High Potency Topical Steroids Research Articles

Clinical outcomes with utilization of high-potency topical steroids in patients with lichen sclerosus-associated vulvar cancer

ObjectivesTo evaluate the impact of high-potency topical steroid use on risk of recurrence of lichen sclerosus-associated vulvar cancer. MethodsThis is a retrospective cohort study evaluating patients with lichen sclerosus (LS)- associated vulvar squamous cell cancer (VSCC). Demographic and clinical outcome data were compared between two comparison groups: patients who received steroids, mainly clobetasol, and patients who did not receive steroids following treatment of LS-related vulvar cancer. Categorical variables were compared using Fisher's exact test or chi-square test. Continuous variables were compared using a two-sided student's t-test. Time to recurrence (TTR) and overall survival (OS) were analyzed using Kaplan-Meier survival plot and compared using Mantel-Cox log rank test. Cox proportional hazard regression models were conducted to generate hazard ratios for both TTR and OS. A p value of <0.05 was considered statistically significant. ResultsA total of 49 patients were included, with 36 patients receiving steroid treatment and 13 patients in the expectant management group. The median age of diagnosis was 68. The average BMI was 31.7 +/− 7.0. The median length of follow up was 41 months. The majority of patients were diagnosed with stage I VSCC. There was no difference in demographics or oncologic management of vulvar cancer between the two cohorts. Overall recurrence was decreased among patients who received steroid treatment when compared to patients who did not, 12 patients (33.3%) versus 9 patients (69.2%) respectively (p = 0.048). ConclusionsHigh-potency topical steroid use following treatment of lichen sclerosus-associated vulvar squamous cell carcinoma is associated with decreased risk of recurrence and prolonged median time to recurrence.

P13 A rare case of Sjögren syndrome in a White woman with Kikuchi–Fujimoto disease

Abstract A 36-year-old White woman was seen in May 2022 for a rash on her upper back, shoulders, cheeks, forehead and extensor surfaces of the upper limbs. It had developed following sun exposure on the beach despite regularly applying SPF50. Over time, the rash became sore but exhibited no signs of vesicles or oozing. Of note, the patient had been recently diagnosed with Kikuchi–Fujimoto disease (KFD) following a lymph node biopsy. She gave history of Raynaud phenomenon since childhood, and arthralgia primarily affecting the small joints of hands. She also experienced episodic dry eyes, dry mouth, peripheral oedema, dyspnoea, abdominal pain and constipation. For the previous month, she had felt fatigued with some undocumented weight loss. Clinical examination revealed an erythematous rash with discrete nonblanching macules and plaques of varying sizes, oval-to-circular in shape, on the involved areas. Lymph nodes were not palpable. Differential diagnosis included cutaneous lupus, other connective tissue disorders, and—less likely—polymorphic light eruption. Skin biopsy showed focal compact hyperkeratosis and parakeratosis with focal subtle spongiosis, intraepidermal neutrophils and lymphocyte exocytosis, with the presence of perivascular and periappendageal chronic inflammation. There was mild basement membrane thickening with focal deposition of fibrinogen at the basement membrane zone on direct immunofluorescence. She was positive for anti-Ro antibodies, with a titre of 84 kU L−1 (normal &amp;lt; 11 kU L−1). A diagnosis of Sjögren syndrome with KFD was made. The patient was advised on photoprotection with a high-potency topical steroid, and referred to rheumatology for review of her joint problems. After 4 weeks, the patient had only some improvement with topical therapy and was started on oral hydroxychloroquine. At the 12-week follow-up, there was significant improvement. Her skin was clear, with improvement in joint pain and fatigue. KFD, also known as necrotizing lymphadenitis, is a benign and self-limited disorder, characterized by regional cervical lymphadenopathy with tenderness, usually accompanied with mild fever and night sweats. Rarely, the skin and joints are involved. There is an established association between KFD and connective tissue disorders, especially Sjögren syndrome (Gates GA, Li Y, Magyar C, Sarantopoulos GP. Kikuchi–Fujimoto disease with unusual cutaneous findings. Am J Dermatopathol 2021; 43:e213–17). This is more prevalent among Asians and rarely reported in White people (Perry AM, Choi SM. Kikuchi-Fujimoto disease: a review. Arch Pathol Lab Med 2018; 142:1341–6), where it may cause diagnostic difficulties. This case highlights the importance of lateral thinking while formulating a differential diagnosis, despite the time pressures of a busy clinic. Although the reported prevalence of KFD among White people has been negligible (Perry et al.), it should not be dismissed solely based on a patient’s ethnicity. Timely and adequate management of rare conditions can reduce patient morbidity and improve their quality of life.

