW AND CONCLUSION

Cephalosporin-induced AGEP is rare and should be properly diagnosed. This serious cutaneous adverse reaction is self-limiting and has a favourable prognosis, usually resolves with drug interruption, and may require additional interventions, such as topical steroids.

Folliculitis Decalvans and Lichen Planopilaris Phenotypic Spectrum: A Case Report

The folliculitis decalvans (FD) and lichen planopilaris (LPP) phenotypic spectrum combines biphasic features of FD and LPP. It is characterized by successive or concomitant occurrence of pustules, crusts, follicular tufts, perifollicular erythema, perifollicular scales, and cicatricial alopecia and includes mixed histologic features of both FD and LPP. Here, we report the case of a 33-year-old female patient with a 30-year history of FD-LPP phenotypic spectrum lesions.

Dermatology: how to manage acne vulgaris

Background

Acne vulgaris is the most common skin disease that can lead to disfigurement and psychological distress. This article aims to provide a narrative updated review on the management of acne vulgaris.

Methods

A PubMed search was performed with Clinical Queries using the key term “acne”. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to articles published in English.

Results

Treatments of acne include proper skin care, topical medications, oral medications and procedural therapies. Topical agents are the first-line treatment for mild-to-moderate acne and can be used as combination therapy for more severe acne. Systemic therapies are usually prescribed for the initial treatment of moderate-to-severe acne as well as for acne that is refractory to topical therapies.

Conclusion

Topical retinoids are the drugs of choice for the treatment and maintenance therapy of patients with mild-to-moderate acne vulgaris. Depending on the severity of the acne, topical retinoids may be used alone or in combination with benzoyl peroxide and topical or oral antibiotics. Oral antibiotics are an important therapy for inflammatory acne unresponsive to topical therapy. Neither topical nor oral antibiotics should be used as monotherapy. Oral contraceptives and/or spironolactone are useful for many women with acne. Oral isotretinoin is the drug of choice for severe, extensive, nodular acne vulgaris but is also often used in moderate cases where scarring is evident, acne-related psychosocial distress is significant or other treatment modalities have failed.

Knowledge about and determinants for diagnosing hidradenitis suppurativa by ministry of health primary healthcare physicians in Jeddah city 2019: An analytical cross-sectional study

Context:

Hidradenitis suppurativa is a noncontagious, inflammatory, chronic and recurrent disease. The prevalence of HS is estimated to be between less than 1 and 4%. It is more common in females than males at a 2:1 ratio. Many cases of HS are either misdiagnosed or remain undiagnosed.

Aims:

To assess knowledge of diagnosing hidradenitis suppurativa by Ministry of Health primary health care physicians in Jeddah city, 2019 and to identify the determinants and knowledge of diagnosing hidradenitis suppurativa.

Settings and Design:

An analytical cross-sectional study conducted in Jeddah city, 2019, among primary health care physicians of the MOH.

Methods and Material:

Estimated sample size was 114. The required primary health care centers were 38 centers. The centers were chosen by a simple random sampling technique. A reliable self-administered questionnaire was used. Ethical approval was obtained.

Statistical Analysis Used:

Descriptive statistics consisted of means, standard deviations, frequency tables, cross tabulation and charts). Categorical variables were compared using the chi–square test to determine significant relationships between variables.

Results:

65.4% (68) diagnosed the disease correctly. Most of their knowledge came from clinical practice (39.4%). There was a significant relationship with current job title and medical degree (P-value < 0.0005).

Conclusion:

The present study showed good knowledge about and ability to diagnose HS. A more advanced medical degree and more years of clinical experience was positively associated with the ability to diagnose HS.

Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee

In 2017, a National Rosacea Society Expert Committee developed and published an updated classification of rosacea to reflect current insights into rosacea pathogenesis, pathophysiology, and management. These developments suggest that a multivariate disease process underlies the various clinical manifestations of the disorder. The new system is consequently based on phenotypes that link to this process, providing clear parameters for research and diagnosis as well as encouraging clinicians to assess and treat the disorder as it may occur in each individual. Meanwhile, a range of therapies has become available for rosacea, and their roles have been increasingly defined in clinical practice as the disorder has become more widely recognized. This update is intended to provide a comprehensive summary of management options, including expert evaluations, to serve as a guide for tailoring treatment and care on an individual basis to achieve optimal patient outcomes.

Facial pustules due to drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms may histopathologically mimic eosinophilic pustular folliculitis: A case report

Pustules with facial and/or neck edema is one characteristic feature of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) at the early stage. Although several retrospective histopathologic studies on DIHS/DRESS have been reported, the detailed histopathologic findings of facial pustules for DIHS/DRESS are unavailable. We herein report a case of DIHS/DRESS with facial pustules that was histopathologically similar to eosinophilic pustular folliculitis (EPF). Eosinophilic infiltration into expanded follicles and sebaceous glands, which is highly characteristic of EPF, was detected in pustules due to DIHS/DRESS in this case. There are numerous pathophysiological similarities between DIHS/DRESS and EPF, which may cause their histopathologic similarity. Our findings suggest that facial pustules of DIHS/DRESS may histopathologically mimic EPF.

Many pustules that itch…

Furuncular myiasis is a cutaneous parasitosis that occurs in tropical regions. It is manifested by lesions with the appearance of pustules, because of the presence of the fly larva in the skin. This misleading appearance can delay diagnosis. The extraction of these Cayor worms can be facilitated by the use of a comedo-extractor.

Folliculitis decalvans: Effectiveness of therapies and prognostic factors in a multicenter series of 60 patients with long-term follow-up

BACKGROUND

Folliculitis decalvans (FD) is a rare neutrophilic cicatricial alopecia that poses a therapeutic challenge.

