Baricitinib treatment for refractory skin changes in POEMS syndrome: a case report

Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome is a multisystem disorder that has limited treatment options. Here, we described a case of a 55-year-old female subject who was treated for multiple drugs, but the skin symptoms continued to progress; the patient responded well to baricitinib. This suggests that JAK/STAT signaling pathways play an essential role in the pathological process of POEMS syndrome.

"It's Like You Stuck a Pin in It:" African American/Black Patients Describe Cutaneous Toxicity From Epidermal Growth Factor Receptor Inhibitors

Background: Epidermal growth factor receptor (EGFR) inhibitors cause cutaneous toxicity in over 90% of patients. Conceivably, healthcare providers could overlook such toxicity in African American/Black patients because of a darker complexion. This qualitative study sought to learn about such cutaneous signs and symptoms and, if present, to report them in patients' own words. Methods: Any patient who self-identified as African American/Black and who had been prescribed an EGFR inhibitor was eligible. The current report focuses on patients' responses to the following question, "What have you noticed since starting your cancer treatment (the EGFR inhibitor), any particular symptoms or reactions, positive or negative?" All interview data were audio-recorded, transcribed, and then independently coded and analyzed by two investigators. Results: Fifteen patients are the focus of this report, and all described cutaneous toxicity. Patients appeared troubled by the cosmetic aspect of these drug-induced skin changes, including their acneiform appearance, describing "little pimples with little, little pus in it." Notable were comments on hyperpigmentation, "I'm a black person but…. became darker." Furthermore, patients experienced physical symptoms: "it itches;" "it's like you stuck a pin in it;" "stinging;" and "burning;". Conclusion: Although cutaneous toxicity from EGFR inhibitors might be more difficult to visualize among darkly complected patients, the graphic descriptions offered in this qualitative study underscore the need for clinicians to heighten their awareness of such toxicity in African American/Black patients.

A rare presentation of POEMS syndrome on magnetic resonance neurography: a case series

Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, skin changes (POEMS) syndrome is a multisystem disease associated with underlying plasma cell neoplasm. Here, we present two cases of POEMS syndrome that manifested on magnetic resonance neurography as an increasing bone mass with cortical disruption, direct invading nerve roots and lumbar gluteal muscles. These features have not been previously reported. We also report a case with diffuse hypertrophy and enhancement of the brachial and lumbosacral plexus, which mimics the most common chronic inflammatory demyelinating polyradiculoneuropathy. Moreover, we detected perineurium effusions in the plexus, coupled with a variety of myofascitis and atrophy in denervated muscle. The case series is of concern to atypical magnetic resonance imaging findings of POEMS syndrome in the bone and peripheral nerve system as critical attacked target organs, which would be facilitating diagnosis.

Differentiation of Lower Extremity Skin Changes in the Intensive Care Setting

Digital and lower extremity skin changes often signify critical underlying disorders. Patients in the intensive care unit also frequently have hemodynamic instability requiring the use of vasoactive medications, which may lead to various presentations of limb ischemia; preexisting conditions increase these patients' risk for arterial embolization. Most arterial emboli are clots that originate in the heart and travel to distant vascular beds, where they cause arterial occlusion, ischemia, and, potentially, infarction; the 2 most common sequelae are stroke and lower limb ischemia. Emboli also arise from atherosclerotic plaques. Other conditions can also cause skin color changes in this vulnerable population. Prompt recognition and differentiation of lower extremity skin changes can result in improved patient outcomes. A thorough literature search was conducted to differentiate the primary causes of lower extremity and digital skin changes in the critically ill patient and outline diagnostic and management techniques.

Modeling Patient Risk for Hospital-Acquired Pressure Injuries During COVID-19: A Retrospective Study

BACKGROUND

COVID-19 negatively impacts many organ systems including the skin. One of the most significant skin-associated adverse events related to hospitalization are pressure injuries.

