Dermatology

A 2-year-old girl with Fitzpatrick skin type VI who had recently emigrated from Djibouti presented to our dermatology clinic for a rash that appeared when she was 2 months old. The lesions occasionally were pruritic after sun exposure or after crawling outside. There was no associated abdominal pain, diarrhea, flushing, or hypotension. Topical moisturizers were not helpful.

The patient had no known allergies or other notable medical history. Physical examination revealed multiple hyperpigmented, oval-shaped, slightly raised papules and plaques on her torso (FIGURE 1), neck, and arms, and fewer lesions on her face and legs. Darier sign was not appreciated on the initial consult. A 4-mm punch biopsy of the patient’s right middle back was performed at this visit.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

The presence of a hyperpigmented skin lesion that becomes pruritic, raised, and erythematous when rubbed (Darier sign) is the major criterion for the diagnosis of cutaneous mastocytosis.¹ Minor criteria include a skin biopsy demonstrating a 4- to 8-fold  increase in the number of mast cells within the papillary dermis and the presence of cKIT mutations.¹ In this case, the patient’s punch biopsy results came back positive for clonal mast cell infiltration of the papillary dermis (FIGURES 2A and 2B), and her physician elicited a slightly positive Darier sign during a follow-up visit.

IMAGES COURTESY OF JOSHUA D. SPARLING, MD

Mastocytosis is characterized by pathognomonic proliferation of clonal mast cells with either cutaneous or systemic involvement.¹ Mast cell expansion most commonly is found in the skin and bone marrow; however, involvement of the gastrointestinal tract, liver, spleen, and lymph nodes also has been documented.¹ Nonhereditary somatic mutations of the cKIT gene have been observed in many studies and may be associated with increased proliferation of clonal mast cells.²

A review of the English-language literature on cutaneous mastocytosis reveals a paucity of reports in darker skin types. However, it is important for clinicians to be able to recognize this disease in all skin types.

Three subcategories. Cutaneous mastocytosis is divided into 3 subcategories: mastocytoma of the skin (1–3 solitary skin lesions), maculopapular cutaneous mastocytosis, also known as urticaria pigmentosa (as seen in our patient; usually ≥ 4 lesions); and diffuse cutaneous mastocytosis (confluent lesions; leathery appearance of skin).^1,3,4 Maculopapular cutaneous mastocytosis, which our patient had, classically develops within the first 6 months of life and presents as hyperpigmented macules and papules.

Keep in mind that systemic involvement in cutaneous mastocytosis occasionally occurs and can be associated with anaphylaxis, flushing, headache, dyspnea, nausea, emesis, diarrhea, abdominal pain, and hepatosplenomegaly.²

Continue to: Narrowing down a broad differential diagnosis

Our cas a ase was made somewhat challenging by the patient’s darkly pigmented skin color, which made any erythema and other cutaneous signs less visible. The differential was broad and included postinflammatory hyperpigmentation from eczema, multiple congenital nevi, sarcoidosis, leprosy, and cutaneous tuberculosis, all of which can be eliminated by performing a biopsy of the lesion.

Diagnostic criteria include biopsy and laboratory findings

In addition to a skin biopsy, initial assessment in cases of suspected cutaneous mastocytosis should include a complete blood cell count with differential, liver function tests (+/- liver ultrasound), a serum tryptase level, and a peripheral smear. Serum tryptase levels > 20 ng/mL have been shown to correlate with a higher probability of systemic mastocytosis. Higher tryptase levels also correlate with severity of disease in children.⁵

Treatment focuses on minimizing mast cell degranulation

Due to the relatively benign course of cutaneous mastocytosis, the mainstay of treatment is focused on minimizing mast cell degranulation to control subsequent symptoms. Avoiding precipitating factors such as temperature extremes, external stimulation of lesions, dry skin, infection, and certain medications (eg, nonsteroidal anti-inflammatory drugs, aspirin, morphine, polymyxin B sulphate, anticholinergics, some systemic anesthetics) that can stimulate mast cell degranulation is encouraged.² H₁ and H₂ antihistamines are the first-line treatment for mild to moderate symptoms. In refractory cases, leukotriene receptor antagonists or oral cromolyn sodium may be considered.²

Regular follow-up every 6 to 12 months should be established after diagnosis.¹ If symptoms persist into adulthood or concern for disease progression is high, a bone marrow biopsy is recommended.¹

Our patient

Our patient’s laboratory results revealed a normal serum tryptase level (3.4 ng/mL; reference range < 11.5 ng/mL) and complete blood cell count. A complete metabolic panel demonstrated elevated and high-normal liver function tests with alanine aminotransferase (ALT) at 111 u/L (reference range, 10–40 u/L) and aspartate aminotransferase (AST) at 55 u/L (reference range, 7–56 u/L).

Continue to: As a precaution...

It is important for clinicians to be able to recognize this disease in all skin types.

As a precaution and for consideration of further work-up, such as the need for a liver ultrasound, the patient was referred to Pediatric Gastroenterology. The specialist repeated the liver function tests, the results of which were lower (ALT, 42 u/L; AST, 24 u/L); a liver ultrasound was thought to be unnecessary.

Our patient’s otherwise negative review of systems led the specialist to feel confident that no systemic disease was present at the time. These results were discussed with the patient’s parents and counseling about trigger avoidance was provided. The patient was given pediatric-dosed oral and topical H₁ antihistamines for symptom relief.

CORRESPONDENCE
Joshua D. Sparling, MD, 6 E Chestnut Street, Ste 340, Augusta, ME 04330; [email protected]

A 2-year-old girl with Fitzpatrick skin type VI who had recently emigrated from Djibouti presented to our dermatology clinic for a rash that appeared when she was 2 months old. The lesions occasionally were pruritic after sun exposure or after crawling outside. There was no associated abdominal pain, diarrhea, flushing, or hypotension. Topical moisturizers were not helpful.

The patient had no known allergies or other notable medical history. Physical examination revealed multiple hyperpigmented, oval-shaped, slightly raised papules and plaques on her torso (FIGURE 1), neck, and arms, and fewer lesions on her face and legs. Darier sign was not appreciated on the initial consult. A 4-mm punch biopsy of the patient’s right middle back was performed at this visit.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

The presence of a hyperpigmented skin lesion that becomes pruritic, raised, and erythematous when rubbed (Darier sign) is the major criterion for the diagnosis of cutaneous mastocytosis.¹ Minor criteria include a skin biopsy demonstrating a 4- to 8-fold  increase in the number of mast cells within the papillary dermis and the presence of cKIT mutations.¹ In this case, the patient’s punch biopsy results came back positive for clonal mast cell infiltration of the papillary dermis (FIGURES 2A and 2B), and her physician elicited a slightly positive Darier sign during a follow-up visit.

IMAGES COURTESY OF JOSHUA D. SPARLING, MD

Mastocytosis is characterized by pathognomonic proliferation of clonal mast cells with either cutaneous or systemic involvement.¹ Mast cell expansion most commonly is found in the skin and bone marrow; however, involvement of the gastrointestinal tract, liver, spleen, and lymph nodes also has been documented.¹ Nonhereditary somatic mutations of the cKIT gene have been observed in many studies and may be associated with increased proliferation of clonal mast cells.²

A review of the English-language literature on cutaneous mastocytosis reveals a paucity of reports in darker skin types. However, it is important for clinicians to be able to recognize this disease in all skin types.

Three subcategories. Cutaneous mastocytosis is divided into 3 subcategories: mastocytoma of the skin (1–3 solitary skin lesions), maculopapular cutaneous mastocytosis, also known as urticaria pigmentosa (as seen in our patient; usually ≥ 4 lesions); and diffuse cutaneous mastocytosis (confluent lesions; leathery appearance of skin).^1,3,4 Maculopapular cutaneous mastocytosis, which our patient had, classically develops within the first 6 months of life and presents as hyperpigmented macules and papules.

Keep in mind that systemic involvement in cutaneous mastocytosis occasionally occurs and can be associated with anaphylaxis, flushing, headache, dyspnea, nausea, emesis, diarrhea, abdominal pain, and hepatosplenomegaly.²

Continue to: Narrowing down a broad differential diagnosis

Our cas a ase was made somewhat challenging by the patient’s darkly pigmented skin color, which made any erythema and other cutaneous signs less visible. The differential was broad and included postinflammatory hyperpigmentation from eczema, multiple congenital nevi, sarcoidosis, leprosy, and cutaneous tuberculosis, all of which can be eliminated by performing a biopsy of the lesion.

Diagnostic criteria include biopsy and laboratory findings

In addition to a skin biopsy, initial assessment in cases of suspected cutaneous mastocytosis should include a complete blood cell count with differential, liver function tests (+/- liver ultrasound), a serum tryptase level, and a peripheral smear. Serum tryptase levels > 20 ng/mL have been shown to correlate with a higher probability of systemic mastocytosis. Higher tryptase levels also correlate with severity of disease in children.⁵

Treatment focuses on minimizing mast cell degranulation

Due to the relatively benign course of cutaneous mastocytosis, the mainstay of treatment is focused on minimizing mast cell degranulation to control subsequent symptoms. Avoiding precipitating factors such as temperature extremes, external stimulation of lesions, dry skin, infection, and certain medications (eg, nonsteroidal anti-inflammatory drugs, aspirin, morphine, polymyxin B sulphate, anticholinergics, some systemic anesthetics) that can stimulate mast cell degranulation is encouraged.² H₁ and H₂ antihistamines are the first-line treatment for mild to moderate symptoms. In refractory cases, leukotriene receptor antagonists or oral cromolyn sodium may be considered.²

Regular follow-up every 6 to 12 months should be established after diagnosis.¹ If symptoms persist into adulthood or concern for disease progression is high, a bone marrow biopsy is recommended.¹

Our patient

Our patient’s laboratory results revealed a normal serum tryptase level (3.4 ng/mL; reference range < 11.5 ng/mL) and complete blood cell count. A complete metabolic panel demonstrated elevated and high-normal liver function tests with alanine aminotransferase (ALT) at 111 u/L (reference range, 10–40 u/L) and aspartate aminotransferase (AST) at 55 u/L (reference range, 7–56 u/L).

Continue to: As a precaution...

It is important for clinicians to be able to recognize this disease in all skin types.

As a precaution and for consideration of further work-up, such as the need for a liver ultrasound, the patient was referred to Pediatric Gastroenterology. The specialist repeated the liver function tests, the results of which were lower (ALT, 42 u/L; AST, 24 u/L); a liver ultrasound was thought to be unnecessary.

Our patient’s otherwise negative review of systems led the specialist to feel confident that no systemic disease was present at the time. These results were discussed with the patient’s parents and counseling about trigger avoidance was provided. The patient was given pediatric-dosed oral and topical H₁ antihistamines for symptom relief.

CORRESPONDENCE
Joshua D. Sparling, MD, 6 E Chestnut Street, Ste 340, Augusta, ME 04330; [email protected]

A 2-year-old girl with Fitzpatrick skin type VI who had recently emigrated from Djibouti presented to our dermatology clinic for a rash that appeared when she was 2 months old. The lesions occasionally were pruritic after sun exposure or after crawling outside. There was no associated abdominal pain, diarrhea, flushing, or hypotension. Topical moisturizers were not helpful.

The patient had no known allergies or other notable medical history. Physical examination revealed multiple hyperpigmented, oval-shaped, slightly raised papules and plaques on her torso (FIGURE 1), neck, and arms, and fewer lesions on her face and legs. Darier sign was not appreciated on the initial consult. A 4-mm punch biopsy of the patient’s right middle back was performed at this visit.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

The presence of a hyperpigmented skin lesion that becomes pruritic, raised, and erythematous when rubbed (Darier sign) is the major criterion for the diagnosis of cutaneous mastocytosis.¹ Minor criteria include a skin biopsy demonstrating a 4- to 8-fold  increase in the number of mast cells within the papillary dermis and the presence of cKIT mutations.¹ In this case, the patient’s punch biopsy results came back positive for clonal mast cell infiltration of the papillary dermis (FIGURES 2A and 2B), and her physician elicited a slightly positive Darier sign during a follow-up visit.

IMAGES COURTESY OF JOSHUA D. SPARLING, MD

Mastocytosis is characterized by pathognomonic proliferation of clonal mast cells with either cutaneous or systemic involvement.¹ Mast cell expansion most commonly is found in the skin and bone marrow; however, involvement of the gastrointestinal tract, liver, spleen, and lymph nodes also has been documented.¹ Nonhereditary somatic mutations of the cKIT gene have been observed in many studies and may be associated with increased proliferation of clonal mast cells.²

A review of the English-language literature on cutaneous mastocytosis reveals a paucity of reports in darker skin types. However, it is important for clinicians to be able to recognize this disease in all skin types.

Three subcategories. Cutaneous mastocytosis is divided into 3 subcategories: mastocytoma of the skin (1–3 solitary skin lesions), maculopapular cutaneous mastocytosis, also known as urticaria pigmentosa (as seen in our patient; usually ≥ 4 lesions); and diffuse cutaneous mastocytosis (confluent lesions; leathery appearance of skin).^1,3,4 Maculopapular cutaneous mastocytosis, which our patient had, classically develops within the first 6 months of life and presents as hyperpigmented macules and papules.

Keep in mind that systemic involvement in cutaneous mastocytosis occasionally occurs and can be associated with anaphylaxis, flushing, headache, dyspnea, nausea, emesis, diarrhea, abdominal pain, and hepatosplenomegaly.²

Continue to: Narrowing down a broad differential diagnosis

Our cas a ase was made somewhat challenging by the patient’s darkly pigmented skin color, which made any erythema and other cutaneous signs less visible. The differential was broad and included postinflammatory hyperpigmentation from eczema, multiple congenital nevi, sarcoidosis, leprosy, and cutaneous tuberculosis, all of which can be eliminated by performing a biopsy of the lesion.

Diagnostic criteria include biopsy and laboratory findings

In addition to a skin biopsy, initial assessment in cases of suspected cutaneous mastocytosis should include a complete blood cell count with differential, liver function tests (+/- liver ultrasound), a serum tryptase level, and a peripheral smear. Serum tryptase levels > 20 ng/mL have been shown to correlate with a higher probability of systemic mastocytosis. Higher tryptase levels also correlate with severity of disease in children.⁵

Treatment focuses on minimizing mast cell degranulation

Due to the relatively benign course of cutaneous mastocytosis, the mainstay of treatment is focused on minimizing mast cell degranulation to control subsequent symptoms. Avoiding precipitating factors such as temperature extremes, external stimulation of lesions, dry skin, infection, and certain medications (eg, nonsteroidal anti-inflammatory drugs, aspirin, morphine, polymyxin B sulphate, anticholinergics, some systemic anesthetics) that can stimulate mast cell degranulation is encouraged.² H₁ and H₂ antihistamines are the first-line treatment for mild to moderate symptoms. In refractory cases, leukotriene receptor antagonists or oral cromolyn sodium may be considered.²

Regular follow-up every 6 to 12 months should be established after diagnosis.¹ If symptoms persist into adulthood or concern for disease progression is high, a bone marrow biopsy is recommended.¹

Our patient

Our patient’s laboratory results revealed a normal serum tryptase level (3.4 ng/mL; reference range < 11.5 ng/mL) and complete blood cell count. A complete metabolic panel demonstrated elevated and high-normal liver function tests with alanine aminotransferase (ALT) at 111 u/L (reference range, 10–40 u/L) and aspartate aminotransferase (AST) at 55 u/L (reference range, 7–56 u/L).

Continue to: As a precaution...

It is important for clinicians to be able to recognize this disease in all skin types.

