Category: Treatment

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Something to Sweat About: Two Cases of Dupilumab-Induced Hyperhidrosis and Bromhidrosis.

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Something to Sweat About: Two Cases of Dupilumab-Induced Hyperhidrosis and Bromhidrosis.

Allergy Rhinol (Providence). 2020 Jan-Dec;11:2152656720927703

Authors: Rowane M, Valencia R, Schend J, Jhaveri D, Hostoffer R

Abstract
Introduction: Atopic dermatitis (AD, eczema) is familial chronic inflammatory skin disease of complex etiology and increasing prevalence. Dupilumab is an IL-4 receptor subunit alpha (IL-4Rα) antagonist that is the first Food and Drug Administration-approved biological therapy for moderate-to-severe adult AD inadequately controlled with topical therapies. Adverse effects reported in the literature include injection site reactions, conjunctivitis, headache, and nasopharyngitis.
Objective: We report the first cases of hyperhidrosis and bromhidrosis as side effects from dupilumab (Dupixent®) for the treatment of AD.
Case Reports: Case 1 is a 20-year-old woman with controlled allergic rhinitis and severe AD reported axillary hyperhidrosis with bromhidrosis, comparable to sweat from high-intensity exercise, with no relief from several different over-the-counter antiperspirants. Case 2 is a 61-year-old woman with history of chronic asthma, allergic contact dermatitis, allergic rhinitis, and AD noticed markedly increased sweating with bromhidrosis that was reminiscent of her menopausal symptomology, about 3 months after initiating dupilimab.
Discussion: Traditional immunosuppressive agents and corticosteroids have limited efficacy, numerous side effects, and increased risk of infection. The safety profile and efficacy of the newly approved IL-4Rα antagonist dupilumab may be favorable to oral immunosuppressants, but its use remains limited to severe recalcitrant cases, due to financial implications and lack of long-term safety data and comparative head-to-head trials.
Conclusion: We report improved outcomes with dupilumab, in addition to unpublished cases of bromhidrosis and hyperhidrosis in 2 patients with AD. This report of additional complications may inspire further clinical research and assist clinicians in considering the option of dupilumab for uncontrolled AD, despite aggressive traditional treatment.

PMID: 32489715 [PubMed]

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Gastrointestinal involvement of primary skin diseases

Abstract
Less is known about gastrointestinal (GI) involvement of primary skin diseases due to the difference in embryology, histology, microbiology and physiology between integument and alimentary tract. Esophagus, following the oropharyngeal mucosa, is the most common GI segment affected by primary skin diseases, especially by eosinophilic esophagitis, lichen planus, and autoimmune bullous dermatoses like pemphigus vulgaris, mucosal membrane pemphigoid and epidermolysis bullosa acquisita. Eosinophilic esophagitis is an emerging chronic atopic disease with esophageal dysfunction as the typical presentation, and esophageal narrowing, rings and stricture as late complications. Esophageal lichen planus mainly involves the proximal to mid‐esophagus in elderly‐aged women with long‐term oral mucosal lesions. In acute attack of pemphigus vulgaris esophageal involvement is not uncommon but often neglected and may cause sloughing esophagitis (esophagitis dissecans superficialis) with acute GI bleeding in rare cases. GI manifestation of hereditary bradykininergic angioedema with colicky acute abdomen mostly affects small intestine, usually in the absence of pruritus or urticaria, and is more severe and long‐lasting than the acquired histaminergic form.
Strong evidence supports association between inflammatory bowel disease, especially Crohn disease, and hidradenitis suppurativa/acne inversa. Patients with vitiligo need surveillance of autoimmune liver disease, autoimmune atrophic gastritis or celiac disease when corresponding symptoms become suspect.
Melanoma is the most common primary tumor metastatic to the GI tract, with small intestine predominantly targeted. Gastrointestinal involvement is not uncommon in disseminated mycosis fungoides. Extramammary Paget’s disease is an intraepidermal adenocarcinoma of controversial origin and a high association between the ano‐genital occurrence and colorectal adenocarcinoma has been reported.
As GI tract is the largest organ system with multidimensional functions, dermatologists in daily practice should be aware of the gastrointestinal morbidities related to primary skin diseases for an early diagnosis and treatment.
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The clinical significance of fungi in atopic dermatitis

Abstract
Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases and is caused by multiple factors including genetic factors, skin barrier defects, host immune responses, allergen sensitivity, environmental effects, and infections. Commonly, bacterial and viral infections are present in the eczematous lesions of AD patients and clearly aggravate the symptoms. However, studies of fungal infections in AD are limited in spite of the fact that there are reports showing that Malassezia, Candida, and some dermatophytes can affect the symptoms of AD. Moreover, certain fungal infections are sometimes overlooked and need to be considered particularly in AD patients with treatment failure as clinical features of those fungal infections could mimic eczematous lesions in AD. Here, we review the epidemiology, pathogenesis, clinical manifestations, and overlooked features of fungal infections associated with the symptoms of AD including the diagnosis and effectiveness of fungal treatments in AD patients.
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Novel pharmacological treatments for generalized anxiety disorder: Pediatric considerations

Abstract

Background
Pediatric anxiety disorders such as generalized anxiety disorder (GAD) are common, impairing, and often undertreated. Moreover, many youth do not respond to standard, evidence‐based psychosocial or psychopharmacologic treatment. An increased understanding of the gamma‐aminobutyric acid (GABA) and glutamate neurotransmitter systems has created opportunities for novel intervention development for pediatric GAD.