PURPOSE

The aim of this study was to determine 8 risk factors that would place hospitalized patients at a higher risk for hospital-acquired pressure injuries (HAPIs) during the COVID-19 pandemic.

METHODS

A retrospective, descriptive analysis was conducted in an urban academic health science center located in the southeastern United States.

RESULTS

There were 247 of 23 093 patients who had pressure injuries and 1053 patients who had a positive COVID-19 diagnosis. Based on the generalized estimating equation model, diagnosis of COVID-19, age, male gender, risk of mortality, severity of illness, and length of stay are statistically significant factors associated with the development of HAPIs.

CONCLUSIONS

Further study should explore pathology of COVID-19 skin changes and what interventions are effective against HAPIs in the COVID-19 population taking into consideration current treatments.

Skin Changes in Cirrhosis

Skin manifestations of systemic disorders give a clue to the organ involved and help identify the possible disease-causing injury. Skin changes of liver cirrhosis are not specific, as they may be seen in disorders not involving the liver. Thus, a constellation of skin changes along with systemic features may help us to identify the disease-causing liver cirrhosis. Pruritus is one of the most common and distressful symptoms of liver cirrhosis, severely affecting the quality of life, which further necessitates understanding cutaneous manifestations of cirrhosis. Other nonspecific cutaneous manifestations include spider telangiectasia, palmar erythema, paper money skin, xanthomas, pigmentation changes, nutritional deficiencies, hair changes, and nail changes. This review discusses the nonspecific skin manifestations associated with liver cirrhosis followed by specific cutaneous findings seen in common diseases causing liver cirrhosis, such as viral infections, biliary tract disorders, chronic alcoholism, and metabolic disorders. Early recognition of cutaneous features can help prevent or delay the development of complications and end-stage disease, decreasing morbidity and mortality.

Cotton versus medical face mask influence on skin characteristics during COVID-19 pandemic: A short-term study

BACKGROUND

In the still ongoing COVID-19 pandemic, one of the main prevention strategy remain to be the use of protective face masks. Changes in skin characteristics and dermatological problems related to wearing different types of masks have been observed. The aim of this study was to compare the short-term effects of cotton versus medical masks on skin biophysical parameters in general population.

MATERIALS AND METHODS

Twenty-eight human volunteers were enrolled and divided in cotton mask and medical mask wearing groups. We measured four skin biophysical parameters: trans-epidermal water loss (TEWL), stratum corneum hydration (SCH), skin pH, and erythema index (EI) before and 3 h after wearing masks on both uncovered and mask-wearing face area.

RESULTS

TEWL increased after 3 h on exposed skin in cotton mask group and slightly decreased in medical mask group There was an increase in SCH after 3 h of wearing protective face masks in both groups. pH of the covered skin slightly decreased while EI increased after 3 h in both groups; changes were not statistically significant. Parameters did not change significantly on uncovered skin.

CONCLUSION

There were no differences between the influence of cotton versus medical protective masks on the skin of healthy volunteers in our study. Both types of masks could be recommended for short-time protection in individuals with healthy skin during COVID-19 pandemic.

Influence of quarantine mask use on skin characteristics: One of the changes in our life caused by the COVID-19 pandemic

BACKGROUND

The influence of various environmental factors on skin properties is well known. However, there is a lack of research into the effect of quarantine masks on skin properties, even though the use of masks has significantly increased after the COVID-19 outbreak. Therefore, this study aimed to investigate the influence of mask use on skin properties.

MATERIALS AND METHODS

Twenty subjects were enrolled in this study. The subjects used approved quarantine masks for 6 hours a day for 2 weeks. We measured eight skin biophysical parameters: temperature, redness, pore volume, texture, elasticity, trans-epidermal water loss (TEWL), sebum content, and pH, and evaluated acne lesions before and after using quarantine masks. The evaluation was performed on the mask-wearing area of the face.

