Light-Related Cutaneous Symptoms of Erythropoietic Protoporphyria and Associations With Light Sensitivity Measurements

Importance

Erythropoietic protoporphyria (EPP) is a rare and underdiagnosed genetic disease characterized by painful sensitivity to light. A better understanding and characterization of its light-induced cutaneous symptoms may aid in the identification of EPP in patients.

Objectives

To describe the cutaneous symptoms of erythropoietic protoporphyria (EPP) and to determine if these symptoms are associated with the degree of light sensitivity.

Design, Setting, and Participants

This was a cross-sectional study of adolescent and adult (≥15 years) patients with EPP across the US conducted by a single academic hospital via a remotely administered survey, measurements of light sensitivity by light dosimetry and by text message symptom assessments. Data analyses were conducted from November 2020 to April 2022.

Exposures

Sunlight exposure.

Main Outcomes and Measures

Self-reported symptoms and association with measured light sensitivity.

Results

The study sample consisted of 35 patients with EPP (mean [SD] age, 39.1 (15.5) years; 21 [60%] female; 14 [40%] male; 35 [100%] White individuals). The patients' median [range] skin tone was 3.0 (1.0-8.0), based on self-reporting from 1 (lightest) to 12 (darkest). A total of 24 participants completed the light dosimeter measurements. Phototoxic reactions were characterized by pain (97%; 34 patients), burning (97%; 34), tingling (97%; 34), pruritus (83%; 29), allodynia (89%; 31), improvement of symptoms with cold (89%; 31), achiness (24%; 12), fatigue (46%; 16), mild swelling (83%; 29), severe swelling (63%; 22), erythema (51%; 18), petechiae (40%; 14), skin cracking (43%; 15), scabbing (46%; 16), scarring (66%; 23), and other chronic skin changes (40%; 14). Patients with EPP reported that their hands, feet, and face were most sensitive to light and that their shoulders and legs were least sensitive; 25.7% (9 patient) reported no chronic skin changes, and 5.7% (2 patients) reported never having had any visible symptoms. None of these findings varied with the degree of light sensitivity except that lower overall light sensitivity was associated with lower ranked sensitivity of the neck and arms.

Conclusions and Relevance

The findings of this cross-sectional study suggest that patients with EPP have distinctive cutaneous symptoms that may aid in identification of this underdiagnosed disease. Characteristic EPP symptoms include light-induced cutaneous burning pain and occasional swelling, particularly over the hands, with a prodrome of pruritus and paresthesias. Minimal skin changes or the absence of visible skin changes during reactions to light, including lack of erythema, do not exclude an EPP diagnosis nor suggest low EPP disease burden.

Immunopathological Assessment of the Oral Mucosa in Dermatitis Herpetiformis

Dermatitis herpetiformis (Duhring's disease, DH) is a chronic blistering cutaneous condition with pruritic polymorphic lesions, consisting of vesicles, papules or nodules and erythema, found predominantly on the extensor surfaces of the limbs, buttocks, and neck. Diagnosis is based on characteristic clinical and immunopathological findings. Oral manifestations of DH have rarely been described. The aim of the study was to evaluate IgA, IgG, IgM and C3 complement deposits in the oral mucosa in DH patients. Direct immunofluorescence (DIF) was performed on the oral mucosa specimens collected from 10 DH patients. Biopsy was taken in a local anesthesia from perilesional site from the buccal mucosa and then preserved in a standard procedure using polyclonal rabbit IgG, IgA, IgM and C3 antibodies. Granular IgA and C3 deposits were found in 6 patients (60%), and in 3 subjects (30%) the result was indeterminate. Significant fluorescence of the deposits along the basement membrane was observed in 2 patients, moderate fluorescence in 3 patients, and in 4 cases the result was indeterminate. C3 deposits were found in 5 subjects (50%), 3 of them being moderate and 2 indeterminate. No IgM and IgG deposits were detected in the collected buccal mucosa specimens.