Comparison of prescribing patterns of non-physician clinicians and dermatologists in the Medicare population.

Non-physician clinicians (NPCs) are playing an increasing role in dermatologic patient care. This study expands upon existing workforce assessments of dermatology NPCs through the use of publicly-available Medicare datasets to better clarify prescribing patterns among independently-billing dermatology NPCs. The findings demonstrate prescribing similarities between NPCs and dermatologists for most medications, including biologic and immunosuppressive medications, although with higher use of oral prednisone, gabapentin, and hydroxyzine among NPCs. Dermatologists more frequently utilized high-potency topical steroids. These data provide initial insights into NPC prescribing patterns and should motivate further study of the identified differences and potential implications for patient care.

Efficacy and safety of dupilumab in bullous pemphigoid: a retrospective multicentric study of 36 patients.

Bullous pemphigoid (BP) is the most common autoimmune blistering disease in Europe and its treatment can be challenging. Several published cases have reported dupilumab efficiency in treatment-refractory patients. We conducted a retrospective multicentric study of 36 patients to evaluate the real-life efficiency of dupilumab in BP. Our results suggest that dupilumab, in association with high-potency topical steroids, could be rapidly effective in various clinical forms of BP and seems to be well tolerated in the elderly.

Prevalence of Type 2 Inflammatory Diseases in Pediatric Patients With Atopic Dermatitis: Real-world Evidence