RESULTS

Skin temperature, redness, and TEWL increased significantly after a 6-hour mask use, while the sebum content increased marginally. Skin elasticity was reduced by the use of masks over 1 and 2 weeks, whereas the pore volume and the number of acne lesions increased after a 2-week mask use. The skin changes caused by mask use showed sex-based differences in the skin elasticity (after 6 hours), redness, and roughness (after 2 weeks).

CONCLUSIONS

The use of quarantine masks causes a change in the skin temperature, redness, and TEWL in the short term and in skin elasticity, pores, and acne in the long term. This study revealed that prolonged mask use could have negative effects on the skin.

Efficacy of ethyl ascorbyl ether-containing cosmetic cream on blue light-induced skin changes

BACKGROUND

Office workers are consistently exposed to blue light, mainly from sunlight and digital device. Recent studies report that blue light has various harmful effects, including cellular changes via reactive oxygen species. Studies on blue light-induced skin changes have only been conducted in vitro and have not been clinically confirmed.

OBJECTIVE

We provide novel methods to evaluate the effect of the product on the recovery of skin changed by blue light.

METHODS

Internet surveys were conducted for workers in their 20s and 40s regarding exposure time to blue light in various environments. To study the effects of long-term exposure to blue light (456 nm) on the skin, we designed three light intensity conditions, and various skin characteristics were observed. After blue light irradiation, various skin characteristics were analyzed before and after applying ethyl ascorbyl ether (EAE)-containing cosmetic cream for 2 weeks.

RESULTS

When exposed to strong blue light for approximately 16 days, the L^* value, skin hydration, transparency, and elasticity decreased, and the melanin index, erythema index, a^* value, and b^* value increased. Furthermore, after short-term blue light irradiation (dose, 269 J/cm² , the equivalent of blue light exposure for approximately 38 days in daily life), the L^* value and elasticity decreased, and the melanin index and erythema index increased. However, when EAE cream was applied on skin for 1-2 weeks, the skin recovered.

CONCLUSION

This study clinically confirms the skin changes caused by blue light and the effect of EAE in relieving such changes.

Skin Responses in Newly Diagnosed Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Gammopathy, and Skin Changes (POEMS) Syndrome After Therapy With Low-Dose Lenalidomide Plus Dexamethasone

Background

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome is a rare paraneoplastic disease with a high prevalence of skin symptoms. Few studies have focused on skin responses to systemic treatment of this disease.

Objective

To evaluate skin responses after treatment with low-dose lenalidomide plus dexamethasone and determine their relationship with vascular endothelial growth factor (VEGF) and hematological responses.

Methods

A total of 41 consecutive Chinese patients who were at least 18 years of age with newly diagnosed POEMS syndrome were enrolled. 36 of them completed 12 cycles of treatment. Skin, serum VEGF, hematological and neurological responses were documented at 1, 2, 3, 6, 9, and 12 months during treatment.

Results

Skin manifestations were not associated with serum VEGF levels at baseline. Of the patients with hyperpigmentation, hemangiomas, hypertrichosis, white nails, or acrocyanosis separately, 26/34 (76.5%), 11/30 (36.7%), 14/15 (93.3%), 21/21 (100%), and 4/4 (100%) achieved complete responses at 12 months. Reduction in hyperpigmentation after 12 months reflected a good VEGF response (P = 0.017).

Conclusion

Low-dose lenalidomide plus dexamethasone therapy is effective in reversing skin changes in patients with POEMS syndrome.

Clinical Trial Registration

Clinicaltrials.gov, identifier NCT01816620

Skin Changes in Patients with Diabetes Melitus Type 2 and their Impact on Quality of Life

Introduction:

Changes in the skin can occur as part of a diabetic, metabolic disorder or diabetic complications. Studies have shown that diabetes has an extremely strong negative impact on quality of life, especially diabetes with complications.

Aim:

Examine the impact of skin changes in patients with type 2 diabetes mellitus on quality of life.