As a precaution and for consideration of further work-up, such as the need for a liver ultrasound, the patient was referred to Pediatric Gastroenterology. The specialist repeated the liver function tests, the results of which were lower (ALT, 42 u/L; AST, 24 u/L); a liver ultrasound was thought to be unnecessary.

Our patient’s otherwise negative review of systems led the specialist to feel confident that no systemic disease was present at the time. These results were discussed with the patient’s parents and counseling about trigger avoidance was provided. The patient was given pediatric-dosed oral and topical H₁ antihistamines for symptom relief.

CORRESPONDENCE
Joshua D. Sparling, MD, 6 E Chestnut Street, Ste 340, Augusta, ME 04330; [email protected]

Advances in cancer therapy have improved survival, such that many cancers have been transformed from a terminal illness to a chronic disease, and the population of patients living with cancer or who are disease-free has grown. However, these patients face complex medical problems because of the systemic effects of their treatment and many endure a constellation of treatment-emergent adverse effects that require ongoing care and support.¹

Primary care physicians have been called on to take a larger role in the care of these adverse effects as the growing number of treatments has meant more affected patients. In addition, an urgent, unmet need has developed for better coordination between specialists and family physicians for providing this supportive care.²

In this article, we (1) describe the most commonly encountered cancer treatment–related skin toxicities, paying particular attention to the effects of epidermal growth factor receptor (EGFR)–targeting therapies, and (2) review up-to-date management recommendations in an area of practice where established clinical guidance from the scientific literature is limited.

Biggest culprit: Targeted cancer therapies

Skin rash and dermatologic adverse effects are commonplace in patients undergoing cancer treatment; timely management can often prevent long-term skin damage.³ Dermatologic effects have been associated with various therapeutic agents, but are most commonly associated with targeted therapies—specifically, agents targeting EGFR.

Why the attention to EGFR inhibition? EGFR is overexpressed or mutated in a multitude of solid tumors; as such, agents have been developed that target this aberrant signaling pathway. EGFR is highly expressed in the skin and dermal tissue, where it plays a number of roles, including protection against ultraviolet radiation damage.⁴

Overall, incidence of EGFR inhibitor–related rash ranges from 45% to 100% of treated patients.

Blockade of the EGFR molecule leads to dermal changes, however, presenting as acneiform rash, skin fissure and xerosis, and pruritus.⁵ In extreme instances, toxic effects can manifest as paronychia, facial hypertrichosis, and trichomegaly. These skin changes can be deforming as well as painful, and can have physiological and psychological consequences.⁶

In turn, a decrease in quality of life (as reported by patients suffering from skin toxicity) can affect cancer treatment adherence and efficacy,⁷ and severe skin changes can result in the need to reduce the dosage of anti-cancer therapies.⁸ Skillful evaluation and appropriate management of skin eruptions in patients undergoing cancer therapy is therefore vital to an overall satisfactory outcome.

Continue to: How common a problem?

How common a problem? The incidence of EGFR inhibitor (EGFRI)–related rash is noteworthy: Overall incidence ranges from 45% to 100% of treated patients, with 10% experiencing Grade 3 to 4 changes (covering > 30% of body surface, restricting activities of daily living, severe itching).⁹ Monoclonal antibody therapies that target EGFR, such as cetuximab, have a reported 90% risk of skin rash, with 10% also being of Grade 3 to 4.¹⁰ Risk factors for rash include skin phototype, male gender, and younger age.^11,12 Common cancer therapies with known skin effects are listed in the TABLE.¹³

What should you look for? The most common clinical manifestation of dermatologic toxicity is an acneiform, or papulopustular, rash marked by eruptions characterized as “acne-like” pustules with monotonous lesion morphology (Figure 1a). A hallmark of these lesions that can be used to help distinguish them from acne vulgaris is the absence of comedones on eruptions.

The timeline of the rash has been well characterized and is another tool that you can use to guide management:

1. During Week 1 of cancer treatment, the patient often experiences sensory disturbances, with erythema and edema.¹⁴
2. Throughout Weeks 2 and 3, erythematous skin evolves into papulopustular eruptions.
3. By Week 4, eruptions typically crust over and leave persistently dry skin for weeks.^15,16

Of note, the rash is dosage related; we recommend scrupulous vigilance when a patient is receiving a high dosage of a targeted therapy agent.

Controlling a rash

Treatment of EGFRI-associated skin changes stems from recommendations from a number of individual investigators and studies; however, few consensus guidelines exist to guide practice. Understanding of the underlying pathophysiological mechanism of skin changes has evolved, but preventive and treatment modalities remain unchanged—and limited.

Continue to: Always counsel patients...

Always counsel patients before a rash develops (and, ideally, before chemotherapy begins) that they should report a rash early in its development, to you or their oncologist, so that timely treatment can occur. Early recognition and intervention have proven benefits and can prevent the rash and its symptoms from becoming worse¹⁷; if the rash remains uncontrolled, dosage reduction of the chemotherapeutic agent is an inevitable reality, and the clinical outcome of the primary disease might therefore not be ideal.¹⁸

Prophylaxis. Daily application of an alcohol-free emollient cream is highly recommended as a preventive measure. Patients should be counseled to avoid activities and skin products that lead to dry skin, including long and hot showers; perfumes or other alcohol-based products; and soaps marketed for treating acne, which have a profound skin-drying effect.

Cornerstones of treatment include topical moisturizers, steroids, and antihistamines for symptom control. Once an identifiable skin rash has developed, a topical steroid cream is first-line treatment. Successful control has been reported with 1% hydrocortisone lotion applied daily to the affected area.¹⁵

Second- and third-line Tx. If the rash progresses in size or severity, we recommend switching to 2% hydrocortisone valerate cream, applied twice daily. For a moderate-to-severe rash, an oral tetracycline is a valid option for its anti-inflammatory effects and, possibly, to prevent secondary infection. In the event of progression, refer the patient to an oncologist, who can consider suspending the anti-EGRF drug temporarily until the rash improves. If disease persists, consultation with a dermatologist is appropriate for consideration of systemic prednisolone.

Alleviating discomfort. Patients commonly report pruritus and mild-to-moderate pain with the rash; standard analgesic therapy is appropriate.¹⁹ Severe pain might indicate secondary infection; in that case, consider antibiotic therapy for presumed cellulitis. Moreover, because of the risk of thrombosis in the cancer population, underlying deep-vein thrombosis must always remain in the differential diagnosis of an erythematous rash.

Continue to: A short course...

A short course of systemic steroids might be beneficial for pain control; however, no data from clinical trials suggest that this is beneficial. Dermatology consultation is recommended before prescribing a systemic steroid.

Regrettably, treatment options for pruritus are limited. Antihistamines, such as diphenhydramine and hydroxyzine, can be considered, but their effectiveness is marginal.²⁰ If a patient reports a painful rash, we recommend that you collaborate with the dermatologist and oncologist to make adjustments to the cancer treatment plan.

Retinoids: Caution is advised. Several case reports and a small investigational study describe a potential role for retinoids such as isotretinoin, a 13-cis retinoic acid, in the treatment of chemotherapy-related skin changes.^21,22 Isotretinoin is available under several trade names in pill and cream formulations.

Retinoids exert their effect at the level of DNA transcription, and act as a transcription factor in keratinocytes. Their downstream signaling pathway includes EGFR signaling ligands; introduction of exogenous retinoids has been shown to deter development of EGFRI-associated skin toxicity.²³ Given the lack of clinical data, retinoid-based medications should be used at the discretion of a dermatologist; thorough discussion is encouraged among the dermatologist, oncologist, and primary care physician before employing a retinoid.

Recommend a sunscreen? Given the endogenous role of EGFR in protecting skin from ultraviolet B damage, some clinicians have recommended that patients use a sunscreen. However, randomized, controlled trials have failed to demonstrate any benefit to their use with regard to incidence or severity of rash or patient-reported discomfort.²⁴ We do not recommend routine use of sunscreen to prevent chemotherapy-induced skin changes, although sensible use during periods of prolonged sun exposure is encouraged.

Continue to: Risk of infection and the role of antibiotics

Risk of infection and the role of antibiotics

Skin damage can lead to further complications—namely, leaving the skin vulnerable to bacterial overgrowth and serious infection.¹⁴ The primary acneiform eruption is believed to be inflammatory in nature, with most cases being sterile and lacking bacterial growth.²⁵ However, rash-associated infections are a common complication and leave the immunocompromised patient at risk of systemic infection: Harandi et al²⁶ reported a 35% rate of secondary infection. Viral or bacterial growth (the primary pathogen is Staphylococcus aureus) within the wound can aggravate the severity of the rash, prohibit effective healing, and exacerbate the disfiguring appearance of the rash.

When a patient reports a painful rash, collaborate with the dermatologist and oncologist to make adjustments to the cancer treatment plan.

The use of a prophylactic antibiotic for treating a rash in this setting has been an active area of discussion and research, although no guidelines or recommendations exist that can be routinely employed. A comprehensive systematic review and meta-analysis demonstrated that, in patients undergoing EGFR-based therapy, those who received a prophylactic antibiotic had a lower risk of developing folliculitis than those who did not (odds ratio = 0.53; 95% confidence interval, 0.39-0.72; P < .01). ²⁷

A consensus agreement on the use of prophylactic antibiotics has yet to be reached. An emerging clinical practice entails the use of oral minocycline (100 mg/d) during the first 4 weeks of EGFRI-based therapy because studies have shown a benefit from this regimen in reducing eruptions.²⁸

Other adverse dermatologic effects to watch for

Paronychia is common in patients undergoing EGFRI therapy but, unlike the acneiform rash that typically occurs within 1 week of treatment, paronychia can occur weeks or months after initiation of therapy. Careful examination of the nail beds is important in patients undergoing EGFRI therapy (FIGURE 1B). Paronychia can affect the nail beds of the fingers and toes—most often, the first digits.²⁹

No evidence-based trials have been conducted to evaluate treatment options; recommendations provided are drawn from the literature and expert opinion. Patients are encouraged to apply petroleum jelly or an emollient daily both as a preventive measure and for mild cases. Patient counseling on the importance of nail hygiene and avoidance of aggressive manicures and pedicures is encouraged.³⁰

Continue to: In the general population...

In the general population, acute and chronic paronychia entail infection with S aureus and Candida spp, respectively. To this end, there is a role for antibacterial and antifungal intervention. As is the case of the EGFRI-associated acneiform rash, inflammation in paronychia is sterile, with only rare pathogen involvement.

There is no role for topical or systemic antibiotics in the cancer population suffering from paronychia. A viable treatment option for moderate lesions is betamethasone valerate, applied 2 or 3 times daily; if there is no resolution, clobetasol cream, applied 2 or 3 times daily, can be prescribed.³⁰ The role of tetracyclines as anti-inflammatory agents in paronychia has not been studied to the extent it has been for acneiform rash; however, studies have shown a protective effect in small patient samples.³¹ In severe disease, the patient can be instructed to temporarily discontinue the drug and you can provide a referral to a dermatologist.

Stomatitis is also an area of concern in this patient population (FIGURE 1c). Prior to initiating treatment, a thorough examination of the patient’s oral cavity and oropharynx should be conducted. Loose or improperly fitting dentures should be adjusted because they can prohibit effective healing after ulceration develops.

If a rash progresses in size or severity, consider switching to hydrocortisone valerate cream, applied twice daily.

Stomatitis initially presents as erythematous or aphthous-like lesions, and can develop into acutely painful, large, continuous lesions.²⁹ Timely management of stomatitis is beneficial to patient outcomes because it can lead to severe pain and interference in oral intake; uncontrolled disease requires interruption and dosage-reduction of cancer therapy.^14,32

Patients should be encouraged to use soft-bristle toothbrushes and rinse with normal saline, not with commercial mouthwashes that typically contain alcohol. Grade 1 stomatitis (ie, pain and erythema) can be treated with triamcinolone dental paste, which can reduce inflammation caused by the ulcers. If disease progresses to Grade 2 to 3 stomatitis (erythema; ulceration; difficulty swallowing, or inability to swallow food), oral erythromycin (250-350 mg/d) or minocycline (50 mg/d) should be prescribed and the patient referred to a dermatologist.³⁰

Continue to: Does rash correlate with cancer treatment efficacy?

Does rash correlate with cancer treatment efficacy?

Despite troubling dermatologic effects of cancer therapies, a retrospective analysis of several clinical trials has revealed another side to this coin: namely, the appearance, and the severity, of a rash correlates positively with objective tumor response.¹⁴ That correlation allows the oncologist to use a rash as a surrogate marker of treatment efficacy²⁰ (although, notably, there remains a lack of prospective trials that would validate a rash as such a marker). Epidermal growth factor receptor-tyrosine kinase inhibitors are mainly prescribed in patients who harbor an activating EGFR mutation; no studies have stratified patients by EGFR mutation and incidence of rash.³³

The upshot? Although there are gaps in our understanding of the relationship between a rash and overall survival, we are nevertheless presented with this para­digm: A patient who is taking an EGFR-tyrosine kinase inhibitor and who develops a rash should be continued on that treatment for as long as can be tolerated, because the rash is presumed to be a sign that the patient is deriving the greatest clinical benefit from therapy.^14,20,33

CORRESPONDENCE
Kevin Zarrabi, MD, MSc, Department of Medicine, Health Science Center T16, Room 020, Stony Brook, NY 11790-8160; [email protected]

ACKNOWLEDGMENT
Ali John Zarrabi, MD, provided skillful editing of the manuscript of this article.

Advances in cancer therapy have improved survival, such that many cancers have been transformed from a terminal illness to a chronic disease, and the population of patients living with cancer or who are disease-free has grown. However, these patients face complex medical problems because of the systemic effects of their treatment and many endure a constellation of treatment-emergent adverse effects that require ongoing care and support.¹

Primary care physicians have been called on to take a larger role in the care of these adverse effects as the growing number of treatments has meant more affected patients. In addition, an urgent, unmet need has developed for better coordination between specialists and family physicians for providing this supportive care.²

In this article, we (1) describe the most commonly encountered cancer treatment–related skin toxicities, paying particular attention to the effects of epidermal growth factor receptor (EGFR)–targeting therapies, and (2) review up-to-date management recommendations in an area of practice where established clinical guidance from the scientific literature is limited.

Biggest culprit: Targeted cancer therapies

Skin rash and dermatologic adverse effects are commonplace in patients undergoing cancer treatment; timely management can often prevent long-term skin damage.³ Dermatologic effects have been associated with various therapeutic agents, but are most commonly associated with targeted therapies—specifically, agents targeting EGFR.

Why the attention to EGFR inhibition? EGFR is overexpressed or mutated in a multitude of solid tumors; as such, agents have been developed that target this aberrant signaling pathway. EGFR is highly expressed in the skin and dermal tissue, where it plays a number of roles, including protection against ultraviolet radiation damage.⁴

Overall, incidence of EGFR inhibitor–related rash ranges from 45% to 100% of treated patients.

Blockade of the EGFR molecule leads to dermal changes, however, presenting as acneiform rash, skin fissure and xerosis, and pruritus.⁵ In extreme instances, toxic effects can manifest as paronychia, facial hypertrichosis, and trichomegaly. These skin changes can be deforming as well as painful, and can have physiological and psychological consequences.⁶

In turn, a decrease in quality of life (as reported by patients suffering from skin toxicity) can affect cancer treatment adherence and efficacy,⁷ and severe skin changes can result in the need to reduce the dosage of anti-cancer therapies.⁸ Skillful evaluation and appropriate management of skin eruptions in patients undergoing cancer therapy is therefore vital to an overall satisfactory outcome.

Continue to: How common a problem?