OBJECTIVES

To describe the therapeutic response in a large number of cases of FD with long-term follow-up and analyze potential prognostic factors associated with severity of form and with a better therapeutic response.

METHODS

This multicenter prospective study included patients with FD who had a minimum of 5 years of follow-up. Severity was assessed by the maximum diameter of the cicatricial area. Therapeutic response was evaluated according to stabilization of the size of the cicatricial areas and the improvement in clinical symptoms.

RESULTS

A total of 60 patients (37 men [61.7%] and 23 women [38.3%]) with a mean age of 40 years were included. Earlier age of onset (P = .01) was statistically associated with severity of form. Treatment with rifampicin and clindamycin, tetracyclines, and intralesional steroids was the most effective. No statistically significant prognostic factors predicting a better therapeutic response were found.

LIMITATIONS

Because FD is a rare disease, the main limitation was the sample size.

CONCLUSIONS

An earlier age of onset was associated with the severe form of the disease. The proposed specific therapeutic protocol can be a very useful tool in clinical dermatologic practice.

Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee

In 2002, the National Rosacea Society assembled an expert committee to develop the first standard classification of rosacea. This original classification was intended to be updated as scientific knowledge and clinical experience increased. Over the last 15 years, significant new insights into rosacea's pathogenesis and pathophysiology have emerged, and the disorder is now widely addressed in clinical practice. Growing knowledge of rosacea's pathophysiology has established that a consistent multivariate disease process underlies the various clinical manifestations of this disorder, and the clinical significance of each of these elements is increasing as more is understood. This review proposes an updated standard classification of rosacea that is based on phenotypes linked to our increased understanding of disease pathophysiology. This updated classification is intended to provide clearer parameters to conduct investigations, guide diagnosis, and improve treatment.

Rosacea: a Clinical Review

Rosacea is a field within dermatology with new insight within immunological research and new treatment-algorithm. Patient education on rosacea and appropriate treatments is an important aspect in helping patients succeed with therapy. Treatment should be tailored to each individual patient, taking into account: symptoms, trigger factors, patients' wishes, most bothersome symptoms, psychological aspect, individual needs. A combination of clinical therapies to treat different symptoms concomitantly may offer the best possible outcomes for the patient. In this review article we describe these aspects.

Acute generalized exanthematous pustulosis (AGEP): A review and update

Acute generalized exanthematous pustulosis is a severe cutaneous adverse reaction characterized by the rapid development of nonfollicular, sterile pustules on an erythematous base. It is attributed to drugs in the majority of cases. Antibiotics are the most common cause of acute generalized exanthematous pustulosis; however, a wide variety of drugs has been associated with this condition. Typically, within 48 hours of ingesting the causative medication, there is acute onset of fever and pustulosis with leukocytosis. In severe cases there can be mucous membrane and systemic organ involvement. Histologic findings include intracorneal, subcorneal, and/or intraepidermal pustules with papillary dermal edema containing neutrophils and eosinophils. Treatment focuses on removal of the causative drug, supportive care, infection prevention, and the often beneficial use of a potent topical steroid.

Medical history of the representation of rosacea in the 19th century

Throughout the 1800s, clinical illustrations helped to formalize what was then the recently developed field of dermatology. Knowledge of skin diseases was given new dimension as artists and clinicians alike strove to accurately document the physical characteristics of numerous dermatoses. Introduction of novel processes and refined techniques advanced the clinical use of disease images. The increasingly superior quality of these images aided in the early distinction between rosacea and acne. This article highlights these illustrative contributions in dermatology, and includes key images that serve as a road map to early clinical understanding of skin diseases.

Management of facial erythema of rosacea: what is the role of topical α-adrenergic receptor agonist therapy?

Several more recent advances have led to a better understanding of the pathophysiologic mechanisms involved in rosacea and therapeutic modalities used for treatment. Although the clinical features may vary among patients, there are some unifying mechanisms that appear to relate to the more common presentations of rosacea. Both neurovascular dysregulation and augmented immune detection and response appear to play central roles that lead to many of the signs and symptoms of rosacea. Diffuse central facial erythema is a very common finding that intensifies during flares and persists to varying degrees between flares. This background of facial redness occurs secondary to vasodilation and fixed vascular changes that develop over time. Physical modalities are commonly used to treat the erythema that persists as a result of fixed changes in superficial cutaneous vasculature that do not remit after treatment with agents whose mechanisms are active primarily against some of the inflammatory processes operative in rosacea (ie metronidazole, azelaic acid, tetracyclines). As enlarged superficial cutaneous vessels that contribute to the fixed background facial redness of rosacea remain vasoactive to sympathetic nervous system innervation, topical α-adrenergic receptor agonists, namely brimonidine and oxymetazoline, are currently under evaluation for the treatment of facial erythema of rosacea. This article focuses on the clinical differentiation of facial erythema of rosacea and its management.

Overwinter Survival of Bean Rust Urediniospores in North Dakota

Bean rust (Uromyces appendiculatus) reached epidemic proportions in North Dakota and Minnesota from 1993 to 1996. Although U. appendiculatus is a macrocyclic autoecious rust, neither pycnia nor aecia have been observed in commercial dry bean (Phaseolus vulgaris) in North Dakota fields. The source of initial inoculum is not clearly understood. This study determined the potential for urediniospore survival overwinter. Uredia-bearing bean leaves from artificially inoculated greenhouse-grown plants were kept outside near a field from November to May from 1990 to 1996. Based on bioassays urediniospores survived overwinter, but viability declined over time. Overwinter survival indicates urediniospores may function as initial inoculum.