Methods:

A prospective study analysed the quality of life in 200 respondents with type 2 diabetes mellitus which had diabetes-related skin changes. Subjects were divided into four groups according to the type of skin changes associated with diabetes mellitus. Group 1 consisted of patients which had skin changes with a greater or lesser association with diabetes mellitus, group 2 patients with infections, group 3 patients with cutaneous manifestations of diabetic complications and group 4 patients with allergic reactions to antidiabetic therapy. Quality of life assessment was performed using the Skindex-29 questionnaire, and the Nijsten categorization was used to assess the impact of skin changes in patients with type 2 diabetes mellitus on quality of life.

Results:

There were (51.95%) respondents in group 1, group 2 (24.02%), group 3 (22.22%) and group 4 (1.8%) respondents. In the scale of emotions in 84 respondents (43.0%) the impact on quality of life was serious, in the scale of symptoms in 96 (48%) was moderate, and in the scale of social and physical functioning 106 (55%) also had a moderate impact on quality of life, as well as in the total score of 94 respondents (47%). There was a statistically significant difference in the scale of social and physical functioning in the presence of skin changes in group 1 (x2 = 7.95; df = 3, p = 0.045) and group 3 (x2 = 12.48, df = 3; p = 0.006), and in the total score of Skindex-29 when it comes to changes in the skin of group 3 (x2 = 7.26, df = 3, p = 0.05).

Conclusion:

the quality of life in patients with type 2 diabetes mellitus which have skin changes is significantly reduced.

Audit of skin changes present in referrals to a specialist lymphoedema service

An audit of 100 new patients attending a specialist lymphoedema clinic revealed 52% presented with chronic oedema. More than half (58%) of the chronic oedema group presented with skin changes whereas 14% of those with lipoedema, 4% with lymphoedema of the arm, and 8% with lymphoedema of the leg developed skin changes. None of the primary lymphoedema group developed skin changes. Chronic venous disease (CVD) was significantly more prevalent in the chronic oedema group. More patients with bilateral chronic oedema suffered from cellulitis (41%) compared to unilateral (27%). Skin changes, CVD and red leg syndrome (RLS) also occur more often in bilateral leg swelling. Incidence of cellulitis is highest in the chronic oedema group (36.5%), closely followed by the primary lymphoedema group (33.3%). 85% of the patients who were weighed (n=93) were overweight, 39% obese, and 29% morbidly obese. The findings from this audit highlight the importance of skin care training for community nurses managing chronic oedema patients.

Cutaneous manifestations in disorders of hepatobiliary system

BACKGROUND

Hepatobiliary diseases are associated with various mucocutaneous changes that are directly and indirectly associated with these diseases. There is a dearth of studies from India dealing with cutaneous manifestations in liver disorders.

AIM

This study was conducted to know the spectrum of cutaneous changes and their correlation with liver function tests in patients with disorders of hepatobiliary system.

METHODS

This was a descriptive study conducted among in patients and outpatients with primary hepatobiliary disorders at a tertiary care center in South India. Detailed history taking and examination was done. Visual analog score (VAS) and 5D itch score was employed to quantify pruritus. Correlation of liver function tests with pruritus and comparison of skin changes in the major disease groups was attempted.

RESULTS

A total of 303 patients were recruited. Hepatic mass/malignancy followed by nonalcoholic liver disease were the most common diagnoses. Icterus followed by pruritus were the most common cutaneous complaints. The mean VAS and 5D itch scores among the patients with pruritus were 4.7 ± 1.9 and 13.6 ± 4.9. The most common mucocutaneous findings observed were icterus (241 patients; 79.5%), ichthyosis/xerosis (172 patients; 56.7%), pallor (131 patients; 43.2%), excoriations (118 patients; 38.9%), hyperpigmented palmar creases (118 patients; 38.9%), clubbing (113 patients; 37.2%), and pedal edema (85 patients; 28%). There was statistically significant correlation between serum bilirubin levels and pruritus.

CONCLUSION

The common mucocutaneous manifestations associated with primary hepatobiliary disorders were icterus, ichthyosis/xerosis, pallor, excoriations, hyperpigmented palmar creases, clubbing, and pedal edema.