How common a problem? The incidence of EGFR inhibitor (EGFRI)–related rash is noteworthy: Overall incidence ranges from 45% to 100% of treated patients, with 10% experiencing Grade 3 to 4 changes (covering > 30% of body surface, restricting activities of daily living, severe itching).⁹ Monoclonal antibody therapies that target EGFR, such as cetuximab, have a reported 90% risk of skin rash, with 10% also being of Grade 3 to 4.¹⁰ Risk factors for rash include skin phototype, male gender, and younger age.^11,12 Common cancer therapies with known skin effects are listed in the TABLE.¹³

What should you look for? The most common clinical manifestation of dermatologic toxicity is an acneiform, or papulopustular, rash marked by eruptions characterized as “acne-like” pustules with monotonous lesion morphology (Figure 1a). A hallmark of these lesions that can be used to help distinguish them from acne vulgaris is the absence of comedones on eruptions.

The timeline of the rash has been well characterized and is another tool that you can use to guide management:

1. During Week 1 of cancer treatment, the patient often experiences sensory disturbances, with erythema and edema.¹⁴
2. Throughout Weeks 2 and 3, erythematous skin evolves into papulopustular eruptions.
3. By Week 4, eruptions typically crust over and leave persistently dry skin for weeks.^15,16

Of note, the rash is dosage related; we recommend scrupulous vigilance when a patient is receiving a high dosage of a targeted therapy agent.

Controlling a rash

Treatment of EGFRI-associated skin changes stems from recommendations from a number of individual investigators and studies; however, few consensus guidelines exist to guide practice. Understanding of the underlying pathophysiological mechanism of skin changes has evolved, but preventive and treatment modalities remain unchanged—and limited.

Continue to: Always counsel patients...

Always counsel patients before a rash develops (and, ideally, before chemotherapy begins) that they should report a rash early in its development, to you or their oncologist, so that timely treatment can occur. Early recognition and intervention have proven benefits and can prevent the rash and its symptoms from becoming worse¹⁷; if the rash remains uncontrolled, dosage reduction of the chemotherapeutic agent is an inevitable reality, and the clinical outcome of the primary disease might therefore not be ideal.¹⁸

Prophylaxis. Daily application of an alcohol-free emollient cream is highly recommended as a preventive measure. Patients should be counseled to avoid activities and skin products that lead to dry skin, including long and hot showers; perfumes or other alcohol-based products; and soaps marketed for treating acne, which have a profound skin-drying effect.

Cornerstones of treatment include topical moisturizers, steroids, and antihistamines for symptom control. Once an identifiable skin rash has developed, a topical steroid cream is first-line treatment. Successful control has been reported with 1% hydrocortisone lotion applied daily to the affected area.¹⁵

Second- and third-line Tx. If the rash progresses in size or severity, we recommend switching to 2% hydrocortisone valerate cream, applied twice daily. For a moderate-to-severe rash, an oral tetracycline is a valid option for its anti-inflammatory effects and, possibly, to prevent secondary infection. In the event of progression, refer the patient to an oncologist, who can consider suspending the anti-EGRF drug temporarily until the rash improves. If disease persists, consultation with a dermatologist is appropriate for consideration of systemic prednisolone.

Alleviating discomfort. Patients commonly report pruritus and mild-to-moderate pain with the rash; standard analgesic therapy is appropriate.¹⁹ Severe pain might indicate secondary infection; in that case, consider antibiotic therapy for presumed cellulitis. Moreover, because of the risk of thrombosis in the cancer population, underlying deep-vein thrombosis must always remain in the differential diagnosis of an erythematous rash.

Continue to: A short course...

A short course of systemic steroids might be beneficial for pain control; however, no data from clinical trials suggest that this is beneficial. Dermatology consultation is recommended before prescribing a systemic steroid.

Regrettably, treatment options for pruritus are limited. Antihistamines, such as diphenhydramine and hydroxyzine, can be considered, but their effectiveness is marginal.²⁰ If a patient reports a painful rash, we recommend that you collaborate with the dermatologist and oncologist to make adjustments to the cancer treatment plan.

Retinoids: Caution is advised. Several case reports and a small investigational study describe a potential role for retinoids such as isotretinoin, a 13-cis retinoic acid, in the treatment of chemotherapy-related skin changes.^21,22 Isotretinoin is available under several trade names in pill and cream formulations.

Retinoids exert their effect at the level of DNA transcription, and act as a transcription factor in keratinocytes. Their downstream signaling pathway includes EGFR signaling ligands; introduction of exogenous retinoids has been shown to deter development of EGFRI-associated skin toxicity.²³ Given the lack of clinical data, retinoid-based medications should be used at the discretion of a dermatologist; thorough discussion is encouraged among the dermatologist, oncologist, and primary care physician before employing a retinoid.

Recommend a sunscreen? Given the endogenous role of EGFR in protecting skin from ultraviolet B damage, some clinicians have recommended that patients use a sunscreen. However, randomized, controlled trials have failed to demonstrate any benefit to their use with regard to incidence or severity of rash or patient-reported discomfort.²⁴ We do not recommend routine use of sunscreen to prevent chemotherapy-induced skin changes, although sensible use during periods of prolonged sun exposure is encouraged.

Continue to: Risk of infection and the role of antibiotics

Risk of infection and the role of antibiotics

Skin damage can lead to further complications—namely, leaving the skin vulnerable to bacterial overgrowth and serious infection.¹⁴ The primary acneiform eruption is believed to be inflammatory in nature, with most cases being sterile and lacking bacterial growth.²⁵ However, rash-associated infections are a common complication and leave the immunocompromised patient at risk of systemic infection: Harandi et al²⁶ reported a 35% rate of secondary infection. Viral or bacterial growth (the primary pathogen is Staphylococcus aureus) within the wound can aggravate the severity of the rash, prohibit effective healing, and exacerbate the disfiguring appearance of the rash.

When a patient reports a painful rash, collaborate with the dermatologist and oncologist to make adjustments to the cancer treatment plan.

The use of a prophylactic antibiotic for treating a rash in this setting has been an active area of discussion and research, although no guidelines or recommendations exist that can be routinely employed. A comprehensive systematic review and meta-analysis demonstrated that, in patients undergoing EGFR-based therapy, those who received a prophylactic antibiotic had a lower risk of developing folliculitis than those who did not (odds ratio = 0.53; 95% confidence interval, 0.39-0.72; P < .01). ²⁷

A consensus agreement on the use of prophylactic antibiotics has yet to be reached. An emerging clinical practice entails the use of oral minocycline (100 mg/d) during the first 4 weeks of EGFRI-based therapy because studies have shown a benefit from this regimen in reducing eruptions.²⁸

Other adverse dermatologic effects to watch for

Paronychia is common in patients undergoing EGFRI therapy but, unlike the acneiform rash that typically occurs within 1 week of treatment, paronychia can occur weeks or months after initiation of therapy. Careful examination of the nail beds is important in patients undergoing EGFRI therapy (FIGURE 1B). Paronychia can affect the nail beds of the fingers and toes—most often, the first digits.²⁹

No evidence-based trials have been conducted to evaluate treatment options; recommendations provided are drawn from the literature and expert opinion. Patients are encouraged to apply petroleum jelly or an emollient daily both as a preventive measure and for mild cases. Patient counseling on the importance of nail hygiene and avoidance of aggressive manicures and pedicures is encouraged.³⁰

Continue to: In the general population...

In the general population, acute and chronic paronychia entail infection with S aureus and Candida spp, respectively. To this end, there is a role for antibacterial and antifungal intervention. As is the case of the EGFRI-associated acneiform rash, inflammation in paronychia is sterile, with only rare pathogen involvement.

There is no role for topical or systemic antibiotics in the cancer population suffering from paronychia. A viable treatment option for moderate lesions is betamethasone valerate, applied 2 or 3 times daily; if there is no resolution, clobetasol cream, applied 2 or 3 times daily, can be prescribed.³⁰ The role of tetracyclines as anti-inflammatory agents in paronychia has not been studied to the extent it has been for acneiform rash; however, studies have shown a protective effect in small patient samples.³¹ In severe disease, the patient can be instructed to temporarily discontinue the drug and you can provide a referral to a dermatologist.

Stomatitis is also an area of concern in this patient population (FIGURE 1c). Prior to initiating treatment, a thorough examination of the patient’s oral cavity and oropharynx should be conducted. Loose or improperly fitting dentures should be adjusted because they can prohibit effective healing after ulceration develops.

If a rash progresses in size or severity, consider switching to hydrocortisone valerate cream, applied twice daily.

Stomatitis initially presents as erythematous or aphthous-like lesions, and can develop into acutely painful, large, continuous lesions.²⁹ Timely management of stomatitis is beneficial to patient outcomes because it can lead to severe pain and interference in oral intake; uncontrolled disease requires interruption and dosage-reduction of cancer therapy.^14,32

Patients should be encouraged to use soft-bristle toothbrushes and rinse with normal saline, not with commercial mouthwashes that typically contain alcohol. Grade 1 stomatitis (ie, pain and erythema) can be treated with triamcinolone dental paste, which can reduce inflammation caused by the ulcers. If disease progresses to Grade 2 to 3 stomatitis (erythema; ulceration; difficulty swallowing, or inability to swallow food), oral erythromycin (250-350 mg/d) or minocycline (50 mg/d) should be prescribed and the patient referred to a dermatologist.³⁰

Continue to: Does rash correlate with cancer treatment efficacy?

Does rash correlate with cancer treatment efficacy?

Despite troubling dermatologic effects of cancer therapies, a retrospective analysis of several clinical trials has revealed another side to this coin: namely, the appearance, and the severity, of a rash correlates positively with objective tumor response.¹⁴ That correlation allows the oncologist to use a rash as a surrogate marker of treatment efficacy²⁰ (although, notably, there remains a lack of prospective trials that would validate a rash as such a marker). Epidermal growth factor receptor-tyrosine kinase inhibitors are mainly prescribed in patients who harbor an activating EGFR mutation; no studies have stratified patients by EGFR mutation and incidence of rash.³³

The upshot? Although there are gaps in our understanding of the relationship between a rash and overall survival, we are nevertheless presented with this para­digm: A patient who is taking an EGFR-tyrosine kinase inhibitor and who develops a rash should be continued on that treatment for as long as can be tolerated, because the rash is presumed to be a sign that the patient is deriving the greatest clinical benefit from therapy.^14,20,33

CORRESPONDENCE
Kevin Zarrabi, MD, MSc, Department of Medicine, Health Science Center T16, Room 020, Stony Brook, NY 11790-8160; [email protected]

ACKNOWLEDGMENT
Ali John Zarrabi, MD, provided skillful editing of the manuscript of this article.

Advances in cancer therapy have improved survival, such that many cancers have been transformed from a terminal illness to a chronic disease, and the population of patients living with cancer or who are disease-free has grown. However, these patients face complex medical problems because of the systemic effects of their treatment and many endure a constellation of treatment-emergent adverse effects that require ongoing care and support.¹

Primary care physicians have been called on to take a larger role in the care of these adverse effects as the growing number of treatments has meant more affected patients. In addition, an urgent, unmet need has developed for better coordination between specialists and family physicians for providing this supportive care.²

In this article, we (1) describe the most commonly encountered cancer treatment–related skin toxicities, paying particular attention to the effects of epidermal growth factor receptor (EGFR)–targeting therapies, and (2) review up-to-date management recommendations in an area of practice where established clinical guidance from the scientific literature is limited.

Biggest culprit: Targeted cancer therapies

Skin rash and dermatologic adverse effects are commonplace in patients undergoing cancer treatment; timely management can often prevent long-term skin damage.³ Dermatologic effects have been associated with various therapeutic agents, but are most commonly associated with targeted therapies—specifically, agents targeting EGFR.

Why the attention to EGFR inhibition? EGFR is overexpressed or mutated in a multitude of solid tumors; as such, agents have been developed that target this aberrant signaling pathway. EGFR is highly expressed in the skin and dermal tissue, where it plays a number of roles, including protection against ultraviolet radiation damage.⁴

Overall, incidence of EGFR inhibitor–related rash ranges from 45% to 100% of treated patients.

Blockade of the EGFR molecule leads to dermal changes, however, presenting as acneiform rash, skin fissure and xerosis, and pruritus.⁵ In extreme instances, toxic effects can manifest as paronychia, facial hypertrichosis, and trichomegaly. These skin changes can be deforming as well as painful, and can have physiological and psychological consequences.⁶

In turn, a decrease in quality of life (as reported by patients suffering from skin toxicity) can affect cancer treatment adherence and efficacy,⁷ and severe skin changes can result in the need to reduce the dosage of anti-cancer therapies.⁸ Skillful evaluation and appropriate management of skin eruptions in patients undergoing cancer therapy is therefore vital to an overall satisfactory outcome.

Continue to: How common a problem?

How common a problem? The incidence of EGFR inhibitor (EGFRI)–related rash is noteworthy: Overall incidence ranges from 45% to 100% of treated patients, with 10% experiencing Grade 3 to 4 changes (covering > 30% of body surface, restricting activities of daily living, severe itching).⁹ Monoclonal antibody therapies that target EGFR, such as cetuximab, have a reported 90% risk of skin rash, with 10% also being of Grade 3 to 4.¹⁰ Risk factors for rash include skin phototype, male gender, and younger age.^11,12 Common cancer therapies with known skin effects are listed in the TABLE.¹³

What should you look for? The most common clinical manifestation of dermatologic toxicity is an acneiform, or papulopustular, rash marked by eruptions characterized as “acne-like” pustules with monotonous lesion morphology (Figure 1a). A hallmark of these lesions that can be used to help distinguish them from acne vulgaris is the absence of comedones on eruptions.

The timeline of the rash has been well characterized and is another tool that you can use to guide management:

1. During Week 1 of cancer treatment, the patient often experiences sensory disturbances, with erythema and edema.¹⁴
2. Throughout Weeks 2 and 3, erythematous skin evolves into papulopustular eruptions.
3. By Week 4, eruptions typically crust over and leave persistently dry skin for weeks.^15,16

Of note, the rash is dosage related; we recommend scrupulous vigilance when a patient is receiving a high dosage of a targeted therapy agent.

Controlling a rash

Treatment of EGFRI-associated skin changes stems from recommendations from a number of individual investigators and studies; however, few consensus guidelines exist to guide practice. Understanding of the underlying pathophysiological mechanism of skin changes has evolved, but preventive and treatment modalities remain unchanged—and limited.

Continue to: Always counsel patients...

Always counsel patients before a rash develops (and, ideally, before chemotherapy begins) that they should report a rash early in its development, to you or their oncologist, so that timely treatment can occur. Early recognition and intervention have proven benefits and can prevent the rash and its symptoms from becoming worse¹⁷; if the rash remains uncontrolled, dosage reduction of the chemotherapeutic agent is an inevitable reality, and the clinical outcome of the primary disease might therefore not be ideal.¹⁸

Prophylaxis. Daily application of an alcohol-free emollient cream is highly recommended as a preventive measure. Patients should be counseled to avoid activities and skin products that lead to dry skin, including long and hot showers; perfumes or other alcohol-based products; and soaps marketed for treating acne, which have a profound skin-drying effect.

Cornerstones of treatment include topical moisturizers, steroids, and antihistamines for symptom control. Once an identifiable skin rash has developed, a topical steroid cream is first-line treatment. Successful control has been reported with 1% hydrocortisone lotion applied daily to the affected area.¹⁵

Second- and third-line Tx. If the rash progresses in size or severity, we recommend switching to 2% hydrocortisone valerate cream, applied twice daily. For a moderate-to-severe rash, an oral tetracycline is a valid option for its anti-inflammatory effects and, possibly, to prevent secondary infection. In the event of progression, refer the patient to an oncologist, who can consider suspending the anti-EGRF drug temporarily until the rash improves. If disease persists, consultation with a dermatologist is appropriate for consideration of systemic prednisolone.

