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Cushing’s syndrome due to intramuscular kenalog injection
4461
5678
Current perspectives among U.S. dermatologists on chemoprevention of nonmelanoma skin cancer: A survey based study Brittany Oliver, BS, George Washington University School of Medicine and Health Sciences; Serena Durrani, Johns Hopkins University; Joel Cohen, MD, AboutSkin Dermatology and DermSurgery; Adam Friedman, MD, George Washington University School of Medicine and Health Sciences
Cushing’s syndrome due to intramuscular kenalog injection Katie Benjegerdes, BS, Texas A&M Health Science Center College of Medicine; Bradley Evanson, MD, Baylor Scott and White Health, Department of Dermatology; Katherine Fiala, MD, Baylor Scott and White Health, Department of Dermatology Cushing’s syndrome is a condition caused by chronic exposure to increased levels of circulating glucocorticoids. This syndrome can be endogenous, or it may be the result of exogenous exposure to synthetic glucocorticoids. Development of Cushing’s syndrome in the pediatric population from exposure to topical, intraarticular, and intralesional corticosteroids has been reported. Although exogenous Cushing’s syndrome resulting from the use of intramuscular corticosteroid injection has been reported in adults, no reports in children were found in our literature search. Here, we present the case of a 13-year-old male who presented to dermatology with deep, violaceous striae located diffusely on his trunk and extremities several months after receiving an unknown ‘‘Jesus shot’’ in Oklahoma, later determined to contain the synthetic corticosteroid triamcinolone.
Background: Nonmelanoma skin cancer (NMSC) is the most common malignancy in the U.S. While curable when caught early, NMSC may cause morbidity in patients suffering recurrences and treatment-related disfigurement. Primary prevention of NMSC with physical photoprotective measures are often not sufficient to impact skin cancer incidence in high-risk individuals. Chemoprevention is the use of agents to prevent, suppress, and reverse carcinogenic progression. Many agents have been investigated, but preclinical and clinical studies are often inconsistent. Methods: A 16-question online survey was developed to assess current practices, perceptions, and general knowledge of U.S. dermatologists pertaining to chemopreventive strategies. The voluntary survey was distributed to practicing dermatologists via dermatology society electronic mailing lists. Software from SurveyGizmo. com was used for survey design and anonymous data collection.
Commercial support: None identified.
Results: Approximately half of the 156 responding dermatologists reported being in practice 16 years or more (47.3%) and working in urban communities (48.7%). 59.3% reported ‘‘frequently’’ using topical or targeted therapies, while only 13.7% reported frequent use of systemic chemopreventive therapies. Dermatologists practicing in urban settings were more likely to indicate they believe knowledge has increased substantially (P ¼.047) as compared to colleagues in other communities. Respondents also reported varying degrees of confidence in selecting appropriate chemopreventive regimens: most feel comfortable determining which agents to use in patients, but 29.1% answered ‘‘neutral’’ or ‘‘disagree’’ when asked if they felt comfortable. More experienced dermatologists were more likely to recommend diet modifications such as increased dietary vitamin D (P ¼.014), low fat diet (P ¼.022), and tea polyphenols (P ¼.04) as methods of chemoprevention. Conclusion: Efforts to identify effective, minimally toxic chemopreventive agents have long been underway, but conflicting reports in the literature make formulation of validated guidelines challenging. Our survey confirms differing perceptions, comfort levels, and practice strategies among U.S. dermatologists with regard to utilizing chemopreventive measures. Broadening awareness of available techniques, correcting misconceptions, and updating practitioners on emerging research is warranted to achieve consensus within the dermatology community and improve patient outcomes. Commercial support: None identified.