Syphilis, the Great Imitator-Clinical and Dermoscopic Features of a Rare Presentation of Secondary Syphilis

Syphilis is characterized by a wide range of variable clinical symptoms; therefore, it is often referred to as "The Great Imitator". Here, we report the case of a 69-year-old hepatitis-C-positive MSM patient, who was admitted to our clinic due to a solitary firm painless erythematous maculopapular lesion with a central crater-like crust on the upper right thigh that occurred two months prior. The dermoscopy showed an erythematous, copper-colored, oval lesion with diffuse monomorphic dotted and glomerular vessels, central crust, and circular scaling (Biett's sign). The histological findings ruled out neoplasia and described a plasma cell infiltrate and endothelial swelling. Finally, the combination of the dermoscopic image, histological findings and the additionally acquired knowledge about the sexual history of the patient at the second visit led to the diagnosis, which was then confirmed with serological tests. Dermoscopy may become a supportive tool to facilitate the recognition of secondary syphilis; however, the reporting of these atypical cases is crucial to highlight the many faces of the disease so that clinicians consider syphilis as part of the differential diagnosis of non-specific lesions.

Infant with red eyelid lesion

The rapid growth of this lesion provided an important clue in the diagnosis.

A Review of the Challenges and Nuances in Treating Rosacea in Asian Skin Types Using Cleansers and Moisturizers as Adjuncts

BACKGROUND

Rosacea is primarily an inflammatory disease of facial skin associated with impaired skin barrier function. While it is commonly thought of as a Caucasian person's disease, it is likely underdiagnosed in people of color, including Asians, leading to missed and delayed diagnoses and increased morbidity. The purpose of this review is to highlight literature on rosacea in Asian people and the role of non-prescription skincare in managing rosacea.

METHODS

Four dermatologists (the panel) completed pre-meeting surveys and participated in a web meeting to discuss the role of skin care in treating rosacea in the Asia Pacific (APAC) region. The survey results were summarized, then presented during the virtual meeting. These survey results and relevant papers identified through a literature review were then discussed. This review shows the fruit of these discussions, as well as the advisors' expert opinions and experiences.

RESULTS

The panel crafted 5 consensus statements regarding the role of skin care in the treatment of rosacea in the APAC region. The most common forms of rosacea seen by the advisors are mostly erythematous and papulopustular. Among the panel, doxycycline is the most popular treatment for papulopustular rosacea. The panel prioritize gentleness when choosing skincare products for patients with rosacea.

CONCLUSIONS

In Asian patients with rosacea, adjunctive skincare is an important part of treatment, maintenance, and prescription treatment. Given the highly sensitive skin of certain Asian patients with rosacea, avoiding potentially irritating substances is crucial. J Drugs Dermatol. 2023;22(1):45-53. doi:10.36849/JDD.7021.

Current understanding of frictional dermatoses: A review

Human skin is continually exposed to internal and external forces, dynamic as well as static. The skin is normally flexible and can resist mechanical trauma due to friction, pressure, vibration, suction and laceration to a considerable degree. However, an excess of these forces can abnormally affect the structure and function of the skin, setting the stage for the development of a skin disorder. Repetitive trauma can cause lichenification, hyperpigmentation, erythema, scaling, fissuring, blisters, ulceration and chronic alterations. Frictional dermatoses is an under-recognised entity with no clear-cut definition and encompasses a variety of terms such as frictional dermatitis, frictional melanosis, frictional pigmentary dermatoses and certain other named entities, many of which are confusing. The authors propose to define frictional dermatoses as 'a group of disorders caused by repetitive trauma to the skin as a result of friction of varied aetiology which can have a wide range of cutaneous manifestations depending on the type of insult.' The exact prevalence of frictional dermatoses as a separate entity is unknown. Authors who conducted this review include a group of dermatologists and post graduate students from various institutions. Literature was reviewed through PubMed, Medscape, Medline, ResearchGate and Google Scholar using the terms 'frictional dermatitis,' 'friction and skin,' 'dermatoses and culture,' 'clothing dermatitis,' 'friction melanosis,' 'PPE induced dermatoses in COVID-19 era,' etc. A total of 122 articles were reviewed and 100 articles among them were shortlisted and included in the study, after removing duplications. The review was followed up with further deliberation which resulted in the formulation of a new definition and classification of frictional dermatoses taking into account the morphology, histopathological characteristics, anatomical region affected and the major predisposing factors. The rising incidence of mechanical dermatoses in the COVID-19 era was also emphasised.

THE ROLE OF NITRIC OXIDE AND PEROXYNITRITE IN THE ERYTHEMAL PERIOD OF ULTRAVIOLET-INDUCED SKIN DAMAGE

OBJECTIVE

The aim: To study the activity of inducible NO synthase in the blood, the content of NO metabolites and peroxynitrite in the skin and blood of guinea pigs during erythema periods after local ultraviolet skin irradiation.