To analyze the prevalence and incidence of type 2 inflammatory disease in pediatric patients with atopic dermatitis (AD) compared with a similar population of patients without AD, utilizing a large United States commercially insured database.The study included 244 776 pediatric AD patients matched 1:1 with non-AD patients from the IBM MarketScan Commercial Database from 2013 to 2017. This US database included representation from a variety of commercial insurance plan types throughout the country with 44% of patients from the South.This was a retrospective study conducted over a 12-month period that used a commercial database of select the patient populations. This database included diagnostic codes entered by clinicians for billing from a variety of providers, including primary care (pediatricians and family practitioners), subspecialists (allergy and dermatology), and emergency department or urgent care clinicians. Date of AD diagnosis was used for patients with AD and a random date for non-AD patients with required insurance 6 months prior and 12 months after date. AD patients were defined as <18 years with ICD 9 code (691.8) or ICD 10 code (L20×) and matched controls had no diagnosis of AD for the entirety of the study. Severity of disease was divided into 3 levels based on treatment. Level 1 included low potency topical steroids (class 5–7) or calcineurin inhibitors, level 2 included mid potency topical steroids or calcineurin inhibitors, and level 3 includes systemic steroids, phototherapy, immunosuppressants, or intravenous immunoglobulin. The prevalence of type 2 diseases including asthma, allergic conjunctivitis, chronic rhinosinusitis, nasal polyps, eosinophilic esophagitis, allergic rhinitis and urticaria was evaluated in 2 comparison groups: severity of disease (level 3 AD versus level 1 and 2) and presence or absence of AD. Furthermore, food allergy was omitted from the evaluation as it was felt it was poorly defined and without standardization. Logistic regression models were used for statistical comparison. Kaplan-Meier curves were used to show time to development of type 2 disease. Hazard ratios using a Cox proportional hazard model were reported for the risk of type 2 disease in AD versus non-AD patients.In this population database, patients who had AD at time of diagnosis (index) were more likely to develop type 2 inflammatory disease compared with patients without AD (odds ratio [OR] of 2.17, [2.15–2.20], P < .001). Asthma, eosinophilic esophagitis, urticaria and rhinitis were among conditions that were twice as likely diagnosed in AD patients. Chronic rhinosinusitis and nasal polyps had a slightly higher likelihood in AD patients (OR 1.10, [1.06–1.13]; P < .001). Patient with level 3 severity had 4 times the likelihood of asthma (OR 4.43, [4.32–4.54]; P < .001). Infants with AD demonstrate a higher risk for development of type 2 disease, with a hazard ratio of 1.47 (1.45–1.50) compared with non-AD patients. Based on the Kaplan-Meier curves, patients with AD had a 51.7% probability of developing type 2 inflammatory disease compared with non-AD patients who had a 38.9% probability.The relative prevalence of type 2 inflammatory disease was higher in pediatric patients with AD in a very large insurance-based database. In addition, the risk of developing type 2 inflammatory disease was higher in infants with AD over a 1-year period. Severity of AD was found to increase both the prevalence and risk.This study used a large national insurance database to examine the prevalence and incidence of type 2 inflammatory diseases (asthma, rhinitis, conjunctivitis, urticaria, eosinophilic esophagitis, and chronic rhinosinusitis or nasal polyps) in pediatric patients with AD. Authors analyzed an impressive cohort size and found a statistically significant higher incidence and prevalence of other allergic diseases within pediatric AD. There were a few limitations to further consider. First, authors were unable to quantify food allergy in this cohort due to concerns of nonstandardization of food allergy diagnostic criteria and associated codes. Though quantifying food allergy was a challenge, perhaps adding epinephrine prescription or food anaphylaxis may have been helpful. Secondly, the scoring of AD severity was based upon treatment regimens which, consequently, grouped all ages into 1 cohort. Patients on a high potency topical steroid were all considered level 2 (on a 1 to 3 scale), whereas in many cases an infant or toddler receiving this treatment would be considered severe. In addition, it was difficult to know if eczema was indeed the indication for the prescriptions. For example, in patients considered severe or level 3, treatments such as systemic steroids may have been given for asthma exacerbation and immunoglobulin replacement may have been used to treat an underlying immunodeficiency. Finally, extending the 1-year observation period would have provided a more complete evaluation of the incidence of other atopic conditions in infants and toddlers less than 2 years of age. This retrospective study added to work establishing an increased burden of type 2 inflammatory diseases found in patients with AD.URL: www.pediatrics.org/cgi/doi/10.1542/peds.10.1016/j.jaad.2021.10.038

DUPILUMAB ASSOCIATED DERMATITIS: AN EMERGING ADVERSE EFFECT

<h3>Introduction</h3> Dupilumab associated head and neck dermatitis (DAHND) refers to persistence or de novo head and neck dermatitis in patients receiving dupilumab for atopic dermatitis. Although not reported in initial clinical trials, it can occur in up to 10% of patients. As shown in this case, the etiology of the dermatitis can be multifactorial and challenging to diagnose and manage. <h3>Case Description</h3> A twelve-year-old boy with a history of severe atopic dermatitis involving 40% TBSA refractory to high potency topical steroids and topical calcineurin inhibitors was started on dupilumab. After two months he had significant improvement of his atopic dermatitis. Two weeks later he developed a new erythematous rash over the face, neck, and upper trunk with overlying scale. Dupilumab was discontinued and he was treated empirically with oral fluconazole with significant but incomplete improvement in symptoms. He then underwent patch testing with clinically relevant reactivity to propylene glycol, MCI/MI, and imidazolidinyl urea. After avoidance of implicated personal care products, his head and neck dermatitis resolved, although the atopic dermatitis flared over the antecubital fossae and flexural surfaces. <h3>Discussion</h3> Th2 blockade by dupilumab can lead to a Th1 or Th17-skewed inflammatory response that unmasks allergic contact dermatitis or <i>Malassezia</i> dermatitis. Initial management involves antifungal therapy and patients with refractory disease should undergo patch testing or evaluation for psoriasis and rosacea. Recognition of DAHND will only become more important as dupilumab becomes widely accessible for patients with atopic dermatitis.