4464 5114 Current practice in management of chondrodermatitis nodularis helicis among dermatologists in Scotland Sze Ting Ngu, MBChB, NHS Lanarkshire; Goutam Dawn, MBBS, NHS Lanarkshire
Cutaneous adverse drug reaction due to vildagliptin Taynara Barreto, MD, Instituto de Dermatologia Professor Rubem David Azulay; Mario Mejia, MD, Instituto de Dermatologia Professor Rubem David Azulay; Mariana Sasse, MD, Instituto de Dermatologia Professor Rubem David Azulay; Felipe Aguinaga, MD, Instituto de Dermatologia Professor Rubem David Azulay; Danielle Quintella, MD, Instituto de Dermatologia Professor Rubem David Azulay
Chondrodermatitis nodularis helicis (CDH) is a benign inflammatory condition of the helix or antihelix of the ear. The pathogenesis is not fully known, but has been associated with decreased blood flow secondary to prolonged pressure upon the auricular cartilage. CDH is thought to be an idiopathic disorder but systemic association with autoimmune and connective tissue disorders have been reported. Diagnosis is mostly made clinically and treatment can be challenging with recurrence being common. There appears to be a lack of clinical guideline in managing CDH. We surveyed Scottish dermatologists to establish what investigations are undertaken, if diagnostic biopsies are performed, therapeutic preferences, how often recurrences are encountered and if patients are followed up. Consultants, associated specialists, specialty doctors and trainees were sent a five-question survey online. 58 of 137 (42.3%) responded. Most dermatologists do not perform any investigations in CDH. Forty-seven (81.0%) would perform biopsies for diagnostic uncertainty. The preferred first-line treatment was lifestyle advice to sleep on opposite side, as indicated by 28 (48.3%) dermatologists. Twenty-two (41.5%) preferred using pressure relieving prosthesis; and 16 (27.6%) performed cryotherapy as first-line treatment. Various surgical treatments were used as first line by 7 (12.1%) dermatologists: conservative surgical excision (3), wedge excision (3), and curettage and cautery (1). Overall, pressure relieving prosthesis was the commonest treatment, used by 53 (91.4%) dermatologists. This is followed by cryotherapy (84.5%), and lifestyle advice to sleep on opposite side or conservative surgical excision (82.8%). Thirty (52.6%) dermatologists encounter recurrence once or twice following successful treatment. Arrangement for follow-up was variable, ranging from 15 (25.9%) indicating never to 19 (32.8%) continuing with follows up until the lesion resolves. Variation in practice among dermatologists is observed. Historically surgical treatment has been the mainstay treatment. However, most recent literature search has shown similar cure and recurrence rates for both surgical and conservative treatments, hence recommended reserving surgical treatments for CDH not responding to conservative approach using decompression devices. Nevertheless, in order to establish guidelines for the best treatment of CNH, larger, prospective, controlled, and randomized long-term studies are still required.
Introduction: Vildagliptin is an oral antihyperglycemic drug that is part of the class of gliptins, dipeptidyl peptidase IV enzyme (DPP-4) inhibitors, acting on metabolism of incretins. In literature, bullous pemphigoid (BP) has been reported in association with gliptins. Other cutaneous adverse effects that have been described for DPP-IV inhibitors include blisters, skin ulcers, photosensitivity, anaphylactic reactions and StevenseJohnson syndrome. Case report: Female patient, 88 years old, presented with history of pruritus and formation of bullae over erythematous lesions mostly in the trunk and a few in the limbs for two months. She had a medical history of diabetes type 2, using a combination of vildagliptin plus metformin for two years. At physical examination, the patient presented erythematous plaques with exulceration, without intact bullae and there was no evidence of mucosal involvement. The diagnostic hypotheses were bullous pemphigoid and cutaneous adverse drug reaction. Skin biopsy was performed showing detached epidermis with parakeratosis, presence of leukocytes and bacteria in the stratum corneum; and perivascular mononuclear inflammatory infiltrate with some eosinophils in the dermis. After biopsy, the patient was treated with high potency topical corticosteroids; however, the symptoms persisted after 6 weeks of follow-up. Vildagliptin was then suspected as a cause and suspended, with improvement of the patient’s condition. Discussion: DPP-4 is widely distributed in the body, being expressed in many tissues including the skin. In keratinocytes, DPP-4 may contribute to cytokines production, tissue differentiation and collagen metabolism. In preclinical studies, gliptins induced dose-dependent ‘‘blistering necrotic’’ skin lesions in monkeys. On PubMed, eight articles correlate gliptins and BP, being vildagliptin the gliptin most implicated in the occurrence of the disease. In the largest study to date, Garcia et al report 169 cases of BP related to gliptins, 113 of those linked to vildagliptin. Gliptins can induce PB by modification of the immune response and/or changes in the antigenic properties of the basal membrane. These mechanisms lead to blisters formation. The gliptins are currently considered drugs with increased risk for the occurrence of bullous pemphigoid and the awareness of that risk can accelerate the accurate diagnosis and prevent unnecessary treatments with serious side effects.
Commercial support: None identified.
Commercial support: None identified.
