A newsletter that delivers the latest in dermatology research directly to you.
seventieth issue
October 2, 2024
Low dose metformin facilitates hair regrowth and improvements in scalp discomfort in central centrifugal cicatricial alopecia
JAMA Dermatology
JAMA Dermatology
From blood sugar to bold strands: Metformin might be the next unexpected treatment for CCCA!
Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia in which chronic inflammation results in hair loss and deposition of scar tissue. Existing treatments for CCCA primarily target the chronic inflammation, not fibrotic scarring, associated with this condition. Metformin is an antidiabetic drug that has demonstrated anti-fibrotic properties, making it a potential treatment for reversing fibrosis in CCCA. This retrospective case series explored daily metformin's efficacy in improving disease among CCCA patients.
What did they find?
Main Takeaway: Metformin demonstrates potential as a targeted therapy for CCCA by altering gene expression to suppress fibrosis and inflammation and stimulate hair growth.
Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia in which chronic inflammation results in hair loss and deposition of scar tissue. Existing treatments for CCCA primarily target the chronic inflammation, not fibrotic scarring, associated with this condition. Metformin is an antidiabetic drug that has demonstrated anti-fibrotic properties, making it a potential treatment for reversing fibrosis in CCCA. This retrospective case series explored daily metformin's efficacy in improving disease among CCCA patients.
What did they find?
- 75% (9/12) of patients experienced improvements in scalp pain, scalp resistance, pruritus, and/or inflammation after at least 6 months of treatment.
- 16.7% (2/12) experienced worsening symptoms.
- 60% (6/12) of patients experienced hair regrowth.
- Transcriptomic analysis of 4 patients showed upregulation of 23 different hair keratin-associated proteins (all fold change > 4) and downregulation of genes involved in extracellular matrix and collagen organization (fold change > 1.5; all false discovery rate < 0.05) after treatment.
- Gene set variation analysis demonstrated a reduction in the expression of genes associated with Th17 cells (mean [SD] GSVA score: pretreatment, 0.17 [0.11]; posttreatment, −0.11 [0.23]; p = 0.04) and the epithelial-mesenchymal transition (mean [SD] GSVA score: pretreatment, 0.22 [0.21]; posttreatment, −0.20 [0.24]; p = 0.03) after treatment.
Main Takeaway: Metformin demonstrates potential as a targeted therapy for CCCA by altering gene expression to suppress fibrosis and inflammation and stimulate hair growth.
Identification of the pigments used in permanent makeup and their ability to elicit allergic contact dermatitis
Journal of the American Academy of Dermatology
Journal of the American Academy of Dermatology
Permanent makeup seems to be scratching just about every itch!
Allergic contact dermatitis (ACD) is a common form of dermatitis caused by CD4+ T-lymphocyte allergen activation on the skin. Allergens within products such as jewelry, fragrances, dyes, pigments, and inks are known to be causes of ACD. A new form of tattooing, permanent makeup (PMU), has been gaining prominence for cosmetic enhancement of eyebrows, eyelids, and lips. However, the inks used in PMU have yet to be examined for allergic potential. This search-based study sought to identify US-sold PMU pigments and review known cases of ACD in such pigments.
What did they find?
Main Takeaway: PMU is mostly composed of organic pigments and some ingredients are reported to cause ACD. However, specific allergens are continually difficult to identify due to limited ingredient labeling and poor FDA regulation of such products.
Allergic contact dermatitis (ACD) is a common form of dermatitis caused by CD4+ T-lymphocyte allergen activation on the skin. Allergens within products such as jewelry, fragrances, dyes, pigments, and inks are known to be causes of ACD. A new form of tattooing, permanent makeup (PMU), has been gaining prominence for cosmetic enhancement of eyebrows, eyelids, and lips. However, the inks used in PMU have yet to be examined for allergic potential. This search-based study sought to identify US-sold PMU pigments and review known cases of ACD in such pigments.
What did they find?
- Across 25 brands and 974 individual products, 79 pigments were identified, of which 25% (20/79) contained inorganic metal pigments. The remaining 75% (59/79) contained organic pigments only.
- A literature search identified 29 patients with confirmed or suspected ACD for 10 of the 79 pigments.
- The average PMU product contained 4 pigments.