Alleviating discomfort. Patients commonly report pruritus and mild-to-moderate pain with the rash; standard analgesic therapy is appropriate.¹⁹ Severe pain might indicate secondary infection; in that case, consider antibiotic therapy for presumed cellulitis. Moreover, because of the risk of thrombosis in the cancer population, underlying deep-vein thrombosis must always remain in the differential diagnosis of an erythematous rash.

Continue to: A short course...

A short course of systemic steroids might be beneficial for pain control; however, no data from clinical trials suggest that this is beneficial. Dermatology consultation is recommended before prescribing a systemic steroid.

Regrettably, treatment options for pruritus are limited. Antihistamines, such as diphenhydramine and hydroxyzine, can be considered, but their effectiveness is marginal.²⁰ If a patient reports a painful rash, we recommend that you collaborate with the dermatologist and oncologist to make adjustments to the cancer treatment plan.

Retinoids: Caution is advised. Several case reports and a small investigational study describe a potential role for retinoids such as isotretinoin, a 13-cis retinoic acid, in the treatment of chemotherapy-related skin changes.^21,22 Isotretinoin is available under several trade names in pill and cream formulations.

Retinoids exert their effect at the level of DNA transcription, and act as a transcription factor in keratinocytes. Their downstream signaling pathway includes EGFR signaling ligands; introduction of exogenous retinoids has been shown to deter development of EGFRI-associated skin toxicity.²³ Given the lack of clinical data, retinoid-based medications should be used at the discretion of a dermatologist; thorough discussion is encouraged among the dermatologist, oncologist, and primary care physician before employing a retinoid.

Recommend a sunscreen? Given the endogenous role of EGFR in protecting skin from ultraviolet B damage, some clinicians have recommended that patients use a sunscreen. However, randomized, controlled trials have failed to demonstrate any benefit to their use with regard to incidence or severity of rash or patient-reported discomfort.²⁴ We do not recommend routine use of sunscreen to prevent chemotherapy-induced skin changes, although sensible use during periods of prolonged sun exposure is encouraged.

Continue to: Risk of infection and the role of antibiotics

Risk of infection and the role of antibiotics

Skin damage can lead to further complications—namely, leaving the skin vulnerable to bacterial overgrowth and serious infection.¹⁴ The primary acneiform eruption is believed to be inflammatory in nature, with most cases being sterile and lacking bacterial growth.²⁵ However, rash-associated infections are a common complication and leave the immunocompromised patient at risk of systemic infection: Harandi et al²⁶ reported a 35% rate of secondary infection. Viral or bacterial growth (the primary pathogen is Staphylococcus aureus) within the wound can aggravate the severity of the rash, prohibit effective healing, and exacerbate the disfiguring appearance of the rash.

When a patient reports a painful rash, collaborate with the dermatologist and oncologist to make adjustments to the cancer treatment plan.

The use of a prophylactic antibiotic for treating a rash in this setting has been an active area of discussion and research, although no guidelines or recommendations exist that can be routinely employed. A comprehensive systematic review and meta-analysis demonstrated that, in patients undergoing EGFR-based therapy, those who received a prophylactic antibiotic had a lower risk of developing folliculitis than those who did not (odds ratio = 0.53; 95% confidence interval, 0.39-0.72; P < .01). ²⁷

A consensus agreement on the use of prophylactic antibiotics has yet to be reached. An emerging clinical practice entails the use of oral minocycline (100 mg/d) during the first 4 weeks of EGFRI-based therapy because studies have shown a benefit from this regimen in reducing eruptions.²⁸

Other adverse dermatologic effects to watch for

Paronychia is common in patients undergoing EGFRI therapy but, unlike the acneiform rash that typically occurs within 1 week of treatment, paronychia can occur weeks or months after initiation of therapy. Careful examination of the nail beds is important in patients undergoing EGFRI therapy (FIGURE 1B). Paronychia can affect the nail beds of the fingers and toes—most often, the first digits.²⁹

No evidence-based trials have been conducted to evaluate treatment options; recommendations provided are drawn from the literature and expert opinion. Patients are encouraged to apply petroleum jelly or an emollient daily both as a preventive measure and for mild cases. Patient counseling on the importance of nail hygiene and avoidance of aggressive manicures and pedicures is encouraged.³⁰

Continue to: In the general population...

In the general population, acute and chronic paronychia entail infection with S aureus and Candida spp, respectively. To this end, there is a role for antibacterial and antifungal intervention. As is the case of the EGFRI-associated acneiform rash, inflammation in paronychia is sterile, with only rare pathogen involvement.

There is no role for topical or systemic antibiotics in the cancer population suffering from paronychia. A viable treatment option for moderate lesions is betamethasone valerate, applied 2 or 3 times daily; if there is no resolution, clobetasol cream, applied 2 or 3 times daily, can be prescribed.³⁰ The role of tetracyclines as anti-inflammatory agents in paronychia has not been studied to the extent it has been for acneiform rash; however, studies have shown a protective effect in small patient samples.³¹ In severe disease, the patient can be instructed to temporarily discontinue the drug and you can provide a referral to a dermatologist.

Stomatitis is also an area of concern in this patient population (FIGURE 1c). Prior to initiating treatment, a thorough examination of the patient’s oral cavity and oropharynx should be conducted. Loose or improperly fitting dentures should be adjusted because they can prohibit effective healing after ulceration develops.

If a rash progresses in size or severity, consider switching to hydrocortisone valerate cream, applied twice daily.

Stomatitis initially presents as erythematous or aphthous-like lesions, and can develop into acutely painful, large, continuous lesions.²⁹ Timely management of stomatitis is beneficial to patient outcomes because it can lead to severe pain and interference in oral intake; uncontrolled disease requires interruption and dosage-reduction of cancer therapy.^14,32

Patients should be encouraged to use soft-bristle toothbrushes and rinse with normal saline, not with commercial mouthwashes that typically contain alcohol. Grade 1 stomatitis (ie, pain and erythema) can be treated with triamcinolone dental paste, which can reduce inflammation caused by the ulcers. If disease progresses to Grade 2 to 3 stomatitis (erythema; ulceration; difficulty swallowing, or inability to swallow food), oral erythromycin (250-350 mg/d) or minocycline (50 mg/d) should be prescribed and the patient referred to a dermatologist.³⁰

Continue to: Does rash correlate with cancer treatment efficacy?

Does rash correlate with cancer treatment efficacy?

Despite troubling dermatologic effects of cancer therapies, a retrospective analysis of several clinical trials has revealed another side to this coin: namely, the appearance, and the severity, of a rash correlates positively with objective tumor response.¹⁴ That correlation allows the oncologist to use a rash as a surrogate marker of treatment efficacy²⁰ (although, notably, there remains a lack of prospective trials that would validate a rash as such a marker). Epidermal growth factor receptor-tyrosine kinase inhibitors are mainly prescribed in patients who harbor an activating EGFR mutation; no studies have stratified patients by EGFR mutation and incidence of rash.³³

The upshot? Although there are gaps in our understanding of the relationship between a rash and overall survival, we are nevertheless presented with this para­digm: A patient who is taking an EGFR-tyrosine kinase inhibitor and who develops a rash should be continued on that treatment for as long as can be tolerated, because the rash is presumed to be a sign that the patient is deriving the greatest clinical benefit from therapy.^14,20,33

CORRESPONDENCE
Kevin Zarrabi, MD, MSc, Department of Medicine, Health Science Center T16, Room 020, Stony Brook, NY 11790-8160; [email protected]

ACKNOWLEDGMENT
Ali John Zarrabi, MD, provided skillful editing of the manuscript of this article.

AUSTIN, TEX. – One day each week, Sasha D. Jaquez, PhD, visits with patients in the dermatology clinic at Dell Children’s Medical Center of Central Texas who wrestle with some aspect of their skin condition, from noncompliance to a recommended treatment regimen to fear of needles when an injection of medicine is required to keep them well.

“Our goal is to help promote the health and development of children, adolescents, and families through the use of evidence-based methods like cognitive-behavioral therapy,” said Dr. Jaquez, who is a pediatric psychologist at the University of Texas, Austin. “We do assessment and treatment of behavioral and emotional difficulties related to their skin condition or medical condition. So if they’re depressed but it’s not related to their skin condition, we will likely refer the patient to a community mental health system.”

During 1-hour visits at the dermatology clinic, Dr. Jaquez uses a mixed approach that includes cognitive-behavioral therapy and motivational interviewing to help patients and family members cope with their problematic behavior or negative thought patterns related to their skin conditions. “We do not have magic wands; we focus on the here and now,” she explained. “We focus on how to move forward in the most efficient way possible by teaching skills, practicing those skills with them in the office, and sending them home to use those skills. I don’t have 100% compliance on this, so if I notice that they’re not doing what I asked of them, we’ll have a conversation about what the barrier is. ‘What is getting in the way?’ I’ll ask. ‘Is this something you’re really wanting, or do you want a magic pill? If you want a magic pill, then our office isn’t where that’s going to come from.’ Sometimes patients aren’t ready to work on feeling better, and that is good for us to know.”

During consultations, she often talks with children and adolescents about how thoughts, feelings, and behaviors are related. She’ll use phrasing like, “The way that you think about something changes the way that you feel, and it changes the way that you act. We have control over our thoughts and behaviors, so if we think it’s going to be a bad day, it’s going to be a bad day. If we think it’s going to be a good day, then we’re going to find the positive aspects in the day and we might let those bad aspects go away. If I do something different [for my skin condition], then I’m going to feel different.”

She recalled the case of a 3-year-old boy with atopic dermatitis who was referred for excessive scratching. His mom stays at home, while dad works and travels frequently. “The parents had differing views on how to treat his medical condition. Mom wanted to do wet wraps while dad wanted to do bleach baths. Their son was getting no treatment because the parents couldn’t agree on anything. Mom noticed that her son scratches when he wants attention and when he’s angry.”

When Dr. Jaquez met with his parents, she encouraged them to agree on a plan to implement at home so that their son would gain some relief. She also advised them to ignore when their son scratches or when he gets angry. “Give him something else to do besides scratch, because if those hands are busy, he won’t be scratching. Let’s change the way this behavior happens. Let’s give him attention all the time instead of just when he’s scratching. That will work very quickly. And it did.”

She makes it a point to talk with patients and their families about living with the stress of a chronic illness like psoriasis or atopic dermatitis. “Let’s figure out, ‘How do we accept that this is how it is, and that they’re going to have to find their own ‘normal?’ ” she said. “I don’t know how many times someone comes into my office and says, ‘I just want to be normal.’ I like to ask patients, ‘what is your normal?’ These kids might have a lower quality of life than a child without a chronic illness, but we want to make sure that they’re living their lives to the fullest. You want to monitor not only adherence [to medication] but also quality of life. Sleep concerns are big. A lot of our kids might not being going to school, or they’re afraid to go to school because they get picked on because people don’t understand their skin condition.”

Dr. Jaquez acknowledged that not all dermatologists have a psychologist on staff or in their referral network, but all are capable of destigmatizing psychological and mental health issues for their patients. “Psychological comorbidities such as depression and anxiety can be associated with certain skin conditions,” she said. “Let them know that this is stressful stuff. Have discussions early, so if the time comes for a referral they won’t think you’re giving up on them. Don’t be afraid to say you have a psychologist that you want to refer to. Say, ‘I have an added team member I would love for you to meet. She’s our psychologist. She works with patients who are having difficulties.’ ”

Giving patients perceived control of their care could also help improve the behavior of concern. For example, when patients with needle phobia require an injection, ask if they would like to lay down, or sit down for the injection. “Giving them this tiny bit of control is going to help them feel more empowered,” she said.

Dr. Jaquez also recommends that clinicians pay attention to nonverbal cues and steer clear of using scare tactics to change their behavior. “Use positive behavioral strategies and try to avoid punishment. Children don’t want to hear ‘stop’ all the time. Parents are tired of saying it, and kids are tired of hearing it. We focus on praising the things that are going well. I advise parents all the time: ‘Catch them being good.’ ”

Dr. Jaquez reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – One day each week, Sasha D. Jaquez, PhD, visits with patients in the dermatology clinic at Dell Children’s Medical Center of Central Texas who wrestle with some aspect of their skin condition, from noncompliance to a recommended treatment regimen to fear of needles when an injection of medicine is required to keep them well.

“Our goal is to help promote the health and development of children, adolescents, and families through the use of evidence-based methods like cognitive-behavioral therapy,” said Dr. Jaquez, who is a pediatric psychologist at the University of Texas, Austin. “We do assessment and treatment of behavioral and emotional difficulties related to their skin condition or medical condition. So if they’re depressed but it’s not related to their skin condition, we will likely refer the patient to a community mental health system.”

During 1-hour visits at the dermatology clinic, Dr. Jaquez uses a mixed approach that includes cognitive-behavioral therapy and motivational interviewing to help patients and family members cope with their problematic behavior or negative thought patterns related to their skin conditions. “We do not have magic wands; we focus on the here and now,” she explained. “We focus on how to move forward in the most efficient way possible by teaching skills, practicing those skills with them in the office, and sending them home to use those skills. I don’t have 100% compliance on this, so if I notice that they’re not doing what I asked of them, we’ll have a conversation about what the barrier is. ‘What is getting in the way?’ I’ll ask. ‘Is this something you’re really wanting, or do you want a magic pill? If you want a magic pill, then our office isn’t where that’s going to come from.’ Sometimes patients aren’t ready to work on feeling better, and that is good for us to know.”

During consultations, she often talks with children and adolescents about how thoughts, feelings, and behaviors are related. She’ll use phrasing like, “The way that you think about something changes the way that you feel, and it changes the way that you act. We have control over our thoughts and behaviors, so if we think it’s going to be a bad day, it’s going to be a bad day. If we think it’s going to be a good day, then we’re going to find the positive aspects in the day and we might let those bad aspects go away. If I do something different [for my skin condition], then I’m going to feel different.”

She recalled the case of a 3-year-old boy with atopic dermatitis who was referred for excessive scratching. His mom stays at home, while dad works and travels frequently. “The parents had differing views on how to treat his medical condition. Mom wanted to do wet wraps while dad wanted to do bleach baths. Their son was getting no treatment because the parents couldn’t agree on anything. Mom noticed that her son scratches when he wants attention and when he’s angry.”

When Dr. Jaquez met with his parents, she encouraged them to agree on a plan to implement at home so that their son would gain some relief. She also advised them to ignore when their son scratches or when he gets angry. “Give him something else to do besides scratch, because if those hands are busy, he won’t be scratching. Let’s change the way this behavior happens. Let’s give him attention all the time instead of just when he’s scratching. That will work very quickly. And it did.”

She makes it a point to talk with patients and their families about living with the stress of a chronic illness like psoriasis or atopic dermatitis. “Let’s figure out, ‘How do we accept that this is how it is, and that they’re going to have to find their own ‘normal?’ ” she said. “I don’t know how many times someone comes into my office and says, ‘I just want to be normal.’ I like to ask patients, ‘what is your normal?’ These kids might have a lower quality of life than a child without a chronic illness, but we want to make sure that they’re living their lives to the fullest. You want to monitor not only adherence [to medication] but also quality of life. Sleep concerns are big. A lot of our kids might not being going to school, or they’re afraid to go to school because they get picked on because people don’t understand their skin condition.”