PATIENTS AND METHODS

Materials and methods: The studies were carried out on 24 guinea pigs, subjected to local ultraviolet irradiation. The control group consisted of intact guinea pigs (n=6). After 2, 4 hours, on the 3rd, 8th day, the activity of inducible NO synthase (in blood), the content of total NO metabolites, nitrite anion, nitrates, peroxynitrite (in blood and skin) were determined.

RESULTS

Results: An increase in the level of peroxynitrite in the blood and of all NO metabolites in the skin was noted 2 hours after irradiation. After 4 hours activation of inducible NO synthase in the blood was observed, accompanied by an increase in the content of all NO metabolites and peroxynitrite both in the blood and in the skin. On the 3rd day high levels of excessive synthesis of NO and peroxynitrite in the blood and skin were also revealed due to the induced expression of this enzyme in the blood. On the 8th day the activity of inducible NO synthase remained high in the blood, which led to the accumulation of all NO metabolites and peroxynitrite in the blood and skin.

CONCLUSION

Conclusions: Thus, local ultraviolet irradiation of the skin of guinea pigs leads to the activation of inducible NO synthase in the blood and an increase in NO synthesis and peroxynitrite in the blood and skin.

Erythromelalgia: A Review of Medical Management Options and Our Approach to Management

Erythromelalgia (EM) is a rare disorder characterized by episodic, burning pain associated with erythema and warmth of the extremities. The feet and hands are most commonly affected. The pain can be so severe that patients may engage in behaviors, sometimes extreme, to cool the affected areas and change their lifestyle to avoid precipitating factors, such as exercise and increased ambient heat. A literature search was performed with PubMed and MEDLINE with the search term erythromelalgia. Inclusion criteria were studies on EM published after 1985 until January 1, 2022, in the English language and studies that provided information on medical treatment of EM. Studies were excluded if they were duplicates or did not include treatment data. No guidelines exist for the treatment of this complex disorder. Lifestyle modifications and pharmacologic treatments (topical and systemic) are discussed in this article, which provides a comprehensive review of published medical management options for erythromelalgia and a proposed approach to management.

Dietary supplementation of n-3 PUFAs ameliorates LL37-induced rosacea-like skin inflammation via inhibition of TLR2/MyD88/NF-κB pathway

Rosacea is a facial chronic inflammatory skin disease with dysfunction of immune and neurovascular system and treatments for rosacea are challenging. N-3 polyunsaturated fatty acids (PUFAs), one of essential fatty acids, are needed for health maintenance and exert anti-inflammation and immunomodulatory effects in a series of cutaneous diseases such as atopic dermatitis and photoaging through dietary supplementation. However, the role of n-3 PUFAs on rosacea remains to be elucidated. In this study, KEGG enrichment analysis and GO analysis indicated that the biological process and signaling pathways, including chemokine signaling pathway, regulated by n-3 PUFAs highly overlapped with those in the pathogenic biological process of rosacea, especially the erythema telangiectasia type. Next, mice were randomized to fed with a customized n-3 PUFAs diet. We showed that n-3 PUFAs ameliorated skin erythema, inhibited dermal inflammatory cell infiltration (mast cells, neutrophils, and CD4 +T cells) and suppressed elevated pro-inflammatory cytokines in LL37-induced rosacea-like mice. Besides, n-3 PUFAs were also verified to repress angiogenesis in LL37-induced mice skin. Further investigation revealed that n-3 PUFAs attenuated LL37-induced inflammation via TLR2/ MyD88/ NF-κB pathway both in mice and in keratinocytes. In conclusion, our findings underscore that dietary supplementation of n-3 PUFAs have the potential to become an efficient and safe clinical therapeutic candidate for rosacea.

Skin, mucosa and nail findings in hospitalized pediatric patients with Coronavirus disease-2019 (COVID-19)

BACKGROUND

Cutaneous manifestations of Coronavirus Disease-2019 (COVID-19) disease have not yet been fully described in hospitalized pediatric patients.

OBJECTIVES

This prospective study aims to demonstrate the skin, mucosal, and nail findings of hospitalized children with COVID-19.

METHODS

The authors included hospitalized pediatric patients. Two dermatologists examined skin, hair, nails, and mucosa. Patients with drug eruptions were excluded with an anamnesis, clinical and laboratory test results.