33863 Successful use of dupilumab for treatment of atopic dermatitis in a liver transplant patient

There is a paucity of data regarding the use of dupilumab treatment of atopic dermatitis (AD) in solid organ transplant patients. We report a case of successful treatment of AD in an orthotopic liver transplant (LT) patient with dupilumab with favorable clinical response and no observed side effects throughout two years of treatment. A 65-year-old Caucasian female with history of orthotopic LT for cirrhosis 17 year prior, presented to dermatology clinic with 2-year history of a pruritic eruption involving bilateral extremities. Punch biopsy revealed spongiotic dermatitis with eosinophils, consistent with atopic dermatitis, allergic contact dermatitis, or id reaction. Photo-patch testing revealed positivity for methyldibromo glutaronitrile, benzalkonium chloride, and benzophenone. Despite numerous trials of medium- and high-potency topical steroids as well as intramuscular and oral corticosteroids, the patient experienced continued pruritus and repeated flares. Phototherapy and immunosuppressives including methotrexate and cyclosporine were contraindicated due to the patient’s photo-allergy and LT status on a stable dose of tacrolimus, respectively. After extensive discussion with the patient’s primary care and transplant teams, the decision was made to begin dupilumab. After 1 month of treatment, the patient experienced near clearance of rash, minimal flares that were easily controlled with adjunct topical corticosteroids, and a 90% improvement in subjective pruritus, with no adverse effects. This response was sustained throughout an additional 2 years of treatment. We report this case of successful dupilumab treatment of AD in a LT patient to raise awareness to the safety and efficacy of its use in this patient population.

Why Does Facial Eczema Differ From Body Eczema?

The pathophysiology of atopic dermatitis (AD) is multifactorial, influenced by genetics, skin barrier dysfunction, and environmental stressors. There is a lack of research comparing the etiologies and pathologic mechanisms accounting for differences in facial vs body eczema. To explore reasons why facial eczema may differ from body eczema. There are key differences in the environments of the face and body that may lead to AD exacerbation. These include differences in the skin microbiome, sebaceous glands concentration, and levels of natural moisturizing factor. The face is exposed to more environmental stress compared with the rest of the body. These stresses include aeroallergens, ultraviolet radiation, and cosmetic products. Management of facial eczema also differs from that of body eczema due to the avoidance of high potency topical steroids on the face. Topical steroids increase microbiome diversity, and lack of topical steroid use on the face can lead to decreased microbiome diversity and increased AD severity. Facial and body eczema differ due to differences seen in anatomical structure and environmental exposures. These differences should be further researched and used in the management of facial vs body eczema and can also be used in the development of new AD treatments. J Drugs Dermatol. 2022;21(10): 1119-1123. doi:10.36849/JDD.6354.

Psoriasis

Key Points Psoriasis is characterized by well-demarcated erythematous papules and plaques with overlying scale. Scalp and face may be common sites in children.Guttate psoriasis can follow a streptococcal infection; consider a throat and perianal swab for streptococci to assist in diagnosis and treatment.Medium- to high-potency topical steroids with or without calcipotriol (Dovonex) or calcipotriene are first-line therapy.Refer to dermatology specialist if persistent or widespread disease for consideration of systemic or light therapy.

Diffuse plate-like sheets of desquamation

Diffuse plate-like sheets of desquamation

Iatrogenic Cushing Syndrome Caused by Long-term Use of High Potency Topical Steroid

Iatrogenic Cushing Syndrome Caused by Long-term Use of High Potency Topical Steroid

Management of a Unique Presentation of a Common Dermatologic Condition.