Quality of life and severity of skin changes in the dynamics of psoriasis

INTRODUCTION

Psoriasis is a chronic skin disease with periods of recurrence and remission. The skin changes which are typical of this disease can have a considerable effect on the patient's psychological state, self-esteem and body image. It can also affect the patient's functioning in all areas of life and quality of life.

AIM

The present study characterized the patient needs to improve the quality of life in specified areas in patients depending on the severity of psoriatic changes.

MATERIAL AND METHODS

The study was conducted in two stages on 100 patients aged from 18 to 66. A dermatological examination was conducted in stage one. Patients' dermatological condition was assessed with the Psoriasis Area and Severity Index (PASI). Clinical and socio-economic information was collected in stage two using a questionnaire, a medical interview and a standardized questionnaire measuring quality of life, the WHOQOL-BREF.

RESULTS

The following factors had the greatest effect on the general quality of life and quality of health ratings in the studied sample: severity of psoriatic changes, duration of the most recent recurrence and sex. Severity of psoriatic changes had a negative effect on the patient's somatic, psychological, environmental and social functioning. Duration of the most recent recurrence had a negative effect on social functioning. Practical implications of this study allow dermatologists to determine the appropriate therapeutic intervention which improves the quality of life of these patients on the one hand, and will increase patient's involvement in the process of treatment on the other hand.

CONCLUSIONS

Quality of life is more impaired by more severe chronic skin disease.

Thermal patterns in zoster

RATIONALE

Varicella zoster virus is a neurotropic virus that causes an infectious disease characterized by skin changes and neuropathic pain. After the resolution of the first infection, the virus lies dormant within the sensory ganglia. The reactivation of the virus causes zoster. An alteration in skin infrared emission might be expected in the areas of the skin affected by inflammatory changes and demyelination of the affected peripheral nerve.

OBJECTIVE

To establish the importance of thermal imaging in the follow up of Zoster Zone with different localization. An infrared thermal camera was used in order to assess if the evolution of the disease determines a thermal pattern.

METHODS AND RESULTS

Infrared thermography can be used for the assessment of the affected area also by using a thermography camera that is sensitive to the infrared spectrum. An intense and diffuse infrared emission is highly suggestive for the inflammation and implies that a more aggressive treatment should be initiated. After the clinical resolution of the affected area, the symmetry of the thermal pattern should be restored. If the asymmetry persists, a neuropathic complication of the virus reactivation could be involved.

DISCUSSIONS

The integration of infrared thermography with the clinical findings is very useful in order to create a complete picture of the zoster lesions and this method could determine the beginning of a correct treatment and, by doing so, minimizing the risk of complications.

Prospective study on prevalence of dermatological changes in patients under hemodialysis in hemodialysis units in Tanta University hospitals, Egypt

Introduction

Chronic hemodialysis patients experience frequent and varied mucocutaneous manifestations in addition to hair and nail disorders. The aim of this study was to evaluate the prevalence of dermatological changes among patients with end-stage renal disease under hemodialysis in a hemodialysis unit in Tanta University hospitals over a period of 6 months, and to evaluate the relations of these dermatological disorders with the duration of hemodialysis as well as with different laboratory parameters in these patients.

Patients and methods

Ninety-three patients with end-stage renal disease on regular hemodialysis (56 males and 37 females) were selected and included in this cross-sectional, descriptive, analytic study. Their ages ranged from 18–80 years. All patients underwent thorough general and dermatological examinations. Laboratory investigations (complete blood counts, renal and liver function tests, serum parathormone levels, serum electrolytes, alkaline phosphatase, random blood sugar, and Hepatitis C virus (HCV) antibodies) were evaluated.