Dr. Jaquez acknowledged that not all dermatologists have a psychologist on staff or in their referral network, but all are capable of destigmatizing psychological and mental health issues for their patients. “Psychological comorbidities such as depression and anxiety can be associated with certain skin conditions,” she said. “Let them know that this is stressful stuff. Have discussions early, so if the time comes for a referral they won’t think you’re giving up on them. Don’t be afraid to say you have a psychologist that you want to refer to. Say, ‘I have an added team member I would love for you to meet. She’s our psychologist. She works with patients who are having difficulties.’ ”

Giving patients perceived control of their care could also help improve the behavior of concern. For example, when patients with needle phobia require an injection, ask if they would like to lay down, or sit down for the injection. “Giving them this tiny bit of control is going to help them feel more empowered,” she said.

Dr. Jaquez also recommends that clinicians pay attention to nonverbal cues and steer clear of using scare tactics to change their behavior. “Use positive behavioral strategies and try to avoid punishment. Children don’t want to hear ‘stop’ all the time. Parents are tired of saying it, and kids are tired of hearing it. We focus on praising the things that are going well. I advise parents all the time: ‘Catch them being good.’ ”

Dr. Jaquez reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – One day each week, Sasha D. Jaquez, PhD, visits with patients in the dermatology clinic at Dell Children’s Medical Center of Central Texas who wrestle with some aspect of their skin condition, from noncompliance to a recommended treatment regimen to fear of needles when an injection of medicine is required to keep them well.

“Our goal is to help promote the health and development of children, adolescents, and families through the use of evidence-based methods like cognitive-behavioral therapy,” said Dr. Jaquez, who is a pediatric psychologist at the University of Texas, Austin. “We do assessment and treatment of behavioral and emotional difficulties related to their skin condition or medical condition. So if they’re depressed but it’s not related to their skin condition, we will likely refer the patient to a community mental health system.”

During 1-hour visits at the dermatology clinic, Dr. Jaquez uses a mixed approach that includes cognitive-behavioral therapy and motivational interviewing to help patients and family members cope with their problematic behavior or negative thought patterns related to their skin conditions. “We do not have magic wands; we focus on the here and now,” she explained. “We focus on how to move forward in the most efficient way possible by teaching skills, practicing those skills with them in the office, and sending them home to use those skills. I don’t have 100% compliance on this, so if I notice that they’re not doing what I asked of them, we’ll have a conversation about what the barrier is. ‘What is getting in the way?’ I’ll ask. ‘Is this something you’re really wanting, or do you want a magic pill? If you want a magic pill, then our office isn’t where that’s going to come from.’ Sometimes patients aren’t ready to work on feeling better, and that is good for us to know.”

During consultations, she often talks with children and adolescents about how thoughts, feelings, and behaviors are related. She’ll use phrasing like, “The way that you think about something changes the way that you feel, and it changes the way that you act. We have control over our thoughts and behaviors, so if we think it’s going to be a bad day, it’s going to be a bad day. If we think it’s going to be a good day, then we’re going to find the positive aspects in the day and we might let those bad aspects go away. If I do something different [for my skin condition], then I’m going to feel different.”

She recalled the case of a 3-year-old boy with atopic dermatitis who was referred for excessive scratching. His mom stays at home, while dad works and travels frequently. “The parents had differing views on how to treat his medical condition. Mom wanted to do wet wraps while dad wanted to do bleach baths. Their son was getting no treatment because the parents couldn’t agree on anything. Mom noticed that her son scratches when he wants attention and when he’s angry.”

When Dr. Jaquez met with his parents, she encouraged them to agree on a plan to implement at home so that their son would gain some relief. She also advised them to ignore when their son scratches or when he gets angry. “Give him something else to do besides scratch, because if those hands are busy, he won’t be scratching. Let’s change the way this behavior happens. Let’s give him attention all the time instead of just when he’s scratching. That will work very quickly. And it did.”

She makes it a point to talk with patients and their families about living with the stress of a chronic illness like psoriasis or atopic dermatitis. “Let’s figure out, ‘How do we accept that this is how it is, and that they’re going to have to find their own ‘normal?’ ” she said. “I don’t know how many times someone comes into my office and says, ‘I just want to be normal.’ I like to ask patients, ‘what is your normal?’ These kids might have a lower quality of life than a child without a chronic illness, but we want to make sure that they’re living their lives to the fullest. You want to monitor not only adherence [to medication] but also quality of life. Sleep concerns are big. A lot of our kids might not being going to school, or they’re afraid to go to school because they get picked on because people don’t understand their skin condition.”

Dr. Jaquez acknowledged that not all dermatologists have a psychologist on staff or in their referral network, but all are capable of destigmatizing psychological and mental health issues for their patients. “Psychological comorbidities such as depression and anxiety can be associated with certain skin conditions,” she said. “Let them know that this is stressful stuff. Have discussions early, so if the time comes for a referral they won’t think you’re giving up on them. Don’t be afraid to say you have a psychologist that you want to refer to. Say, ‘I have an added team member I would love for you to meet. She’s our psychologist. She works with patients who are having difficulties.’ ”

Giving patients perceived control of their care could also help improve the behavior of concern. For example, when patients with needle phobia require an injection, ask if they would like to lay down, or sit down for the injection. “Giving them this tiny bit of control is going to help them feel more empowered,” she said.

Dr. Jaquez also recommends that clinicians pay attention to nonverbal cues and steer clear of using scare tactics to change their behavior. “Use positive behavioral strategies and try to avoid punishment. Children don’t want to hear ‘stop’ all the time. Parents are tired of saying it, and kids are tired of hearing it. We focus on praising the things that are going well. I advise parents all the time: ‘Catch them being good.’ ”

Dr. Jaquez reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – Among children with psoriasis, there appears to be no strong evidence that biologic immunomodulating drugs increase the 6-month risk of serious infections, compared with systemic nonbiologics or phototherapy, according to results from the largest population-based study of its kind to date.

However, children with psoriasis face a 64% increased risk of infection, compared with risk-matched pediatric patients without the disease.

“We know that pediatric psoriasis affects up to 1.3% of children, and we know that is associated with multiple potential comorbidities and that it has a significant impact on quality of life for children affected,” lead study author Maria Schneeweiss, MD, said at the annual meeting of the Society for Pediatric Dermatology. “Increasingly, we see that biologic and nonbiologic systemic agents are used to treat moderate to severe pediatric psoriasis. While we have a lot of experience in adult psoriasis and a lot of comparative safety studies of these drugs in adult psoriasis, there are very few population-based studies on the safety of these systemic agents for treating pediatric psoriasis.”

In an effort to evaluate the 6-month risk of serious bacterial and opportunistic infections in children with psoriasis treated with systemic immunomodulatory medications, Dr. Schneeweiss and Joseph F. Merola, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and Jennifer Huang, MD, of Boston Children’s Hospital drew from longitudinal, patient-level U.S. claims data in the MarketScan database between 2003 and 2017. They limited the analysis to patients younger than age 18; those who had a recorded diagnosis of psoriasis; and those who were treated with biologics, nonbiologic immunomodulatory agents, or phototherapy. The researchers used hospital discharge diagnoses to compute the risk of serious bacterial and opportunistic infections, and propensity score matching to determine relative risks.

A total of 54,355 children with psoriasis were identified in the database. Before propensity score matching, 635 patients initiated biologic therapy, 919 initiated nonbiologic systemic agents, and 2,537 initiated phototherapy. Their mean age was 12-14 years and slightly more than half were female. In nonbiologic initiators, the 6-month risk of serious infections was 4.75 per 1,000 patients, while in biologic initiators it was 5.44 per 1,000 patients, resulting in a propensity score–matched ratio of 0.60. There was no statistically significant increased risk when the use of nonbiologics was compared with the use of phototherapy.

Independent of treatment, the risk of infection among psoriasis patients was 1.1 per 1,000 patients, which was 60% higher than matched pediatric patients without psoriasis (risk ratio, 1.64).

“When treating pediatric patients with psoriasis, clinicians should remain mindful that the presence of psoriasis itself may increase the risk of infection in children and adolescents, independent of treatment, but that biologic immunomodulatory agents do not further increase that risk,” Dr. Schneeweiss said in an interview. “Our findings suggest that, while there may be an increased risk of certain infections based on the presence of psoriasis alone, all appropriate treatment options should be discussed with patients in shared decision making with their physician. Patients should understand the risks, benefits, and alternatives to any treatment option but not necessarily be restricted as such and have access to newer, targeted and highly effective therapy as appropriate to each individual case.”

She added that, based on the National Psoriasis Foundation guidance of treat-to-target strategies, “our pediatric patients should be offered the same level of disease control as all psoriasis patients.”

She acknowledged certain limitations of the analysis, including the inability to stratify by disease severity and to determine specific doses of medication used.

The study was funded by the Brigham and Women’s Hospital departments of dermatology and medicine. Dr. Schneeweiss and Dr. Huang reported having no financial disclosures. Dr. Merola reported that he has served as a consultant and/or investigator for numerous pharmaceutical companies.

[email protected]

AUSTIN, TEX. – Among children with psoriasis, there appears to be no strong evidence that biologic immunomodulating drugs increase the 6-month risk of serious infections, compared with systemic nonbiologics or phototherapy, according to results from the largest population-based study of its kind to date.

However, children with psoriasis face a 64% increased risk of infection, compared with risk-matched pediatric patients without the disease.

“We know that pediatric psoriasis affects up to 1.3% of children, and we know that is associated with multiple potential comorbidities and that it has a significant impact on quality of life for children affected,” lead study author Maria Schneeweiss, MD, said at the annual meeting of the Society for Pediatric Dermatology. “Increasingly, we see that biologic and nonbiologic systemic agents are used to treat moderate to severe pediatric psoriasis. While we have a lot of experience in adult psoriasis and a lot of comparative safety studies of these drugs in adult psoriasis, there are very few population-based studies on the safety of these systemic agents for treating pediatric psoriasis.”

In an effort to evaluate the 6-month risk of serious bacterial and opportunistic infections in children with psoriasis treated with systemic immunomodulatory medications, Dr. Schneeweiss and Joseph F. Merola, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and Jennifer Huang, MD, of Boston Children’s Hospital drew from longitudinal, patient-level U.S. claims data in the MarketScan database between 2003 and 2017. They limited the analysis to patients younger than age 18; those who had a recorded diagnosis of psoriasis; and those who were treated with biologics, nonbiologic immunomodulatory agents, or phototherapy. The researchers used hospital discharge diagnoses to compute the risk of serious bacterial and opportunistic infections, and propensity score matching to determine relative risks.

A total of 54,355 children with psoriasis were identified in the database. Before propensity score matching, 635 patients initiated biologic therapy, 919 initiated nonbiologic systemic agents, and 2,537 initiated phototherapy. Their mean age was 12-14 years and slightly more than half were female. In nonbiologic initiators, the 6-month risk of serious infections was 4.75 per 1,000 patients, while in biologic initiators it was 5.44 per 1,000 patients, resulting in a propensity score–matched ratio of 0.60. There was no statistically significant increased risk when the use of nonbiologics was compared with the use of phototherapy.

Independent of treatment, the risk of infection among psoriasis patients was 1.1 per 1,000 patients, which was 60% higher than matched pediatric patients without psoriasis (risk ratio, 1.64).

“When treating pediatric patients with psoriasis, clinicians should remain mindful that the presence of psoriasis itself may increase the risk of infection in children and adolescents, independent of treatment, but that biologic immunomodulatory agents do not further increase that risk,” Dr. Schneeweiss said in an interview. “Our findings suggest that, while there may be an increased risk of certain infections based on the presence of psoriasis alone, all appropriate treatment options should be discussed with patients in shared decision making with their physician. Patients should understand the risks, benefits, and alternatives to any treatment option but not necessarily be restricted as such and have access to newer, targeted and highly effective therapy as appropriate to each individual case.”

She added that, based on the National Psoriasis Foundation guidance of treat-to-target strategies, “our pediatric patients should be offered the same level of disease control as all psoriasis patients.”

She acknowledged certain limitations of the analysis, including the inability to stratify by disease severity and to determine specific doses of medication used.

The study was funded by the Brigham and Women’s Hospital departments of dermatology and medicine. Dr. Schneeweiss and Dr. Huang reported having no financial disclosures. Dr. Merola reported that he has served as a consultant and/or investigator for numerous pharmaceutical companies.

[email protected]

AUSTIN, TEX. – Among children with psoriasis, there appears to be no strong evidence that biologic immunomodulating drugs increase the 6-month risk of serious infections, compared with systemic nonbiologics or phototherapy, according to results from the largest population-based study of its kind to date.

However, children with psoriasis face a 64% increased risk of infection, compared with risk-matched pediatric patients without the disease.

“We know that pediatric psoriasis affects up to 1.3% of children, and we know that is associated with multiple potential comorbidities and that it has a significant impact on quality of life for children affected,” lead study author Maria Schneeweiss, MD, said at the annual meeting of the Society for Pediatric Dermatology. “Increasingly, we see that biologic and nonbiologic systemic agents are used to treat moderate to severe pediatric psoriasis. While we have a lot of experience in adult psoriasis and a lot of comparative safety studies of these drugs in adult psoriasis, there are very few population-based studies on the safety of these systemic agents for treating pediatric psoriasis.”

In an effort to evaluate the 6-month risk of serious bacterial and opportunistic infections in children with psoriasis treated with systemic immunomodulatory medications, Dr. Schneeweiss and Joseph F. Merola, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and Jennifer Huang, MD, of Boston Children’s Hospital drew from longitudinal, patient-level U.S. claims data in the MarketScan database between 2003 and 2017. They limited the analysis to patients younger than age 18; those who had a recorded diagnosis of psoriasis; and those who were treated with biologics, nonbiologic immunomodulatory agents, or phototherapy. The researchers used hospital discharge diagnoses to compute the risk of serious bacterial and opportunistic infections, and propensity score matching to determine relative risks.

A total of 54,355 children with psoriasis were identified in the database. Before propensity score matching, 635 patients initiated biologic therapy, 919 initiated nonbiologic systemic agents, and 2,537 initiated phototherapy. Their mean age was 12-14 years and slightly more than half were female. In nonbiologic initiators, the 6-month risk of serious infections was 4.75 per 1,000 patients, while in biologic initiators it was 5.44 per 1,000 patients, resulting in a propensity score–matched ratio of 0.60. There was no statistically significant increased risk when the use of nonbiologics was compared with the use of phototherapy.

Independent of treatment, the risk of infection among psoriasis patients was 1.1 per 1,000 patients, which was 60% higher than matched pediatric patients without psoriasis (risk ratio, 1.64).

“When treating pediatric patients with psoriasis, clinicians should remain mindful that the presence of psoriasis itself may increase the risk of infection in children and adolescents, independent of treatment, but that biologic immunomodulatory agents do not further increase that risk,” Dr. Schneeweiss said in an interview. “Our findings suggest that, while there may be an increased risk of certain infections based on the presence of psoriasis alone, all appropriate treatment options should be discussed with patients in shared decision making with their physician. Patients should understand the risks, benefits, and alternatives to any treatment option but not necessarily be restricted as such and have access to newer, targeted and highly effective therapy as appropriate to each individual case.”

She added that, based on the National Psoriasis Foundation guidance of treat-to-target strategies, “our pediatric patients should be offered the same level of disease control as all psoriasis patients.”

She acknowledged certain limitations of the analysis, including the inability to stratify by disease severity and to determine specific doses of medication used.

The study was funded by the Brigham and Women’s Hospital departments of dermatology and medicine. Dr. Schneeweiss and Dr. Huang reported having no financial disclosures. Dr. Merola reported that he has served as a consultant and/or investigator for numerous pharmaceutical companies.

[email protected]

The skin biopsy confirmed toxic epidermal necrolysis (TEN), possibly secondary to one of the antibiotics he’d been given upon hospital admission. The health care team suspected that the patient had Stevens-Johns Syndrome when he sought care and that it had evolved into TEN. Both diseases are life-threatening and require intensive in-hospital care.