CONTEXTSkin rashes are a common complaint seen in the primary care setting. There are many dermatologic conditions which a primary care provider (PCP) should be able to recognize and manage. One such condition is granuloma annulare (GA), which commonly presents as smooth, annular plaques on the trunk and/or extremities. Rashes like GA rarely present as unique variants and may be difficult for PCPs to determine from patient history and physical exam alone. Patch granuloma annulare (patch GA) is an example that may clinically mimic a cutaneous lymphoma known as mycosis fungoides (MF). PCPs should ideally be able to recognize the utility of performing a skin biopsy and/or referring the patient to a dermatologist when history and physical exam alone are insufficient. The histologic findings of skin biopsies often become essential in establishing a proper diagnosis and guiding patient management in unique dermatologic variants.EXAMPLE CASEThe patient in this clinical practice report is a Caucasian female in her late 60s who presented to a dermatology clinic with a two-year history of a worsening widespread eruption on her trunk and extremities. She had been evaluated previously by her PCP about 4 months prior and, without obtaining skin biopsies, treated her with a medium potency topical corticosteroid cream. The eruption had spread over her hips, buttocks, back, thighs, wrists, and elbows. Multiple skin biopsies of affected sites were taken by the second author and revealed findings consistent with patch GA. The patient was started on topical betamethasone dipropionate 0.05% ointment twice daily and noted marked improvement of her symptoms.CONCLUSIONSAlthough GA is a benign condition of the skin that may be readily detected by PCPs, skin biopsies may be necessary to establish a proper diagnosis when this condition presents as a unique variant (e.g., patch GA). Therapy for patch GA often begins with a trial of high-potency topical steroid therapy in combination with ultraviolet light exposure, depending on disease severity and patient preference. Early evaluation with a skin biopsy by her PCP or an earlier referral to a dermatologist to have skin biopsies performed likely would have helped establish a prompter diagnosis and treatment plan for this patient.

Pediatric Vulvar Lichen Sclerosus: A Survey of Disease Course.

To assess long-term outcomes of lichen sclerosus (LS) in the female pediatric population, specifically in relation to patient age, treatment type and duration, and remission. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Retrospective chart review was conducted to identify female pediatric patients (0-18 years of age) who were diagnosed with LS between January 1, 2015 and January 1, 2020 at the University of North Carolina Dermatology and/or Obstetrics and Gynecology Departments. Patients were contacted via telephone for follow-up interviews consisting of a series of questions regarding patient age, symptom onset, time of diagnosis, treatment, and current symptoms. Of the 128 patients identified, 61 patients consented and participated in follow-up interviews. At the time of study follow-up, 55/61 (90%) of participants reported their symptoms were improved. Patients reported using a variety of treatments, with medium- to high-potency topical steroids being the most common. At the time of follow-up, 53/61 (87%) of patients reported being asymptomatic, 37/53 (70%) of whom were not using any form of maintenance therapy. Those who achieved symptom resolution did so at an average of 8.4 years of age. There was no significant difference in age in asymptomatic patients receiving maintenance therapy and those receiving no maintenance therapy. There was a positive correlation for the duration of LS treatment and time in remission (P < .001). Increased patient age at time of follow-up also correlated positively with time in remission (P < .001). In our cohort, the need for continued maintenance therapy was not correlated with age or, by proxy, pubertal status. Thus, LS remission might be determined more by early and successful pharmacological interventions.

High-Potency Topical Steroid Treatment of Multiple Keratoacanthomas Associated With Prurigo Nodularis.

Patients who present with multiple keratoacanthomas (KAs) associated with prurigo nodularis often pose a treatment challenge. These lesions often require aggressive treatment, such as Mohs micrographic surgery, surgical excision, electrodesiccation and curettage, intralesional steroid injection, and long-term acitretin. 5-Fluorouracil (5-FU) cream 5% has been shown to be effective; however, topical options are limited when 5-FU fails. We have found success using a high-potency topical steroid under occlusion, resulting in resolution of KAs and prurigo nodules.

Erosive pustular dermatosis of the scalp may not be mutually exclusive with other dermatoses

Erosive pustular dermatosis of the scalp is an uncommon neutrophilic process representing a diagnostic and therapeutic challenge. It often occurs in older patients with prior sun exposure and manifests with hyperkeratosis and crust that may be difficult to distinguish from other inflammatory or neoplastic processes. Although erosive pustular dermatosis of the scalp may respond effectively to high potency topical steroids or other antiinflammatory regimens, caution is advised to avoid overlooking differential diagnoses that may not be mutually exclusive, especially squamous cell carcinoma.

Treatment Options in Vulvar Lichen Sclerosus: A Scoping Review.