Results

This study revealed that most patients had nonspecific skin changes, including xerosis, pruritus, pallor, ecchymosis, hyperpigmentation, and follicular hyperkeratosis. Nail and hair changes were commonly found, especially half and half nail, koilonychia, subungal hyperkeratosis, melanonychia, onychomycosis, and brittle and lusterless hair. Mucous membrane changes detected were pallor, xerostomia, macroglossia, bleeding gums, aphthous stomatitis, and yellow sclera. There was a significant positive correlation between the presence of pruritus and serum parathormone level. There was a significant negative correlation between the presence of mucous membrane changes and hemoglobin level.

Conclusion

Nonspecific mucocutaneous manifestations are common in patients on hemodialysis, particularly xerosis, dyspigmentation, and pruritus. Early and prompt recognition and treatment of dermatological conditions in patients on dialysis may improve their quality of life.

Mediastinal kaposiform hemangioendothelioma and Kasabach-Merritt phenomenon in a patient with no skin changes and a normal chest CT

A 16-month-old previously healthy boy was admitted to the hospital with respiratory distress and thrombocytopenia. Initial workup demonstrated large pleural and pericardial effusions. The patient had no cutaneous abnormality on physical examination, and his initial chest CT (computed tomography) was nondiagnostic. He required multiple platelet transfusions, chest tube placement, and pericardiocentesis. Sixteen days after admission, a chest MRI (magnetic resonance imaging) revealed a large infiltrative mass of the superior mediastinum, consistent with kaposiform hemangioendothelioma (KHE). The patient's thrombocytopenia was due to associated Kasabach-Merritt phenomenon (KMP). The patient now has complete resolution of KMP after medical treatment with prednisolone, aminocaproic acid, vincristine, and aspirin.

Genistein aglycone, a soy-derived isoflavone, improves skin changes induced by ovariectomy in rats

BACKGROUND AND PURPOSE

Ovariectomy accelerates age-related skin changes as adequate oestrogen levels are required to control structural integrity and functional capacity of skin. Genistein, a soy-derived isoflavone, has been tested in anti-ageing cosmetic preparations with interesting results on skin elasticity, photoaging and skin cancer prevention. We investigated the effects of genistein aglycone and compared them with systemic raloxifene hydrochloride and 17-α-ethinyloestradiol on skin changes in aged, ovariectomized (OVX) rats.

EXPERIMENTAL APPROACH

Six months after ovariectomy, rats were randomly allocated to different groups and treated, daily, with genistein aglycone (1 and 10mg·kg(-1) s.c.), raloxifene hydrochloride (0.05 and 0.5mg·kg(-1) s.c.) or 17-α-ethinyloestradiol (0.003 and 0.03mg·kg(-1) s.c.) for 12 weeks. Controls were untreated OVX and sham OVX rats. At the end of the treatment period, a skin biopsy was carried out and skin samples were assessed for molecular, histological and functional changes.

KEY RESULTS

Skin samples of untreated OVX rats showed a decrease in TGF-β1, VEGF, MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1 and TIMP-2 compared with sham OVX rats. All the treatments significantly restored this depressed molecular profile revealed in OVX rats. Genistein aglycone, 1mg·kg(-1) , also significantly increased the thickness of collagen and breaking strength of skin in the OVX rats.

CONCLUSIONS AND IMPLICATIONS

Relatively long-term, systemic treatment with genistein aglycone shows comparable efficacy to oestrogen in reversing some molecular, histological and functional changes of the skin associated with ovariectomy in aged rats. This suggests that genistein aglycone might be an effective alternative therapy for the management of age-related skin changes in postmenopausal women.

Cutaneous manifestations of internal malignant disease

The skin can provide clues to the well-being of our patients. Some skin changes, such as hypertrichosis lanuginosa acquisita or erythema gyratum repens, are so specific that there is a virtual certainty of internal malignancy. Other changes, such as severe pruritus, are significant management problems in late-stage lymphoma and leukemia. Still others, such as herpes zoster in a cancer patient in remission, may be a marker for recurrent malignant disease. This review will discuss many of the skin changes associated with systemic cancer.