Methods
This narrative review examines potential candidates for pediatric GAD: eszopiclone, riluzole, eglumegad (LY354740), pimavanserin, agomelatine.

Results
The pharmacology, preclinical data, clinical trial findings and known side effects of eszopiclone, riluzole, eglumegad (LY354740), pimavanserin, agomelatine, are reviewed, particularly with regard to their potential therapeutic relevance to pediatric GAD.

Conclusion
Notwithstanding numerous challenges, some of these agents represent potential candidate drugs for pediatric GAD. Further treatment development studies of agomelatine, eszopiclone, pimavanserin and riluzole for pediatric GAD also have the prospect of informing the understanding of GABAergic and glutamatergic function across development.

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Psychopharmacology in dermatology: Treatment of primary psychiatric conditions in dermatology

Abstract
The role of psychotropic drugs in Psychodermatology is still debatable, due to the quality of the evidence that supports it. There are several case reports and open trials with variable results. There is an additional difficulty in finding therapists trained in effective psychotherapy techniques, justify the need for more research on the available pharmacological options. The present review emphasizes pharmacological treatment in Psychodermatology, specifically in cases of primary psychiatric disorders that are expressed with self‐inflicted cutaneous signs and symptoms, in which drugs can play a central role in ameliorating symptoms or be useful in combination with psychotherapeutic approach of these disorders.
This article is protected by copyright. All rights reserved.
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Topographic Computer Analysis for Acne Scar Treatment on Face accompanying Biopsy Study after Dermal Injection of Hydrotoxin Mixture

Abstract

Background
Acne during youth can leave permanent facial scarring. The depressed acne scars can be treated by injection of stabilized hyaluronic acid (S‐HA) into the dermis. Due to the large number of acne scars, manual injection methods are technically difficult, and bear high risk of lump formation in the dermis. Therefore, the author designed a specific injection method to solve the two abovementioned problems.

Materials/Methods
102 Patients who suffered from acne scars were treated with a mixture of S‐HA (Restylane Vital®) and abobotulinumtoxinA (Dysport®). Using an automatic injector, microdroplets of the mixture (0.001cc of S‐HA and 0.125 U abobotulinumtoxinA) were delivered into 1000 intradermal sites on whole face except eyelids. This instrument radically reduced injection amounts per site (0.001cc), lessened manual operator efforts, and ensured consistent injection depth (from 0.8mm to 1.2mm depending on individual dermal thickness) into the facial dermis. The changes in each depression site of acne scars were evaluated by topographical computer analysis (point‐roughness), based on the 40 magnification microscopic photos generated. Depth measurements of each small acne scar point were taken one by one at the exact same point before and after the treatments. Global Aesthetic Improvement Scale (GAIS) was measured for improvement of acne scars at 1 and 6 months post‐treatment. Additionally, serial histologic examinations of the biopsy specimens evaluated neocollagenesis, neoelastinogenesis, and longevity state of the S‐HA.

Results
78 patients showed improvements of depressed acne scars in physical examinations, medical photos, and dermascopic photos.
Using topographic computer analysis, the average point‐roughness decreased 27.48 % (at 1‐month) from 29.042±6.85 (baseline) to 21.05±6.30 µm (P

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Challenges of COVID‐19 pandemic for dermatology

Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is a new coronavirus responsible for the pandemic named coronavirus disease 2019 (COVID‐19). The disease causes SARS with a significant morbidity and mortality. We provide a review with a focus on COVID‐19 in dermatology. We discuss triage of suspected infectious patients, protection of medical doctors and nurses. We discuss the available data on cutaneous symptoms, although disease‐specific symptoms have yet not been observed. COVID‐19 is a challenge for the treatment of dermatologic patients, either with severe inflammatory disorders or with skin cancer. The consequences for systemic treatment are obvious but it will be most important to collect the clinical data for a better decision process. Last but not least, education in dermatology for students will not be temporarily possible in the classical settings. COVID‐19, although not a skin disease, by itself has an immense impact on dermatology.
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Overall safety of relamorelin in adults with diabetic gastroparesis: Analysis of phase 2a and 2b trial data

Summary

Background
Relamorelin, a pentapeptide ghrelin receptor agonist, accelerated gastric emptying significantly and improved symptoms in adults with diabetic gastroparesis in phase 2 trials.

Aim
To assess the safety and tolerability of relamorelin across phase 2 trials.

Methods
Safety assessments in patients aged 18‐75 years (weight, adverse events [AEs] and laboratory tests) from two randomised, double‐blind phase 2 trials (NCT01571297, NCT02357420; results published previously) were reviewed descriptively. Analysis of covariance assessed treatment effect on glycated haemoglobin (HbA1c) and blood glucose post hoc. Phase 2a and 2b trial durations were, respectively, 4 weeks (relamorelin 10 µg once or twice daily [b.d.] or placebo b.d.) and 12 weeks (relamorelin 10, 30 or 100 µg or placebo b.d.) with 1‐ and 2‐week, single‐blind placebo run‐ins.

Results
Among 204 phase 2a and 393 phase 2b patients, respectively, 67% and 62% were female, and 88% and 89% had type 2 diabetes. Proportions of patients reporting serious AEs were similar across treatment groups, as were those with ≥1 treatment‐emergent AE (TEAE). TEAE‐related discontinuations were proportionally higher in relamorelin groups than placebo. Of 12 serious TEAEs in phase 2a, none occurred in >1 patient. In phase 2b, five serious TEAEs were reported in >1 patient, and one (100 µg) died (urosepsis), all unrelated to relamorelin. In phase 2b, increased HbA1c and fasting blood glucose levels were dose‐related (P