RESULTS

Out of 46 enlisted patients, 19 (41,3%) patients displayed skin, mucosal or nail findings. Skin findings were seen on 14 (30.4%) patients. Ten (22%) patients presented skin findings matching described patterns. Half of the patients with patterned rashes had confluent erythematous/maculopapular/morbilliform rashes. Eleven out of 46 (23.9%) patients developed periorbital erythema and edema. Ten (22%) patients had at least one oral mucosal finding. One telogen effluvium, one blue nail, and one flag sign on nails were noticed. Nine (19.5%) patients out of 46 had developed MIS-C. MIS-C patients had mucocutaneous manifestations except one (88.8%).

STUDY LIMITATIONS

The authors have detected a higher rate of mucocutaneous manifestations compared to out-patients with mild COVID-19 because the study is based on hospitalized patients only.

CONCLUSIONS

Pediatric COVID-19 patients are more susceptible to developing mucocutaneous manifestations compared to adults. The authors propose COVID-19 should be acknowledged as one of the viral exanthem rashes of childhood. The authors noticed that the most common findings were periorbital erythema and edema. The confluent erythematous/maculopapular/morbilliform rashes appear to be the most common patterns associated with severe COVID-19.

A chronic EBV infection causing persistent facial erythema multiforme and a retrospective literature review: A case report

RATIONALE

Epstein-Barr virus (EBV) infection is associated with a variety of diseases and can involve multiple organs and systems, with complex and nonspecific clinical manifestations that are easily misdiagnosed. Chronic EBV infection with persistent erythema multiforme (EM) on the cheek as the main manifestation is very rare and has been reported rarely.

PATIENT CONCERNS

This article reports a case of an adolescent female with chronic EBV infection who presented with chronic symmetrical erythema lesions on the face for 4 years, exacerbated with photophobia, lacrimation, Henoch-Schonlein purpura (HSP)-like rash, decline in granulocyte and erythrocyte lineages, hematuria, and proteinuria for 1 week.

DIAGNOSES

The disease was initially misdiagnosed as systemic lupus erythematosus (SLE) and later confirmed as chronic EBV infection by skin biopsy. In the case, EBV infection not only caused chronic facial EM, but also induced acute HSP and purpura nephritis (hematuria and proteinuria type).

INTERVENTIONS

The child was treated with 1 week of glucocorticosteroids in adequate doses combined with acyclovir antiviral therapy and 3 sessions of hemoperfusion. After discharge, she took prednisone acetate (15 mg twice a day) orally for 1 month and then discontinued.

OUTCOMES

She was discharged with her rash relieved and normal blood routine test and urine routine test. After 13 months of long-term follow-up, her facial erythema and hyperpigmentation became lighter, and there was no new rash on the whole body, and no abnormality in continuous monitoring of complete blood count and urine test.

LESSONS

This case suggests the need to be alert for chronic EBV infection in adolescent females with chronic facial EM rash and multiple organs and systems injury, in addition to connective tissue diseases such as SLE.

Peristomal Skin Complications in Ileostomy and Colostomy Patients: What We Need to Know from a Public Health Perspective

BACKGROUND

Peristomal skin complications (PSCs) are the most common skin problems seen after ostomy surgery. They have a considerable impact on a patient's quality of life and contribute to a higher cost of care.

METHODS

A systematic review was conducted, querying three databases. The analysis was performed on international studies focused on the clinical-epidemiological burden of PSCs in adult patients with ileostomy/colostomy.

RESULTS

Overall, 23 studies were considered. The main diseases associated with ostomy surgery were rectal, colon and gynecological cancers, inflammatory bowel diseases, diverticulitis, bowel obstruction and intestinal perforation. Erythema, papules, skin erosions, ulcers and vesicles were the most common PSCs for patients with an ostomy (or stoma). A PSCs incidence ranging from 36.3% to 73.4% was described. Skin complications increased length of stay (LOS) and rates of readmission within 120 days of surgery.

CONCLUSIONS

PSCs data are still limited. A knowledge of their burden is essential to support health personnel and decision-makers in identifying the most appropriate responses to patients' needs. Proper management of these complications plays a fundamental role in improving the patient's quality of life. A multidisciplinary approach, as well as increased patient education and their empowerment, are priority measures to be implemented to foster a value-based healthcare.