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. The aim of this review is to focus on first-line, second-line, and maintenance therapies as well as follow-up of women with VLS. With numerous controversies, we decided to conduct a scoping review on this subject. A review protocol was developed, and the Knowledge Resource Services website was used to run a search of articles pertaining to VLS with keywords “Vulvar,” “Vulval,” and “Lichen Sclerosus.” The search was limited to published data from the last 10 years, i.e., July 2009 onward, and researches published in English language. A total of 338 articles pertaining to VLS were obtained. Out of this, 62 were original articles related to management of VLS. Effective treatments such as high-potency topical steroids are now the standard of care and first-line treatment. Follow-up may be done every three to six months for the first two years and then at least yearly to ensure adequacy of treatment and encourage compliance. Long-term follow-up in specialist clinics is recommended for women who have persistent complaints, thickened skin, or history of neoplastic lesion. Monitoring young patients yearly is recommended as there are chances of recurrence.

Dupilumab Injection in the Management of Steroid-Induced Rosacea: A New Case Report

Background: Topical corticosteroids (TCS) are used frequently for various inflammatory skin conditions. The prolonged daily and inappropriate use of TCS may cause adverse effects such as erythema, atrophy, and telangiectasia. Steroid rosacea or addiction is a distinct adverse effect of inappropriate use of TCS. It occurs most commonly in adult women applying mid- or high-potency TCS to the face. Dupilumab is an interleukin 4 (IL-4) receptor α-antagonist approved for treatment Moderate-to-Severe Atopic Dermatitis in childhoods and adults. The role of dupilumab injection in steroid-induced rosacea management is rarely discussed. Aim: To document a new case presentation of atopic dermatitis on high potency topical facial steroid addiction for a duration of 4 years in a young female patient who was successful treated with dupilumab injection and withdrawal therapy. Case Report: A 32-year-old female patient with a history of atopic dermatitis presented with a history of worsening pruritic facial rashes for a one-month duration and on high potency TCS (Clobetasol Propionate ointment 0.05%) since 4 years ago with multiple treatments failure of steroidal withdrawal treated successfully in combination with dupilumab injection. Conclusion: Dupilumab injection considers effective and inducing rapid resolution of signs and symptoms of steroid-induced rosacea in patients with a history of atopic dermatitis in combination with withdrawal therapy without a rebound effect.

Cutaneous adverse events to immune checkpoint inhibitors in pediatric populations: A retrospective cohort study

Cutaneous adverse events to immune checkpoint inhibitors in pediatric populations: A retrospective cohort study

Erosive pustular dermatosis of the scalp: causes and treatments.

Erosive pustular dermatosis of the scalp is a rare condition which primarily affects older women after local trauma and has historically been treated with topical steroids. As it is a rare entity and resembles other dermatologic conditions, it may easily be misdiagnosed. Identifying the causes and evaluating the efficacy of treatments of erosive pustular dermatosis of the scalp (EPDS) is of great importance to both avoid misdiagnosis and ensure optimal treatment of this rare condition. There are numerous causes. In addition to surgeries and physical injuries, topical and procedural treatments for actinic keratoses and androgenetic alopecia can trigger the development of lesions. There are also documented associations with several autoimmune and systemic conditions. Besides corticosteroids, topical tacrolimus and photodynamic therapy were the most commonly used treatments for EPDS. They were effective with few recurrences and adverse effects. Other successful treatment options were topical dapsone, silicone gels, calcipotriol, acitretin, and isotretinoin. Oral dapsone can be used in cases of disseminated disease. Zinc sulfate should be considered with low-serum zinc levels. While cyclosporine was effective, there were adverse effects that may limit its use. It is important for dermatologists to be aware of the wide array of potential causes of erosive pustular dermatosis and include it on their differential. Additionally, although high-potency topical steroids have been historically used as the first-line treatment, there are many other effective treatments that may avoid recurrence and skin atrophy, particularly in the elderly population.

Diabetes mellitus and hyperglycemic complications in bullous pemphigoid

Diabetes mellitus and hyperglycemic complications in bullous pemphigoid