JUNE 2017
J AM ACAD DERMATOL
AB87
5678
Current perspectives among U.S. dermatologists on chemoprevention of nonmelanoma skin cancer: A survey based study Brittany Oliver, BS, George Washington University School of Medicine and Health Sciences; Serena Durrani, Johns Hopkins University; Joel Cohen, MD, AboutSkin Dermatology and DermSurgery; Adam Friedman, MD, George Washington University School of Medicine and Health Sciences
Cushing’s syndrome due to intramuscular kenalog injection Katie Benjegerdes, BS, Texas A&M Health Science Center College of Medicine; Bradley Evanson, MD, Baylor Scott and White Health, Department of Dermatology; Katherine Fiala, MD, Baylor Scott and White Health, Department of Dermatology Cushing’s syndrome is a condition caused by chronic exposure to increased levels of circulating glucocorticoids. This syndrome can be endogenous, or it may be the result of exogenous exposure to synthetic glucocorticoids. Development of Cushing’s syndrome in the pediatric population from exposure to topical, intraarticular, and intralesional corticosteroids has been reported. Although exogenous Cushing’s syndrome resulting from the use of intramuscular corticosteroid injection has been reported in adults, no reports in children were found in our literature search. Here, we present the case of a 13-year-old male who presented to dermatology with deep, violaceous striae located diffusely on his trunk and extremities several months after receiving an unknown ‘‘Jesus shot’’ in Oklahoma, later determined to contain the synthetic corticosteroid triamcinolone.
Background: Nonmelanoma skin cancer (NMSC) is the most common malignancy in the U.S. While curable when caught early, NMSC may cause morbidity in patients suffering recurrences and treatment-related disfigurement. Primary prevention of NMSC with physical photoprotective measures are often not sufficient to impact skin cancer incidence in high-risk individuals. Chemoprevention is the use of agents to prevent, suppress, and reverse carcinogenic progression. Many agents have been investigated, but preclinical and clinical studies are often inconsistent. Methods: A 16-question online survey was developed to assess current practices, perceptions, and general knowledge of U.S. dermatologists pertaining to chemopreventive strategies. The voluntary survey was distributed to practicing dermatologists via dermatology society electronic mailing lists. Software from SurveyGizmo. com was used for survey design and anonymous data collection.
Commercial support: None identified.
Results: Approximately half of the 156 responding dermatologists reported being in practice 16 years or more (47.3%) and working in urban communities (48.7%). 59.3% reported ‘‘frequently’’ using topical or targeted therapies, while only 13.7% reported frequent use of systemic chemopreventive therapies. Dermatologists practicing in urban settings were more likely to indicate they believe knowledge has increased substantially (P ¼.047) as compared to colleagues in other communities. Respondents also reported varying degrees of confidence in selecting appropriate chemopreventive regimens: most feel comfortable determining which agents to use in patients, but 29.1% answered ‘‘neutral’’ or ‘‘disagree’’ when asked if they felt comfortable. More experienced dermatologists were more likely to recommend diet modifications such as increased dietary vitamin D (P ¼.014), low fat diet (P ¼.022), and tea polyphenols (P ¼.04) as methods of chemoprevention. Conclusion: Efforts to identify effective, minimally toxic chemopreventive agents have long been underway, but conflicting reports in the literature make formulation of validated guidelines challenging. Our survey confirms differing perceptions, comfort levels, and practice strategies among U.S. dermatologists with regard to utilizing chemopreventive measures. Broadening awareness of available techniques, correcting misconceptions, and updating practitioners on emerging research is warranted to achieve consensus within the dermatology community and improve patient outcomes. Commercial support: None identified.