TEN is part of a spectrum of disorders that includes erythema multiforme (< 10% of the body surface is involved); SJS/TEN (10%-30% involvement with erythematous or pruritic macules, widespread blisters on the trunk and face, and erosions of ≥ 1 mucous membranes); and TEN (> 30% involvement).

Drugs most commonly known to cause SJS and TEN include sulfonamide antibiotics, allopurinol, nonsteroidal anti-inflammatory agents, amine antiepileptic drugs (phenytoin and carbamazepine), and lamotrigine. Fifty percent of SJS/TEN cases have no identifiable cause. Not all SJS is secondary to drug exposure, but it is the job of the clinician to investigate this cause and stop any suspicious medications.

In this case, trimethoprim/sulfamethoxazole was discontinued immediately and the patient was transferred to a burn unit and given intravenous gamma-globulin 1 g/kg for 3 days. Fortunately, the patient survived with intensive supportive care in the burn unit. The exfoliation of > 30% of the skin is like a large secondary burn, and a burn unit is the optimal location for lifesaving measures.

‌

Photo courtesy of Robert T. Gilson, MD, and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Milana C, Smith M. Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1161-1168.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The skin biopsy confirmed toxic epidermal necrolysis (TEN), possibly secondary to one of the antibiotics he’d been given upon hospital admission. The health care team suspected that the patient had Stevens-Johns Syndrome when he sought care and that it had evolved into TEN. Both diseases are life-threatening and require intensive in-hospital care.

TEN is part of a spectrum of disorders that includes erythema multiforme (< 10% of the body surface is involved); SJS/TEN (10%-30% involvement with erythematous or pruritic macules, widespread blisters on the trunk and face, and erosions of ≥ 1 mucous membranes); and TEN (> 30% involvement).

Drugs most commonly known to cause SJS and TEN include sulfonamide antibiotics, allopurinol, nonsteroidal anti-inflammatory agents, amine antiepileptic drugs (phenytoin and carbamazepine), and lamotrigine. Fifty percent of SJS/TEN cases have no identifiable cause. Not all SJS is secondary to drug exposure, but it is the job of the clinician to investigate this cause and stop any suspicious medications.

In this case, trimethoprim/sulfamethoxazole was discontinued immediately and the patient was transferred to a burn unit and given intravenous gamma-globulin 1 g/kg for 3 days. Fortunately, the patient survived with intensive supportive care in the burn unit. The exfoliation of > 30% of the skin is like a large secondary burn, and a burn unit is the optimal location for lifesaving measures.

‌

Photo courtesy of Robert T. Gilson, MD, and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Milana C, Smith M. Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1161-1168.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The skin biopsy confirmed toxic epidermal necrolysis (TEN), possibly secondary to one of the antibiotics he’d been given upon hospital admission. The health care team suspected that the patient had Stevens-Johns Syndrome when he sought care and that it had evolved into TEN. Both diseases are life-threatening and require intensive in-hospital care.

TEN is part of a spectrum of disorders that includes erythema multiforme (< 10% of the body surface is involved); SJS/TEN (10%-30% involvement with erythematous or pruritic macules, widespread blisters on the trunk and face, and erosions of ≥ 1 mucous membranes); and TEN (> 30% involvement).

Drugs most commonly known to cause SJS and TEN include sulfonamide antibiotics, allopurinol, nonsteroidal anti-inflammatory agents, amine antiepileptic drugs (phenytoin and carbamazepine), and lamotrigine. Fifty percent of SJS/TEN cases have no identifiable cause. Not all SJS is secondary to drug exposure, but it is the job of the clinician to investigate this cause and stop any suspicious medications.

In this case, trimethoprim/sulfamethoxazole was discontinued immediately and the patient was transferred to a burn unit and given intravenous gamma-globulin 1 g/kg for 3 days. Fortunately, the patient survived with intensive supportive care in the burn unit. The exfoliation of > 30% of the skin is like a large secondary burn, and a burn unit is the optimal location for lifesaving measures.

‌

Photo courtesy of Robert T. Gilson, MD, and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Milana C, Smith M. Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1161-1168.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The Food and Drug Administration has approved the Humira biosimilar Hadlima (adalimumab-bwwd), making it the fourth adalimumab biosimilar approved in the United States, the agency announced.

Wikimedia Commons/FitzColinGerald/Creative Commons License

Hadlima is approved for seven of the reference product’s indications, which include rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, and ulcerative colitis.

The product will launch in the United States on June 30, 2023. Other FDA-approved adalimumab biosimilars – Amjevita (adalimunab-atto), Cyltezo (adalimumab-adbm), Hyrimoz (adalimumab-adaz) – similarly will not reach the U.S. market until 2023.

Hadlima is developed by Samsung Bioepis and commercialized by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co.

*This article was updated on July 24, 2019.

[email protected]

The Food and Drug Administration has approved the Humira biosimilar Hadlima (adalimumab-bwwd), making it the fourth adalimumab biosimilar approved in the United States, the agency announced.

Wikimedia Commons/FitzColinGerald/Creative Commons License

Hadlima is approved for seven of the reference product’s indications, which include rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, and ulcerative colitis.

The product will launch in the United States on June 30, 2023. Other FDA-approved adalimumab biosimilars – Amjevita (adalimunab-atto), Cyltezo (adalimumab-adbm), Hyrimoz (adalimumab-adaz) – similarly will not reach the U.S. market until 2023.

Hadlima is developed by Samsung Bioepis and commercialized by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co.

*This article was updated on July 24, 2019.

[email protected]

The Food and Drug Administration has approved the Humira biosimilar Hadlima (adalimumab-bwwd), making it the fourth adalimumab biosimilar approved in the United States, the agency announced.

Wikimedia Commons/FitzColinGerald/Creative Commons License

Hadlima is approved for seven of the reference product’s indications, which include rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, and ulcerative colitis.

The product will launch in the United States on June 30, 2023. Other FDA-approved adalimumab biosimilars – Amjevita (adalimunab-atto), Cyltezo (adalimumab-adbm), Hyrimoz (adalimumab-adaz) – similarly will not reach the U.S. market until 2023.

Hadlima is developed by Samsung Bioepis and commercialized by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co.

*This article was updated on July 24, 2019.

[email protected]

The Food and Drug Administration has expanded the indication for apremilast (Otezla) to include the treatment of oral ulcers associated with Behçet’s disease in adults, according to an announcement from the manufacturer, Celgene.

FDA approval was based on results of the randomized, placebo-controlled, double-blind, phase 3 RELIEF trial, in which 207 patients with Behçet’s disease with active ulcers underwent treatment for 12 weeks with 30 mg apremilast or placebo. When measured on a visual analog scale, the reduction in pain from oral ulcers after 12 weeks in patients receiving apremilast was 42.7 points, compared with 18.7 points in the placebo group. Just over 50% of apremilast patients achieved complete response by week 12, compared with 22.3% in the placebo group.

The most common adverse events associated with apremilast during RELIEF were diarrhea, nausea, headache, and upper respiratory infection. This was consistent with apremilast’s known safety profile.


Apremilast is also indicated for treatment of patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy, and for patients with active psoriatic arthritis.

“Oral ulcers are a recurring and debilitating manifestation that affects nearly everyone living with Behçet’s disease and have an important negative impact on the quality of life for these patients. In the clinical trial, Otezla demonstrated improvements in measures of oral ulcers at week 12. Otezla has the potential to be a needed treatment option for U.S. patients and their physicians, who previously had limited options available,” Yusuf Yazici, MD, clinical associate professor in the department of medicine at New York University, said in the announcement.

[email protected]

The Food and Drug Administration has expanded the indication for apremilast (Otezla) to include the treatment of oral ulcers associated with Behçet’s disease in adults, according to an announcement from the manufacturer, Celgene.

FDA approval was based on results of the randomized, placebo-controlled, double-blind, phase 3 RELIEF trial, in which 207 patients with Behçet’s disease with active ulcers underwent treatment for 12 weeks with 30 mg apremilast or placebo. When measured on a visual analog scale, the reduction in pain from oral ulcers after 12 weeks in patients receiving apremilast was 42.7 points, compared with 18.7 points in the placebo group. Just over 50% of apremilast patients achieved complete response by week 12, compared with 22.3% in the placebo group.

The most common adverse events associated with apremilast during RELIEF were diarrhea, nausea, headache, and upper respiratory infection. This was consistent with apremilast’s known safety profile.


Apremilast is also indicated for treatment of patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy, and for patients with active psoriatic arthritis.

“Oral ulcers are a recurring and debilitating manifestation that affects nearly everyone living with Behçet’s disease and have an important negative impact on the quality of life for these patients. In the clinical trial, Otezla demonstrated improvements in measures of oral ulcers at week 12. Otezla has the potential to be a needed treatment option for U.S. patients and their physicians, who previously had limited options available,” Yusuf Yazici, MD, clinical associate professor in the department of medicine at New York University, said in the announcement.

[email protected]

The Food and Drug Administration has expanded the indication for apremilast (Otezla) to include the treatment of oral ulcers associated with Behçet’s disease in adults, according to an announcement from the manufacturer, Celgene.

FDA approval was based on results of the randomized, placebo-controlled, double-blind, phase 3 RELIEF trial, in which 207 patients with Behçet’s disease with active ulcers underwent treatment for 12 weeks with 30 mg apremilast or placebo. When measured on a visual analog scale, the reduction in pain from oral ulcers after 12 weeks in patients receiving apremilast was 42.7 points, compared with 18.7 points in the placebo group. Just over 50% of apremilast patients achieved complete response by week 12, compared with 22.3% in the placebo group.

The most common adverse events associated with apremilast during RELIEF were diarrhea, nausea, headache, and upper respiratory infection. This was consistent with apremilast’s known safety profile.


Apremilast is also indicated for treatment of patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy, and for patients with active psoriatic arthritis.

“Oral ulcers are a recurring and debilitating manifestation that affects nearly everyone living with Behçet’s disease and have an important negative impact on the quality of life for these patients. In the clinical trial, Otezla demonstrated improvements in measures of oral ulcers at week 12. Otezla has the potential to be a needed treatment option for U.S. patients and their physicians, who previously had limited options available,” Yusuf Yazici, MD, clinical associate professor in the department of medicine at New York University, said in the announcement.

[email protected]

AUSTIN – Not long ago, Rajani Katta, MD, received a text message from a friend who expressed concern about a rash that developed in the underarm of her teenage daughter.

The culprit turned out to be the lavender essential oil contained in an “all natural” deodorant that her daughter had recently switched to – a storyline that Dr. Katta encounters with increasing frequency in her role as clinical professor of dermatology at the University of Texas Health Science Center at Houston.

“Some people may think that you can’t get an allergic reaction to natural products, but we are seeing many allergic reactions to essential oils,” Dr. Katta said at the annual meeting of the Society for Pediatric Dermatology. “When you talk about a natural allergy, it is more likely to occur if your skin barrier is compromised, so I think that’s why we’re seeing it, especially in young girls in the underarm area. If you shave the underarm, you impair that skin barrier and you’re more likely to develop a reaction to something you’re using over it.”

Her list of recommended deodorants includes Almay Roll-On Antiperspirant & Deodorant, Crystal Body Deodorant Stick, Crystal Roll-On Body Deodorant, Vanicream Deodorant for Sensitive Skin (aluminum-free), Vanicream Antiperspirant/Deodorant, and CertainDri Clinical Strength Roll-On. They are fragrance-free and lack propylene glycol, which is a common allergen.

Increasingly, essential oils are being added to lip balms and toothpastes, said Dr. Katta, who is also author of the 2018 book “Glow: The Dermatologist’s Guide to a Whole Foods Younger Skin Diet.” She recalled one patient who presented with chronic chapped lips. “It doesn’t matter how many lip glosses I try; it just keeps getting worse,” the patient told her. The likely culprit turned out to be ingredients contained in flavored lip balm from EOS. Reports of blistering and cracking of the lips from use of the products prompted a class action lawsuit and a notice to consumers from the Food and Drug Administration.

Another patient presented with cracked lips after switching to an “all natural” toothpaste that was labeled “gluten free.”

“It looked great,” Dr. Katta recalled. “Unfortunately it was not flavoring free. She reacted to multiple essential oils, including tea tree oil, contained in the toothpaste. This is being added to a number of toothpastes, and I think we’re going to see more of these types of reactions.”

Other toothpastes contain balsam of Peru, “which is consistently one of the top allergens in patch test clinics,” she said. “One of the components of balsam of Peru is a cinnamon compound, which can be an issue.”

Dr. Katta advises her patients to use Vaseline petroleum jelly as a lip balm and recommends Tom’s of Maine Silly Strawberry Flavor (this flavor only) toothpaste for children.

A few years ago, a teenager presented to Dr. Katta with intense bullae on the dorsum of the foot after wearing shoes without socks. “She was wearing white canvas Keds, which looked very innocuous,” she said. Patch testing revealed that the teen reacted to four different rubber accelerators. “When we contacted the company, they [acknowledged] using rubber cement to make the canvas Keds,” Dr. Katta said. “Rubber cement is an adhesive and it does contain rubber accelerators. Later, I saw two cases of children who had walked around all day at the amusement park wearing their Sperry Topsiders without any socks. We couldn’t get any information from that manufacturer, but I suspect that they also use a rubber-based glue to make those shoes.” She characterized shoes as “a real setup for a foot allergy because you have friction, sweat that’s pulling allergen out of an object, and sweat is carrying it over, especially to the dorsum of the foot.”


Dr. Katta has also noticed an uptick in the number of young patients who develop allergic reactions to dyes used to make workout clothing. “If you ever see rashes that do not involve the axillary vault but do have peraxillary accentuation, think textile allergy,” she said. “We’re seeing a lot of reactions to disperse blue clothing dyes. When you think about textile allergy from the dyes, it tends to be the blue and black clothing. It’s more likely in the setting of synthetic fabrics because they leach out dyes more easily, and it’s more likely in the setting of sweat because sweat helps pull allergen out. I’m seeing it a lot from sports uniforms and tight black leggings and tight sports bras that people are wearing. I’m also seeing some from bathing suits and swim shirts.”

Exposure to products containing the preservative methylisothiazolinone (MI) is also on the rise. It ranks as the second most frequent allergen for which the North American Contact Dermatitis Group is seeing positive results on patch testing, with rates of 13.4%. MI can be found in many skin care products and “probably about half of school glues, fabric glues, and craft glues,” Dr. Katta said. “Stick versus liquid doesn’t make a difference.” Children and teens often use craft glues, laundry detergents, and other products to create “slime” as a way to learn about viscosity, polymers, and chemical reactions. “Sometimes these children have sensitive skin, or they’re using it with prolonged contact, so they may be sensitizing themselves to the MI,” she said.

She concluded her remarks by noting that an increasing number of young patients are developing reactions to wearable medical devices such as insulin pumps and glucose monitors. “With this, the first thing to think about is frictional irritant dermatitis,” she said. “You can put Scanpor medical paper tape on people’s back for 48 hours straight to patch test them. Some people are incredibly reactive to the friction of just that tape. You also have to think about trapped allergen. One of my patients reacted to colophony, fragrance mix, and propylene glycol, all of which were contained in his skin care products. Some people are getting advice from other patients to use Mastisol liquid adhesive to help their glucose monitors stick better. Mastisol has a high rate of cross-reactivity with balsam of Peru, so it’s a fragrance allergen. That’s the first thing you want to ask patients about: what products they’re using.”