Main Takeaway: PMU is mostly composed of organic pigments and some ingredients are reported to cause ACD. However, specific allergens are continually difficult to identify due to limited ingredient labeling and poor FDA regulation of such products.
Increased risk of death, major adverse cardiac events, and infection seen with oral corticosteroid treatment in bullous pemphigoid as compared to topical corticosteroids
British Journal of Dermatology
British Journal of Dermatology
Topical corticosteroids stay on top for bullous pemphigoid treatment with fewer risks than oral corticosteroids!
Bullous pemphigoid (BP) is an autoimmune disorder that can lead to diffuse cutaneous blistering. Topical and oral corticosteroids (CS) are first-line therapies for BP; however, long-term use leads to adverse effects due to immunosuppression, and discontinuation can potentially cause disease relapse. This retrospective cohort study sought to evaluate the risk of death, major adverse cardiac events (MACEs), infection, and relapse in topical vs. oral CS at various dosage levels.
What did they find?
Main Takeaway: Although oral CS have a decreased risk of relapse, their increased risk of death, MACEs, and infection suggests that topical CS may be a better option for BP treatment.
Bullous pemphigoid (BP) is an autoimmune disorder that can lead to diffuse cutaneous blistering. Topical and oral corticosteroids (CS) are first-line therapies for BP; however, long-term use leads to adverse effects due to immunosuppression, and discontinuation can potentially cause disease relapse. This retrospective cohort study sought to evaluate the risk of death, major adverse cardiac events (MACEs), infection, and relapse in topical vs. oral CS at various dosage levels.
What did they find?
- Increased risk of death was seen in patients with any exposure (low and medium-high doses) to oral CS vs. patients treated with topical clobetasol propionate [HR (1.43), 95% CI (1.28–1.58)].
- Increased risks for MACE [HR (1.33), 95% CI (1.08–1.64)] and infections [HR (1.33), 95% CI (1.15–1.54)] were seen with oral CS treatment.
- Decreased risk of continued disease or relapse was seen in patients treated with oral CS [HR (0.85), 95% CI (0.77–0.94)].
Main Takeaway: Although oral CS have a decreased risk of relapse, their increased risk of death, MACEs, and infection suggests that topical CS may be a better option for BP treatment.
Early insights on infantile hemangioma precursor lesions present at day of life 1 from a retrospective case series
Pediatric Dermatology
Pediatric Dermatology
Spotting the Red Flags Early!
Infantile hemangiomas (IHs) are the most common vascular tumors in infants. They are not typically present at birth and often emerge in the first weeks of life. However, increasing literature shows these lesions may actually be present at birth and initially go unrecognized, being attributed to birth trauma or normal neonatal physiology. This retrospective case series focused on neonates with precursor lesions documented on day of life (DOL) 1 and their progression to classical IHs through the use of photos and clinical observation.
What did they find?
Main Takeaway: Close clinical observation on DOL 1 can lead to early detection of IH precursor lesions, improving diagnostic accuracy, reducing unnecessary interventions, and allowing for better management of IHs.
Infantile hemangiomas (IHs) are the most common vascular tumors in infants. They are not typically present at birth and often emerge in the first weeks of life. However, increasing literature shows these lesions may actually be present at birth and initially go unrecognized, being attributed to birth trauma or normal neonatal physiology. This retrospective case series focused on neonates with precursor lesions documented on day of life (DOL) 1 and their progression to classical IHs through the use of photos and clinical observation.
What did they find?
- 9 neonates (7 females, 2 males) who exhibited well-defined precursor lesions at DOL 1, with subsequent development into classic IHs were included.
- The differential diagnosis for precursor lesions included capillary, venous, and lymphatic malformation, in addition to congenital hemangioma.
- 3 underwent ultrasound imaging, and 1 was found to have an IH at DOL 19, while the remaining 2 patients (DOL 9 and 14) did not detect any radiologic changes despite the presence of precursor lesions.
Main Takeaway: Close clinical observation on DOL 1 can lead to early detection of IH precursor lesions, improving diagnostic accuracy, reducing unnecessary interventions, and allowing for better management of IHs.
What are the antimicrobial susceptibility profiles of S. aureus strains from atopic dermatitis patients worldwide?
Global Dermatology
Global Dermatology
Antibacterial resistance is ~a tough bug~ to crack!
Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting millions globally, with up to 70% of individuals colonized by Staphylococcus aureus, a common trigger for flares and infections. Differentiating between flares and superinfections can be difficult, often leading to the empirical use of antibiotics. This systematic review analyzed the global antimicrobial susceptibility patterns of S. aureus strains in individuals with atopic dermatitis, highlighting differences based on regional antibiotic resistance and country income levels.
What did they find?
Main Takeaway: S. aureus exhibited suboptimal antimicrobial susceptibility to β-lactams, erythromycin, fusidic acid, and clindamycin in patients with atopic dermatitis, with significant regional differences observed between low- and middle-income countries compared to high-income countries
Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting millions globally, with up to 70% of individuals colonized by Staphylococcus aureus, a common trigger for flares and infections. Differentiating between flares and superinfections can be difficult, often leading to the empirical use of antibiotics. This systematic review analyzed the global antimicrobial susceptibility patterns of S. aureus strains in individuals with atopic dermatitis, highlighting differences based on regional antibiotic resistance and country income levels.
What did they find?
- Four of the most commonly reported antibiotics had antimicrobial susceptibility rates of ≤ 85%, including methicillin (85%; 95% CI: 76%-91%), erythromycin (73%; 95% CI: 61-83%), fusidic acid (80%; 95% CI: 62-91%), and clindamycin (79%; 95% CI: 65-89%).
- Significant differences in antimicrobial susceptibility were noted by country income level, with lower susceptibility rates in lower middle-income countries compared to high-income countries for erythromycin (59% lower middle-income vs 76% high-income) and methicillin (62% lower middle-income vs 86% high-income).
- Subgroup analysis revealed no significant changes in antibiotic susceptibility over time, but variations were observed by patient age and healthcare settings:
- Antimicrobial susceptibility rates for fusidic acid were higher for children (87%; 95% CI: 72-95%) compared to adults (56%; 95% CI: 44-67%).
- Susceptibility profiles for trimethoprim and sulfamethoxazole were lower in primary care (50%; 95% CI: 31-69%) compared to tertiary care (98%; 95% CI: 87-100%) settings.
- Antimicrobial susceptibility rates for fusidic acid were higher for children (87%; 95% CI: 72-95%) compared to adults (56%; 95% CI: 44-67%).
Main Takeaway: S. aureus exhibited suboptimal antimicrobial susceptibility to β-lactams, erythromycin, fusidic acid, and clindamycin in patients with atopic dermatitis, with significant regional differences observed between low- and middle-income countries compared to high-income countries
Say Goodbye to Sweaty Hands
Hyperhidrosis, a condition characterized by excessive sweating, can significantly impact patients' quality of life. Many seek relief through treatments like intradermal botulinum toxin injections, which have been shown to be both safe and effective. However, for optimal results, the injection sites must be evenly spaced to ensure proper coverage. Typically, dots are manually marked 1-2 cm apart prior to injection, but this process can be time-consuming, leading to inconsistent use. To simplify the procedure, researchers developed a 3D-printed mold with 1 cm spaced conical spikes. This mold is pressed into gauze soaked with povidone-iodine, acting as an 'ink pad,' and then applied to the injection area, ensuring precise and uniform site marking. See the image below for a visual representation of this technique.
Hyperhidrosis, a condition characterized by excessive sweating, can significantly impact patients' quality of life. Many seek relief through treatments like intradermal botulinum toxin injections, which have been shown to be both safe and effective. However, for optimal results, the injection sites must be evenly spaced to ensure proper coverage. Typically, dots are manually marked 1-2 cm apart prior to injection, but this process can be time-consuming, leading to inconsistent use. To simplify the procedure, researchers developed a 3D-printed mold with 1 cm spaced conical spikes. This mold is pressed into gauze soaked with povidone-iodine, acting as an 'ink pad,' and then applied to the injection area, ensuring precise and uniform site marking. See the image below for a visual representation of this technique.
Main Takeaway: The use of a 3D-printed mold outlining injection sites for hyperhidrosis presents a novel technique for equal distribution of botulinum toxin to the area to treat. This method could be translated to other injectable treatments, such as steroid injections for alopecia areata.
DERMLITE Dermoscopy QUESTION OF THE WEEK
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