4464 5114 Current practice in management of chondrodermatitis nodularis helicis among dermatologists in Scotland Sze Ting Ngu, MBChB, NHS Lanarkshire; Goutam Dawn, MBBS, NHS Lanarkshire
Cutaneous adverse drug reaction due to vildagliptin Taynara Barreto, MD, Instituto de Dermatologia Professor Rubem David Azulay; Mario Mejia, MD, Instituto de Dermatologia Professor Rubem David Azulay; Mariana Sasse, MD, Instituto de Dermatologia Professor Rubem David Azulay; Felipe Aguinaga, MD, Instituto de Dermatologia Professor Rubem David Azulay; Danielle Quintella, MD, Instituto de Dermatologia Professor Rubem David Azulay
Chondrodermatitis nodularis helicis (CDH) is a benign inflammatory condition of the helix or antihelix of the ear. The pathogenesis is not fully known, but has been associated with decreased blood flow secondary to prolonged pressure upon the auricular cartilage. CDH is thought to be an idiopathic disorder but systemic association with autoimmune and connective tissue disorders have been reported. Diagnosis is mostly made clinically and treatment can be challenging with recurrence being common. There appears to be a lack of clinical guideline in managing CDH. We surveyed Scottish dermatologists to establish what investigations are undertaken, if diagnostic biopsies are performed, therapeutic preferences, how often recurrences are encountered and if patients are followed up. Consultants, associated specialists, specialty doctors and trainees were sent a five-question survey online. 58 of 137 (42.3%) responded. Most dermatologists do not perform any investigations in CDH. Forty-seven (81.0%) would perform biopsies for diagnostic uncertainty. The preferred first-line treatment was lifestyle advice to sleep on opposite side, as indicated by 28 (48.3%) dermatologists. Twenty-two (41.5%) preferred using pressure relieving prosthesis; and 16 (27.6%) performed cryotherapy as first-line treatment. Various surgical treatments were used as first line by 7 (12.1%) dermatologists: conservative surgical excision (3), wedge excision (3), and curettage and cautery (1). Overall, pressure relieving prosthesis was the commonest treatment, used by 53 (91.4%) dermatologists. This is followed by cryotherapy (84.5%), and lifestyle advice to sleep on opposite side or conservative surgical excision (82.8%). Thirty (52.6%) dermatologists encounter recurrence once or twice following successful treatment. Arrangement for follow-up was variable, ranging from 15 (25.9%) indicating never to 19 (32.8%) continuing with follows up until the lesion resolves. Variation in practice among dermatologists is observed. Historically surgical treatment has been the mainstay treatment. However, most recent literature search has shown similar cure and recurrence rates for both surgical and conservative treatments, hence recommended reserving surgical treatments for CDH not responding to conservative approach using decompression devices. Nevertheless, in order to establish guidelines for the best treatment of CNH, larger, prospective, controlled, and randomized long-term studies are still required.
Introduction: Vildagliptin is an oral antihyperglycemic drug that is part of the class of gliptins, dipeptidyl peptidase IV enzyme (DPP-4) inhibitors, acting on metabolism of incretins. In literature, bullous pemphigoid (BP) has been reported in association with gliptins. Other cutaneous adverse effects that have been described for DPP-IV inhibitors include blisters, skin ulcers, photosensitivity, anaphylactic reactions and StevenseJohnson syndrome. Case report: Female patient, 88 years old, presented with history of pruritus and formation of bullae over erythematous lesions mostly in the trunk and a few in the limbs for two months. She had a medical history of diabetes type 2, using a combination of vildagliptin plus metformin for two years. At physical examination, the patient presented erythematous plaques with exulceration, without intact bullae and there was no evidence of mucosal involvement. The diagnostic hypotheses were bullous pemphigoid and cutaneous adverse drug reaction. Skin biopsy was performed showing detached epidermis with parakeratosis, presence of leukocytes and bacteria in the stratum corneum; and perivascular mononuclear inflammatory infiltrate with some eosinophils in the dermis. After biopsy, the patient was treated with high potency topical corticosteroids; however, the symptoms persisted after 6 weeks of follow-up. Vildagliptin was then suspected as a cause and suspended, with improvement of the patient’s condition. Discussion: DPP-4 is widely distributed in the body, being expressed in many tissues including the skin. In keratinocytes, DPP-4 may contribute to cytokines production, tissue differentiation and collagen metabolism. In preclinical studies, gliptins induced dose-dependent ‘‘blistering necrotic’’ skin lesions in monkeys. On PubMed, eight articles correlate gliptins and BP, being vildagliptin the gliptin most implicated in the occurrence of the disease. In the largest study to date, Garcia et al report 169 cases of BP related to gliptins, 113 of those linked to vildagliptin. Gliptins can induce PB by modification of the immune response and/or changes in the antigenic properties of the basal membrane. These mechanisms lead to blisters formation. The gliptins are currently considered drugs with increased risk for the occurrence of bullous pemphigoid and the awareness of that risk can accelerate the accurate diagnosis and prevent unnecessary treatments with serious side effects.
Commercial support: None identified.
Commercial support: None identified.
JUNE 2017
J AM ACAD DERMATOL
AB87