One of her patients thought she was reacting to adhesive tape on her skin, but in fact she was reacting to two different acrylates: ethylene glycol dimethacrylate (EGDMA) and hydroxyethyl methacrylate (HEMA). “I know about these allergens because I see reactions from butterfly needles in dialysis patients,” Dr. Katta explained. “What happens is, these acrylates are glues or plastics used somewhere else on the device, and they can migrate through barriers.”

In one published case, a 9-year-old boy developed a reaction to ethyl cyanoacrylate contained in a glucose sensor adhesive (Dermatitis. 2017; 28[4]:289-91). It never touched the boy’s skin directly but was presumed to migrate through that tape. “The bottom line is that acrylates may induce contact dermatitis even through perceived barriers,” she said. “Their use anywhere in medical devices may prove problematic.”

Dr. Katta reported that she is a member of the advisory board for Vichy Laboratories.
 

[email protected]

AUSTIN – Not long ago, Rajani Katta, MD, received a text message from a friend who expressed concern about a rash that developed in the underarm of her teenage daughter.

The culprit turned out to be the lavender essential oil contained in an “all natural” deodorant that her daughter had recently switched to – a storyline that Dr. Katta encounters with increasing frequency in her role as clinical professor of dermatology at the University of Texas Health Science Center at Houston.

“Some people may think that you can’t get an allergic reaction to natural products, but we are seeing many allergic reactions to essential oils,” Dr. Katta said at the annual meeting of the Society for Pediatric Dermatology. “When you talk about a natural allergy, it is more likely to occur if your skin barrier is compromised, so I think that’s why we’re seeing it, especially in young girls in the underarm area. If you shave the underarm, you impair that skin barrier and you’re more likely to develop a reaction to something you’re using over it.”

Her list of recommended deodorants includes Almay Roll-On Antiperspirant & Deodorant, Crystal Body Deodorant Stick, Crystal Roll-On Body Deodorant, Vanicream Deodorant for Sensitive Skin (aluminum-free), Vanicream Antiperspirant/Deodorant, and CertainDri Clinical Strength Roll-On. They are fragrance-free and lack propylene glycol, which is a common allergen.

Increasingly, essential oils are being added to lip balms and toothpastes, said Dr. Katta, who is also author of the 2018 book “Glow: The Dermatologist’s Guide to a Whole Foods Younger Skin Diet.” She recalled one patient who presented with chronic chapped lips. “It doesn’t matter how many lip glosses I try; it just keeps getting worse,” the patient told her. The likely culprit turned out to be ingredients contained in flavored lip balm from EOS. Reports of blistering and cracking of the lips from use of the products prompted a class action lawsuit and a notice to consumers from the Food and Drug Administration.

Another patient presented with cracked lips after switching to an “all natural” toothpaste that was labeled “gluten free.”

“It looked great,” Dr. Katta recalled. “Unfortunately it was not flavoring free. She reacted to multiple essential oils, including tea tree oil, contained in the toothpaste. This is being added to a number of toothpastes, and I think we’re going to see more of these types of reactions.”

Other toothpastes contain balsam of Peru, “which is consistently one of the top allergens in patch test clinics,” she said. “One of the components of balsam of Peru is a cinnamon compound, which can be an issue.”

Dr. Katta advises her patients to use Vaseline petroleum jelly as a lip balm and recommends Tom’s of Maine Silly Strawberry Flavor (this flavor only) toothpaste for children.

A few years ago, a teenager presented to Dr. Katta with intense bullae on the dorsum of the foot after wearing shoes without socks. “She was wearing white canvas Keds, which looked very innocuous,” she said. Patch testing revealed that the teen reacted to four different rubber accelerators. “When we contacted the company, they [acknowledged] using rubber cement to make the canvas Keds,” Dr. Katta said. “Rubber cement is an adhesive and it does contain rubber accelerators. Later, I saw two cases of children who had walked around all day at the amusement park wearing their Sperry Topsiders without any socks. We couldn’t get any information from that manufacturer, but I suspect that they also use a rubber-based glue to make those shoes.” She characterized shoes as “a real setup for a foot allergy because you have friction, sweat that’s pulling allergen out of an object, and sweat is carrying it over, especially to the dorsum of the foot.”


Dr. Katta has also noticed an uptick in the number of young patients who develop allergic reactions to dyes used to make workout clothing. “If you ever see rashes that do not involve the axillary vault but do have peraxillary accentuation, think textile allergy,” she said. “We’re seeing a lot of reactions to disperse blue clothing dyes. When you think about textile allergy from the dyes, it tends to be the blue and black clothing. It’s more likely in the setting of synthetic fabrics because they leach out dyes more easily, and it’s more likely in the setting of sweat because sweat helps pull allergen out. I’m seeing it a lot from sports uniforms and tight black leggings and tight sports bras that people are wearing. I’m also seeing some from bathing suits and swim shirts.”

Exposure to products containing the preservative methylisothiazolinone (MI) is also on the rise. It ranks as the second most frequent allergen for which the North American Contact Dermatitis Group is seeing positive results on patch testing, with rates of 13.4%. MI can be found in many skin care products and “probably about half of school glues, fabric glues, and craft glues,” Dr. Katta said. “Stick versus liquid doesn’t make a difference.” Children and teens often use craft glues, laundry detergents, and other products to create “slime” as a way to learn about viscosity, polymers, and chemical reactions. “Sometimes these children have sensitive skin, or they’re using it with prolonged contact, so they may be sensitizing themselves to the MI,” she said.

She concluded her remarks by noting that an increasing number of young patients are developing reactions to wearable medical devices such as insulin pumps and glucose monitors. “With this, the first thing to think about is frictional irritant dermatitis,” she said. “You can put Scanpor medical paper tape on people’s back for 48 hours straight to patch test them. Some people are incredibly reactive to the friction of just that tape. You also have to think about trapped allergen. One of my patients reacted to colophony, fragrance mix, and propylene glycol, all of which were contained in his skin care products. Some people are getting advice from other patients to use Mastisol liquid adhesive to help their glucose monitors stick better. Mastisol has a high rate of cross-reactivity with balsam of Peru, so it’s a fragrance allergen. That’s the first thing you want to ask patients about: what products they’re using.”

One of her patients thought she was reacting to adhesive tape on her skin, but in fact she was reacting to two different acrylates: ethylene glycol dimethacrylate (EGDMA) and hydroxyethyl methacrylate (HEMA). “I know about these allergens because I see reactions from butterfly needles in dialysis patients,” Dr. Katta explained. “What happens is, these acrylates are glues or plastics used somewhere else on the device, and they can migrate through barriers.”

In one published case, a 9-year-old boy developed a reaction to ethyl cyanoacrylate contained in a glucose sensor adhesive (Dermatitis. 2017; 28[4]:289-91). It never touched the boy’s skin directly but was presumed to migrate through that tape. “The bottom line is that acrylates may induce contact dermatitis even through perceived barriers,” she said. “Their use anywhere in medical devices may prove problematic.”

Dr. Katta reported that she is a member of the advisory board for Vichy Laboratories.
 

[email protected]

AUSTIN – Not long ago, Rajani Katta, MD, received a text message from a friend who expressed concern about a rash that developed in the underarm of her teenage daughter.

The culprit turned out to be the lavender essential oil contained in an “all natural” deodorant that her daughter had recently switched to – a storyline that Dr. Katta encounters with increasing frequency in her role as clinical professor of dermatology at the University of Texas Health Science Center at Houston.

“Some people may think that you can’t get an allergic reaction to natural products, but we are seeing many allergic reactions to essential oils,” Dr. Katta said at the annual meeting of the Society for Pediatric Dermatology. “When you talk about a natural allergy, it is more likely to occur if your skin barrier is compromised, so I think that’s why we’re seeing it, especially in young girls in the underarm area. If you shave the underarm, you impair that skin barrier and you’re more likely to develop a reaction to something you’re using over it.”

Her list of recommended deodorants includes Almay Roll-On Antiperspirant & Deodorant, Crystal Body Deodorant Stick, Crystal Roll-On Body Deodorant, Vanicream Deodorant for Sensitive Skin (aluminum-free), Vanicream Antiperspirant/Deodorant, and CertainDri Clinical Strength Roll-On. They are fragrance-free and lack propylene glycol, which is a common allergen.

Increasingly, essential oils are being added to lip balms and toothpastes, said Dr. Katta, who is also author of the 2018 book “Glow: The Dermatologist’s Guide to a Whole Foods Younger Skin Diet.” She recalled one patient who presented with chronic chapped lips. “It doesn’t matter how many lip glosses I try; it just keeps getting worse,” the patient told her. The likely culprit turned out to be ingredients contained in flavored lip balm from EOS. Reports of blistering and cracking of the lips from use of the products prompted a class action lawsuit and a notice to consumers from the Food and Drug Administration.

Another patient presented with cracked lips after switching to an “all natural” toothpaste that was labeled “gluten free.”

“It looked great,” Dr. Katta recalled. “Unfortunately it was not flavoring free. She reacted to multiple essential oils, including tea tree oil, contained in the toothpaste. This is being added to a number of toothpastes, and I think we’re going to see more of these types of reactions.”

Other toothpastes contain balsam of Peru, “which is consistently one of the top allergens in patch test clinics,” she said. “One of the components of balsam of Peru is a cinnamon compound, which can be an issue.”

Dr. Katta advises her patients to use Vaseline petroleum jelly as a lip balm and recommends Tom’s of Maine Silly Strawberry Flavor (this flavor only) toothpaste for children.

A few years ago, a teenager presented to Dr. Katta with intense bullae on the dorsum of the foot after wearing shoes without socks. “She was wearing white canvas Keds, which looked very innocuous,” she said. Patch testing revealed that the teen reacted to four different rubber accelerators. “When we contacted the company, they [acknowledged] using rubber cement to make the canvas Keds,” Dr. Katta said. “Rubber cement is an adhesive and it does contain rubber accelerators. Later, I saw two cases of children who had walked around all day at the amusement park wearing their Sperry Topsiders without any socks. We couldn’t get any information from that manufacturer, but I suspect that they also use a rubber-based glue to make those shoes.” She characterized shoes as “a real setup for a foot allergy because you have friction, sweat that’s pulling allergen out of an object, and sweat is carrying it over, especially to the dorsum of the foot.”


Dr. Katta has also noticed an uptick in the number of young patients who develop allergic reactions to dyes used to make workout clothing. “If you ever see rashes that do not involve the axillary vault but do have peraxillary accentuation, think textile allergy,” she said. “We’re seeing a lot of reactions to disperse blue clothing dyes. When you think about textile allergy from the dyes, it tends to be the blue and black clothing. It’s more likely in the setting of synthetic fabrics because they leach out dyes more easily, and it’s more likely in the setting of sweat because sweat helps pull allergen out. I’m seeing it a lot from sports uniforms and tight black leggings and tight sports bras that people are wearing. I’m also seeing some from bathing suits and swim shirts.”

Exposure to products containing the preservative methylisothiazolinone (MI) is also on the rise. It ranks as the second most frequent allergen for which the North American Contact Dermatitis Group is seeing positive results on patch testing, with rates of 13.4%. MI can be found in many skin care products and “probably about half of school glues, fabric glues, and craft glues,” Dr. Katta said. “Stick versus liquid doesn’t make a difference.” Children and teens often use craft glues, laundry detergents, and other products to create “slime” as a way to learn about viscosity, polymers, and chemical reactions. “Sometimes these children have sensitive skin, or they’re using it with prolonged contact, so they may be sensitizing themselves to the MI,” she said.

She concluded her remarks by noting that an increasing number of young patients are developing reactions to wearable medical devices such as insulin pumps and glucose monitors. “With this, the first thing to think about is frictional irritant dermatitis,” she said. “You can put Scanpor medical paper tape on people’s back for 48 hours straight to patch test them. Some people are incredibly reactive to the friction of just that tape. You also have to think about trapped allergen. One of my patients reacted to colophony, fragrance mix, and propylene glycol, all of which were contained in his skin care products. Some people are getting advice from other patients to use Mastisol liquid adhesive to help their glucose monitors stick better. Mastisol has a high rate of cross-reactivity with balsam of Peru, so it’s a fragrance allergen. That’s the first thing you want to ask patients about: what products they’re using.”

One of her patients thought she was reacting to adhesive tape on her skin, but in fact she was reacting to two different acrylates: ethylene glycol dimethacrylate (EGDMA) and hydroxyethyl methacrylate (HEMA). “I know about these allergens because I see reactions from butterfly needles in dialysis patients,” Dr. Katta explained. “What happens is, these acrylates are glues or plastics used somewhere else on the device, and they can migrate through barriers.”

In one published case, a 9-year-old boy developed a reaction to ethyl cyanoacrylate contained in a glucose sensor adhesive (Dermatitis. 2017; 28[4]:289-91). It never touched the boy’s skin directly but was presumed to migrate through that tape. “The bottom line is that acrylates may induce contact dermatitis even through perceived barriers,” she said. “Their use anywhere in medical devices may prove problematic.”

Dr. Katta reported that she is a member of the advisory board for Vichy Laboratories.
 

[email protected]

AUSTIN – The incidence of pediatric invasive melanoma has decreased since 2002, but males are more likely to die from the disease, compared with females. The risk of death is also significantly increased in black patients, other nonwhite patients, and in cases where surgery was not performed.

Doug Brunk/MDedge News

Those are key findings from a study that set out to investigate the incidence of pediatric melanoma over the last 2 decades and factors influencing survival. At the annual meeting of the Society for Pediatric Dermatology, one of the study authors, Spandana Maddukuri, said that pediatric melanoma is the most common skin cancer in the pediatric population, accounting for 1-3% of all pediatric malignancies and 1%-4% of all cases of melanoma (Pediatr Surg. 2013;48[11]:2207-13).

“Nonmodifiable risk factors are similar to those in adult melanoma and include fair skin, light hair and eye color, increased number of congenital nevi, and family history of melanoma,” said Ms. Maddukuri, a third-year student at New Jersey Medical School, Newark. “Environmental risk factors are similar to those in adult melanoma and include exposure to UV radiation. About 60% of children do not meet standard ABCDE [asymmetrical, border, color, diameter, evolving] diagnosis criteria, which often leads to delayed diagnosis.”

Some of the characteristics that are more commonly found in pediatric lesions include amelanosis, bleeding, uniform color, and variable diameter (J Am Acad Dermatol. 2013; 68[6]:913-25).

Ms. Maddukuri and colleagues queried the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for cases of malignant melanoma that were diagnosed in individuals aged younger than 20 years between 2002 and 2015. After excluding all cases of adult melanoma and all cases of in situ melanoma, they included 1,620 patients in the final analysis and divided them into five age groups: less than 1 year, 1-4 years, 5-9 years, 10-14 years, and 15-19 years. They calculated the overall incidence rate per 100,000 population of pediatric melanoma based on data from the 2000 U.S. Census. Age-, sex-, and race-specific incidence rates were also calculated. Kaplan-Meier and Cox regression analyses to investigate disease-specific survival and risk factors.

With each successive age group, the investigators observed that incidence rate was significantly higher than that of the previous age group (P less than .005). “However, the most striking increase in incidence occurs between the age group of 10-14 and 15-19,” she said. “Sex also influenced incidence rates. Males had an incidence rate of 0.396 per 100,000 population while females had an incidence rate of 0.579 per 100,000 population.”


Race also influenced incidence rates. White patients had the highest incidence rate of 0.605 per 100,000 population, while blacks had the lowest incident rate at 0.042 per 100,000 population. American Indian and Alaska Native patients had incidence rates of 0.046 per 100,000 population, while Asians and Pacific Islanders had an incidence rate of 0.127 per 100,000 population.