The Assessment of Skin Homeostasis Changes after Using Different Types of Excipients in Healthy Individuals

Excipients are used as vehicles for topical treatments; however, there are not many studies that evaluate the impact of different excipients themselves. The aim of this research is to assess skin homeostasis changes in healthy individuals after using water/oil (W/O), oil/water (O/W), Beeler base, foam and Vaseline excipients. A within-person randomized trial was conducted that included healthy individuals without previous skin diseases. Skin barrier function parameters, including stratum corneum hydration (SCH), transepidermal water loss (TEWL), pH, temperature, erythema, melanin and elasticity (R0, R2, R5 and R7), were measured on the volar forearm before and after using each excipient. Sixty participants were included in the study, with a mean age of 32 years. After applying w/o excipient erythema decreased by 25 AU, (p < 0.001) and elasticity increased by 6%. After using the o/w excipient, erythema decreased by 39.36 AU (p < 0.001) and SCH increased by 6.85 AU (p = 0.009). When applying the Beeler excipient, erythema decreased by 41.23 AU (p < 0.001) and SCH increased by 15.92 AU (p < 0.001). Foam and Vaseline decreased TEWL and erythema. Excipients have a different impact on skin barrier function. Knowing the effect of excipients on the skin could help to develop new topical treatments and help specialists to choose the best excipient according to the pathology.

590 nm LED Irradiation Improved Erythema through Inhibiting Angiogenesis of Human Microvascular Endothelial Cells and Ameliorated Pigmentation in Melasma

Melasma is a common refractory acquired pigmentary skin disease that mainly affects middle-aged women. The pathogenesis of melasma is still uncertain, while abnormal vascular endothelial cells may play a role. We previously demonstrated the yellow light of light-emitting diodes (LED) could inhibit melanogenesis through the photobiomodulation (PBM) of melanocytes and keratinocytes. In the current study, we investigated the effect of 590 nm LED on the function of human microvascular endothelial cells (HMEC-1). We revealed 0-40 J/cm² 590 nm LED had no toxic effect on HMEC-1 in vitro. 590 nm LED irradiation significantly reduced cell migration, tube formation, as well as the expression of vascular endothelial growth factor (VEGF) and stem cell factor (SCF), a pro-melanogenic factor. Moreover, we illustrated that 590 nm LED inhibited the phosphorylation of the AKT/PI3K/mTOR signaling pathway, and the inhibitory effect on HMEC-1 could be partially reversed by insulin-like growth factor 1 (IGF-1), an AKT/PI3K/mTOR pathway agonist. Besides, we conducted a pilot clinical study and observed a marked improvement on facial erythema and pigmentation in melasma patients after amber LED phototherapy. Taken together, 590 nm LED inhibited HMEC-1 migration, tube formation and the secretion of VEGF and SCF, predominantly through the inhibition of the AKT/PI3K/mTOR pathway, which may serve as a novel therapeutic option for melasma.

A typical case had rare immediate and delayed red man syndrome multiple times after norvancomycin injection: A case report

BACKGROUND

Red man syndrome (RMS) is an adverse effect of vancomycin that usually occurs within minutes to tens of minutes after infusion. Previous literature reported that RMS rarely occurs again after the infusion speed is controlled.

METHODS

We report a case of immediate and delayed RMS that presented with fever, persistent lower extremity rash, shock, lymphadenopathy and pulmonary edema. This patient subsequently diagnosed with Sjögren's Syndrome, the time from NVCM infusion to RMS onset of this case ranged from 10 minutes to 54 hours, which are all rare in clinic and hard to distinguish severe RMS and IgE-mediated anaphylaxis.

RESULTS

After multidisciplinary consultation, the patient was diagnosed with RMS based on clinical manifestations and laboratory results. Patients' symptoms, signs, body temperature and disease progress were monitored, and an active search for causes was conducted. After a 20-day treatment, all the symptoms disappeared, the patient was transferred to immunology department to treat SS.

CONCLUSION SUBSECTIONS

We reported a patient repeatedly developed fever and even shock when the infusion speed is normal, which was rare and similar as anaphylaxis. Therefore, the progression of RMS and its differentiation from allergy need to be further studied.

Developing Low-Cost Mobile Device and Apps for Accurate Skin Spectrum Measurement via Low-Cost Spectrum Sensors and Deep Neural Network Technology

In recent years, skin spectral information has been gradually applied in various fields, such as the cosmetics industry and clinical medicine. However, the high price and the huge size of the skin spectrum measurement device make the related applications of the skin spectrum unable to be widely used in practical applications. We used convolutional neural network (CNN) to achieve a satisfying accuracy of the Fitzpatrick skin-type classification by using a simple self-developed device in 2018. Leveraging on the hardware, firmware, and software app-developing experience, a low-cost miniature skin spectrum measurement system (LMSSMS) using deep neural network (DNN) technology was further studied, and the feasibility of the system is verified in this paper. The developed LMSSMS is divided into three parts: (1) miniature skin spectrum measurement device (MSSMD), (2) DNN model, and (3) mobile app. The MSSMD was developed with innovative low-cost MSSC, 3D printing, and a simple LED light source. The DNN model is designed to enhance measurement accuracy. Finally, the mobile app is used to control and show the measurement results. The developed app also includes a variety of skin-spectrum-related applications, such as erythema index and melanin index (EI/MI) measurement, Fitzpatrick skin-type classification, Pantone SkinTone classification, sun-exposure estimation, and body-fat measurement. In order to verify the feasibility of LMSSMS, we used the standard instrumentation device as a reference. The results show that the accuracy of the LMSSMS can reach 94.7%, which also confirms that this development idea has much potential for further development.

Discovery of resident memory T cells in inflammatory vitiligo: A case report

RATIONALE

The purpose of this report was to describe resident memory cluster of differentiation 8 (CD8) + T cells may contribute to the progression of inflammatory vitiligo.

PATIENT CONCERNS

A 32-year-old male has a stable vitiligo for 1 year, then some patches present inflammatory erythema. Two years later, the inflammatory patches enlarged and joined together, and the remaining 2 common patches shows repigmentation and no change respectively. Both CD69 + CD8 + T cells and CD103 + CD8 + T cells showed marked increase in inflammatory vitiligo than common vitiligo.

DIAGNOSIS

Histological findings show that the numbers of lymphocytes are increased in inflammatory vitiligo than common vitiligo. Immunofluorescence staining show that the numbers of CD69 + CD8 + T cells demonstrated a marked increase in inflammatory vitiligo than common vitiligo.

INTERVENTIONS

Without any intervention.

OUTCOMES

The previous upper 2 patches on the abdomen with erythematous rim were enlarged and joined together. However the lowest lesion with uninflamed common rim on the abdomen remained static, the one on the right groin showed spot-like repigmentation.

LESSONS

This case report demonstrates that resident memory CD8 + T cells may contribute to the progression of inflammatory vitiligo.

Exposure to solar UV radiation of Polish teenagers after the first COVID-19 lockdown in March-April 2020

In Poland, schools were closed from March to June 2020 due to the COVID-19 epidemic. During the lockdown (March-April), everyone was advised to stay at home. From May, students were allowed to spend time outdoors. We examine their exposure to solar UV radiation during the period of virtual learning at schools (May-June), vacations (July-August) and the first month of typical learning (September). Primary and high school students aged 12-18 completed a questionnaire on the details of their outdoor activities and the weather at the exposure site. A total of 146 anonymous questionnaires were registered for the study. The survey responses provided input to a radiative transfer model to estimate erythemal and vitamin D doses obtained by teenagers during outdoor activities. The results from 48% of the questionnaires indicated that students' exposure exceeded 1 minimal erythema dose (MED) during the day. Corresponding doses of sun-synthesized vitamin D, in excess of 1000 international units (IU) and 2000 IU, were found in 77% and 66% of the surveys, respectively. Only 12% of the teenagers declared that they use sunscreen. The overexposure (> 1 MED) increased with age. It was found in 72% and 26% of surveys among the students aged 17-18 and 12-14, respectively. Teenagers seem to have tried to compensate for the lack of sunlight during the lockdown by engaging in outdoor activities permitted since May. While those activities could have improved their vitamin D levels, they also put them at a higher risk of developing erythema.

Annular skin lesions in infancy

Annular skin lesions have a unique morphology, and the dramatic appearance of these skin eruptions in infants can cause concern for parents and clinicians. Annular lesions appearing during infancy (defined here as birth to 1 year of age) lend to a broad differential, ranging from benign cutaneous disorders to severe systemic diseases. This review summarizes the pathogenesis, clinical and histopathologic findings, and management options of possible etiologies for annular skin lesions in infants, including annular erythema of infancy, neonatal lupus erythematosus, dermatophyte infections, hemorrhagic edema of infancy, and urticaria multiforme.