The researchers found that increased survival was associated with white race, female sex, treatment with surgical intervention, and age older than 5 years. No differences in survival were observed regarding the primary anatomic location or extent of disease. The hazard ratio of death from invasive melanoma was significantly increased in males (HR, 2.34), black patients (HR, 3.96), other nonwhite patients (HR, 3.64), and in cases where surgery was not performed (HR, 6.04).

“It is surprising that, although incidence is significantly higher in white patients and females, compared to black patients and males, respectively, the risk of dying from melanoma is much higher in black patients and males,” Ms. Maddukuri said in an interview at the meeting. “Overall, the dermatologic community is on the right track in screening and diagnosing pediatric melanoma, as seen by the decreased incidence over the last 2 decades. However, increased awareness regarding pediatric melanoma is still encouraged. I believe we were able to identify certain populations that need more attention in terms of screening, diagnosis, and treatment, which are patients less than 5 years old, black and other nonwhite patients, and males.”

She acknowledged certain shortcomings of the study, including a limited clinical history of the patient population because of the nature of the database. She also said that further studies are required to investigate the contributing factors to decreasing incidence and to evaluate the relationship of the favorable prognostic factors to increased survival. The researchers are currently working on correlating incidence rates with UV exposure and geographical location.

They reported having no financial disclosures.

[email protected]

AUSTIN – The incidence of pediatric invasive melanoma has decreased since 2002, but males are more likely to die from the disease, compared with females. The risk of death is also significantly increased in black patients, other nonwhite patients, and in cases where surgery was not performed.

Doug Brunk/MDedge News

Those are key findings from a study that set out to investigate the incidence of pediatric melanoma over the last 2 decades and factors influencing survival. At the annual meeting of the Society for Pediatric Dermatology, one of the study authors, Spandana Maddukuri, said that pediatric melanoma is the most common skin cancer in the pediatric population, accounting for 1-3% of all pediatric malignancies and 1%-4% of all cases of melanoma (Pediatr Surg. 2013;48[11]:2207-13).

“Nonmodifiable risk factors are similar to those in adult melanoma and include fair skin, light hair and eye color, increased number of congenital nevi, and family history of melanoma,” said Ms. Maddukuri, a third-year student at New Jersey Medical School, Newark. “Environmental risk factors are similar to those in adult melanoma and include exposure to UV radiation. About 60% of children do not meet standard ABCDE [asymmetrical, border, color, diameter, evolving] diagnosis criteria, which often leads to delayed diagnosis.”

Some of the characteristics that are more commonly found in pediatric lesions include amelanosis, bleeding, uniform color, and variable diameter (J Am Acad Dermatol. 2013; 68[6]:913-25).

Ms. Maddukuri and colleagues queried the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for cases of malignant melanoma that were diagnosed in individuals aged younger than 20 years between 2002 and 2015. After excluding all cases of adult melanoma and all cases of in situ melanoma, they included 1,620 patients in the final analysis and divided them into five age groups: less than 1 year, 1-4 years, 5-9 years, 10-14 years, and 15-19 years. They calculated the overall incidence rate per 100,000 population of pediatric melanoma based on data from the 2000 U.S. Census. Age-, sex-, and race-specific incidence rates were also calculated. Kaplan-Meier and Cox regression analyses to investigate disease-specific survival and risk factors.

With each successive age group, the investigators observed that incidence rate was significantly higher than that of the previous age group (P less than .005). “However, the most striking increase in incidence occurs between the age group of 10-14 and 15-19,” she said. “Sex also influenced incidence rates. Males had an incidence rate of 0.396 per 100,000 population while females had an incidence rate of 0.579 per 100,000 population.”


Race also influenced incidence rates. White patients had the highest incidence rate of 0.605 per 100,000 population, while blacks had the lowest incident rate at 0.042 per 100,000 population. American Indian and Alaska Native patients had incidence rates of 0.046 per 100,000 population, while Asians and Pacific Islanders had an incidence rate of 0.127 per 100,000 population.

The researchers found that increased survival was associated with white race, female sex, treatment with surgical intervention, and age older than 5 years. No differences in survival were observed regarding the primary anatomic location or extent of disease. The hazard ratio of death from invasive melanoma was significantly increased in males (HR, 2.34), black patients (HR, 3.96), other nonwhite patients (HR, 3.64), and in cases where surgery was not performed (HR, 6.04).

“It is surprising that, although incidence is significantly higher in white patients and females, compared to black patients and males, respectively, the risk of dying from melanoma is much higher in black patients and males,” Ms. Maddukuri said in an interview at the meeting. “Overall, the dermatologic community is on the right track in screening and diagnosing pediatric melanoma, as seen by the decreased incidence over the last 2 decades. However, increased awareness regarding pediatric melanoma is still encouraged. I believe we were able to identify certain populations that need more attention in terms of screening, diagnosis, and treatment, which are patients less than 5 years old, black and other nonwhite patients, and males.”

She acknowledged certain shortcomings of the study, including a limited clinical history of the patient population because of the nature of the database. She also said that further studies are required to investigate the contributing factors to decreasing incidence and to evaluate the relationship of the favorable prognostic factors to increased survival. The researchers are currently working on correlating incidence rates with UV exposure and geographical location.

They reported having no financial disclosures.

[email protected]

AUSTIN – The incidence of pediatric invasive melanoma has decreased since 2002, but males are more likely to die from the disease, compared with females. The risk of death is also significantly increased in black patients, other nonwhite patients, and in cases where surgery was not performed.

Doug Brunk/MDedge News

Those are key findings from a study that set out to investigate the incidence of pediatric melanoma over the last 2 decades and factors influencing survival. At the annual meeting of the Society for Pediatric Dermatology, one of the study authors, Spandana Maddukuri, said that pediatric melanoma is the most common skin cancer in the pediatric population, accounting for 1-3% of all pediatric malignancies and 1%-4% of all cases of melanoma (Pediatr Surg. 2013;48[11]:2207-13).

“Nonmodifiable risk factors are similar to those in adult melanoma and include fair skin, light hair and eye color, increased number of congenital nevi, and family history of melanoma,” said Ms. Maddukuri, a third-year student at New Jersey Medical School, Newark. “Environmental risk factors are similar to those in adult melanoma and include exposure to UV radiation. About 60% of children do not meet standard ABCDE [asymmetrical, border, color, diameter, evolving] diagnosis criteria, which often leads to delayed diagnosis.”

Some of the characteristics that are more commonly found in pediatric lesions include amelanosis, bleeding, uniform color, and variable diameter (J Am Acad Dermatol. 2013; 68[6]:913-25).

Ms. Maddukuri and colleagues queried the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for cases of malignant melanoma that were diagnosed in individuals aged younger than 20 years between 2002 and 2015. After excluding all cases of adult melanoma and all cases of in situ melanoma, they included 1,620 patients in the final analysis and divided them into five age groups: less than 1 year, 1-4 years, 5-9 years, 10-14 years, and 15-19 years. They calculated the overall incidence rate per 100,000 population of pediatric melanoma based on data from the 2000 U.S. Census. Age-, sex-, and race-specific incidence rates were also calculated. Kaplan-Meier and Cox regression analyses to investigate disease-specific survival and risk factors.

With each successive age group, the investigators observed that incidence rate was significantly higher than that of the previous age group (P less than .005). “However, the most striking increase in incidence occurs between the age group of 10-14 and 15-19,” she said. “Sex also influenced incidence rates. Males had an incidence rate of 0.396 per 100,000 population while females had an incidence rate of 0.579 per 100,000 population.”


Race also influenced incidence rates. White patients had the highest incidence rate of 0.605 per 100,000 population, while blacks had the lowest incident rate at 0.042 per 100,000 population. American Indian and Alaska Native patients had incidence rates of 0.046 per 100,000 population, while Asians and Pacific Islanders had an incidence rate of 0.127 per 100,000 population.

The researchers found that increased survival was associated with white race, female sex, treatment with surgical intervention, and age older than 5 years. No differences in survival were observed regarding the primary anatomic location or extent of disease. The hazard ratio of death from invasive melanoma was significantly increased in males (HR, 2.34), black patients (HR, 3.96), other nonwhite patients (HR, 3.64), and in cases where surgery was not performed (HR, 6.04).

“It is surprising that, although incidence is significantly higher in white patients and females, compared to black patients and males, respectively, the risk of dying from melanoma is much higher in black patients and males,” Ms. Maddukuri said in an interview at the meeting. “Overall, the dermatologic community is on the right track in screening and diagnosing pediatric melanoma, as seen by the decreased incidence over the last 2 decades. However, increased awareness regarding pediatric melanoma is still encouraged. I believe we were able to identify certain populations that need more attention in terms of screening, diagnosis, and treatment, which are patients less than 5 years old, black and other nonwhite patients, and males.”

She acknowledged certain shortcomings of the study, including a limited clinical history of the patient population because of the nature of the database. She also said that further studies are required to investigate the contributing factors to decreasing incidence and to evaluate the relationship of the favorable prognostic factors to increased survival. The researchers are currently working on correlating incidence rates with UV exposure and geographical location.

They reported having no financial disclosures.

[email protected]

AUSTIN – After searching online for information about a suspected pediatric dermatologic condition, one in five parents and/or pediatric patients make dermatology appointments sooner than they normally would, results from a novel survey showed.

In an interview at the annual meeting of the Society for Pediatric Dermatology, study author Jamie P. Schlarbaum noted that about one-third of Americans use the Internet to research their condition or symptoms prior to visiting a physician, mostly through Google. “While nearly 50% of parents look up health care information online for their children, rashes were the most common search in pediatrics in 2011,” said Mr. Schlarbaum, who is a fourth-year medical student at the University of Minnesota, Minneapolis. “However, no studies have examined the characteristics and implications of these searches; our study is the first in pediatric dermatology and also adds a new dimension to concern in an online era: How these searches influence health care behaviors.”

During February 2018–February 2019, Kristen Hook, MD, a pediatric dermatologist in Minneapolis and the study’s principal investigator, and Mr. Schlarbaum administered a survey to 220 parents/guardians and pediatric patients who had appointments in pediatric dermatology at a University of Minnesota clinic. The survey consisted of questions about demographics, search tools, search terms, and health care decisions based on this information.

Of the 220 respondents, more than half (59%) did not use an online search engine/tool prior to their appointment. Compared with parents who did not use an online search tool, those who did were slightly younger (34 vs. 36 years, respectively), more likely to be college educated (68% vs. 48%), and less likely to have the patient in question be their first child (37% vs. 52%).

Google ranked as the most common search engine used by the survey respondents (92%), followed distantly by WebMD (18%). About 15% of respondents became more concerned about the pediatric skin condition after searching online, and 20% made appointments sooner because of the information they gleaned from their searches. “Online dermatology clearly has an influence on care today,” Mr. Schlarbaum said. “As we become an even more technologically advanced and dependent society, we anticipate that both of these numbers will grow.”

The researchers also found that survey respondents self-diagnosed a number of dermatologic conditions based on their time spent online, including eczema (33%), moles (15%), and infections (11%). “The big takeaway [from this study] is to ask your parents and teenagers if they’ve looked up information online,” Mr. Schlarbaum said. “Whether it’s photos of the ‘worst cases’ or concerning differentials that might pop up, it’s worth it to take a few seconds to ask what they’re worried about and why.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. The researchers reported having no financial disclosures.

[email protected]

AUSTIN – After searching online for information about a suspected pediatric dermatologic condition, one in five parents and/or pediatric patients make dermatology appointments sooner than they normally would, results from a novel survey showed.

In an interview at the annual meeting of the Society for Pediatric Dermatology, study author Jamie P. Schlarbaum noted that about one-third of Americans use the Internet to research their condition or symptoms prior to visiting a physician, mostly through Google. “While nearly 50% of parents look up health care information online for their children, rashes were the most common search in pediatrics in 2011,” said Mr. Schlarbaum, who is a fourth-year medical student at the University of Minnesota, Minneapolis. “However, no studies have examined the characteristics and implications of these searches; our study is the first in pediatric dermatology and also adds a new dimension to concern in an online era: How these searches influence health care behaviors.”

During February 2018–February 2019, Kristen Hook, MD, a pediatric dermatologist in Minneapolis and the study’s principal investigator, and Mr. Schlarbaum administered a survey to 220 parents/guardians and pediatric patients who had appointments in pediatric dermatology at a University of Minnesota clinic. The survey consisted of questions about demographics, search tools, search terms, and health care decisions based on this information.

Of the 220 respondents, more than half (59%) did not use an online search engine/tool prior to their appointment. Compared with parents who did not use an online search tool, those who did were slightly younger (34 vs. 36 years, respectively), more likely to be college educated (68% vs. 48%), and less likely to have the patient in question be their first child (37% vs. 52%).

Google ranked as the most common search engine used by the survey respondents (92%), followed distantly by WebMD (18%). About 15% of respondents became more concerned about the pediatric skin condition after searching online, and 20% made appointments sooner because of the information they gleaned from their searches. “Online dermatology clearly has an influence on care today,” Mr. Schlarbaum said. “As we become an even more technologically advanced and dependent society, we anticipate that both of these numbers will grow.”

The researchers also found that survey respondents self-diagnosed a number of dermatologic conditions based on their time spent online, including eczema (33%), moles (15%), and infections (11%). “The big takeaway [from this study] is to ask your parents and teenagers if they’ve looked up information online,” Mr. Schlarbaum said. “Whether it’s photos of the ‘worst cases’ or concerning differentials that might pop up, it’s worth it to take a few seconds to ask what they’re worried about and why.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. The researchers reported having no financial disclosures.

[email protected]

AUSTIN – After searching online for information about a suspected pediatric dermatologic condition, one in five parents and/or pediatric patients make dermatology appointments sooner than they normally would, results from a novel survey showed.

In an interview at the annual meeting of the Society for Pediatric Dermatology, study author Jamie P. Schlarbaum noted that about one-third of Americans use the Internet to research their condition or symptoms prior to visiting a physician, mostly through Google. “While nearly 50% of parents look up health care information online for their children, rashes were the most common search in pediatrics in 2011,” said Mr. Schlarbaum, who is a fourth-year medical student at the University of Minnesota, Minneapolis. “However, no studies have examined the characteristics and implications of these searches; our study is the first in pediatric dermatology and also adds a new dimension to concern in an online era: How these searches influence health care behaviors.”

During February 2018–February 2019, Kristen Hook, MD, a pediatric dermatologist in Minneapolis and the study’s principal investigator, and Mr. Schlarbaum administered a survey to 220 parents/guardians and pediatric patients who had appointments in pediatric dermatology at a University of Minnesota clinic. The survey consisted of questions about demographics, search tools, search terms, and health care decisions based on this information.

Of the 220 respondents, more than half (59%) did not use an online search engine/tool prior to their appointment. Compared with parents who did not use an online search tool, those who did were slightly younger (34 vs. 36 years, respectively), more likely to be college educated (68% vs. 48%), and less likely to have the patient in question be their first child (37% vs. 52%).

Google ranked as the most common search engine used by the survey respondents (92%), followed distantly by WebMD (18%). About 15% of respondents became more concerned about the pediatric skin condition after searching online, and 20% made appointments sooner because of the information they gleaned from their searches. “Online dermatology clearly has an influence on care today,” Mr. Schlarbaum said. “As we become an even more technologically advanced and dependent society, we anticipate that both of these numbers will grow.”

The researchers also found that survey respondents self-diagnosed a number of dermatologic conditions based on their time spent online, including eczema (33%), moles (15%), and infections (11%). “The big takeaway [from this study] is to ask your parents and teenagers if they’ve looked up information online,” Mr. Schlarbaum said. “Whether it’s photos of the ‘worst cases’ or concerning differentials that might pop up, it’s worth it to take a few seconds to ask what they’re worried about and why.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. The researchers reported having no financial disclosures.

[email protected]