Pathogenesis of annular lesions: Why a ring presentation?

Annular lesions represent a distinct morphology which characterizes many well-known dermatologic conditions. Little is definitively known regarding the pathogenesis of annular lesions, however there a few well-regarded hypotheses. Lesions that clear centrally while enlarging peripherally may result from a local central tissue anergy, or tolerance. The central area in lesions due to dermatophyte infections or subacute cutaneous lupus erythematous may have a central immunity to the antigen that trigged the lesion. The peripheral spread of inflammatory mediators may also contribute to lesions that expand centrifugally. In a highly active immune response, some of the inflammatory mediators may spread to adjacent tissue, which can propagate the inflammatory reaction. The additional hypotheses regarding pathogenesis are disease specific with individual mechanisms having been proposed. This chapter will describe both general and disease specific mechanisms that may contribute to the formation of annular lesions.

Efficacy and safety of permeation enhancers: a kinetic evaluation approach and molecular mechanism study in the skin

This study sought to provide approach for evaluating and predicting the efficacy and safety of permeation enhancers on the basis of their kinetic distribution behavior in the skin dictated by physicochemical properties. Herein, the efficacy-safety regularity of eight permeation enhancers were studied with ex vivo skin permeation study, small-angle X-ray scattering, MTT assay, H&E staining, and in vivo skin erythema analysis, classifying into the following three categories: high enhancement-low irritation, medium enhancement-high irritation, and low enhancement-low irritation. These three modes were positively correlated with the distribution amount of permeation enhancers in the skin layers and verified by the in vitro tape-stripping study. The kinetic parameter, effective-safety index (I_ES), was proposed to describe the regularity of enhancement effect tendency and irritation risk, and the relationship between I_ES and physicochemical properties of permeation enhancers was analyzed with multiple regression analysis. According to the results of modulated temperature differential scanning calorimetry and dielectric spectrum, permeation enhancers with high lipophilicity and low polarity had I_ES > 1, suggesting high enhancement effect and low irritation due to their higher affinity with the stratum corneum (SC) than with epidermis (EP). Permeation enhancers with medium lipophilicity and medium polarity exhibited 0 <I_ES ≤ 1, showing medium enhancement effect and high irritation, as determined by their comparable affinity with the SC and epidermis (EP). However, permeation enhancers with low lipophilicity and high polarity had I_ES → 0, demonstrating low enhancement effect and irritation, as indicated by their poor affinity with the SC. In summary, different physicochemical properties of permeation enhancers influenced their affinities with skin layers, resulting in their different enhancement effect and irritation potential. This study will provide a theoretical basis and criteria for evaluating and predicting the safety and efficacy of permeation enhancers, which will enable a more rational selection of permeation enhancers in the optimization of transdermal patches.

Solar UV Measured under Built-Shade in Public Parks: Findings from a Randomized Trial in Denver and Melbourne

Reducing exposure to ultraviolet radiation (UV) is crucial for preventing UV-induced diseases of the skin and eyes. Shade may offer significant protection from UV. More empirical research to quantify the UV protection offered from built shade is needed to guide disease prevention practices and confidence in investment in shade. This study quantified UV levels under built-shade relative to unshaded passive recreation areas (PRAs) over summer months in parks in two cities. In a randomized controlled trial, n = 1144 UV measurements were conducted at the center and periphery of PRAs in a total sample of 144 public parks as part of pretest and posttest measures of use of the PRAs by park visitors for three recruitment waves per city during 2010 to 2014. Following pretest, 36 PRAs received built-shade and 108 did not. Regression analyses modelled pre-post change in UV (Standard Erythemal Dose (SED) per 30 min) at PRAs; and environmental predictors. Mean UV at the center of built-shade PRAs decreased from pretest to posttest (x¯ = 3.39, x¯ = 0.93 SED), a change of x¯ = -3.47 SED relative to control PRAs (p < 0.001) adjusting for the covariates of ambient SED, (cosine) solar elevation and cloud cover. Clouds decreased and solar elevation increased UV levels under shade. No significant differences in UV by shade design occurred. A substantial reduction in exposure to UV can be achieved using built-shade with shade cloth designs, offering considerable protection for shade users. Supplementary sun protection is recommended for extended periods of shade use during clear sky days.