DermHelpCentral

Topical Ivermectin for Rosacea

"The etiology of papulopustular rosacea (PPR) is not well understood yet appears to involve both the innate and adaptive immune response in addition to possible infestation with Demodex mites. Current treatments for PPR consist mainly of antibiotics. Ivermectin cream 1%, a new topical treatment for PPR, possesses both anti-inflammatory and anti-parasitic properties. After 12 weeks of treatment, subjects treated with ivermectin cream 1% had significantly greater reductions in PPR symptoms and enhanced disease-related quality of life improvements compared to subjects who received vehicle. Furthermore, PPR symptoms continued to improve with prolonged treatment (40 weeks). Ivermectin cream 1% offers a multi-pronged approach to combat the complex pathophysiology of rosacea."  Full Text Ivermectin 1% Cream for Rosacea. Gita Gupta, MD, et. al.

This recent article was written by researches who are deeply in the pockets of Big PhRMA, however, topical Ivermectin may still be worth trying.  It is unlikely to be covered by drug plans.  On GoodRx Soolantra will run ~ $300 for 30 grams. 5% permethrin cream is also available and is much less expensive.  It is similar to ivermectin but is a higher percentage and may prove more irritating.  Dr. Yoon Cohen writes: "Permethrin and Ivermectin are both paralytic agents that block different ion channel. Permethrin is a synthetic pyrethrin that disables nerve cell Na+ transport channels in parasites resulting in paralysis. Ivermectin blocks glutamate-gated chloride channel resulting in paralysis. In my personal experience, permethrin 5% cream was not that irritating. If patients find 5% cream too strong, we could try permethrin 1% lotion. The only problem with permethrin would be with patients who have allergy to sesquiterpene lactone allergens (Chrysanthemum, ragweed, sunflower, artichoke, arnica, daisy, marigold plants) as there is cross react with permethrin." Dr. Cohen thinks "topical ivermectin may have a role for some individuals who cannot take topical permethrin or oral ivermectin, but it wouldn't be the first go-to drug for sure....although you see more and more of free Soonlantra samples around in clinics these days."

There are ways to save on Soolantra but it is very complicated.  See: Soolantra Savings and Support (and let us know if you can make out heads or tails from the site).

Recent ad for Soolantra gets the award for the most unpleasant drug promo ever!

Caveat Emptor

Inaccurate and unreliable medical tests are prompting abortions, promoting unnecessary surgeries, putting tens of thousands of people on unneeded drugs and raising medical costs, the Food and Drug Administration has concluded. Life-threatening diseases go undetected in some cases. In others, patients are treated for conditions they do not have.

“Patients have been demonstrably harmed or may have been harmed by tests that did not meet F.D.A. requirements.”

The findings come at a time when the use of laboratory-developed tests is booming.

This sobering article should give one pause for thought.  Tests are not the definitive answer we often think (and h ope) they are.  See: F.D.A. Targets Inaccurate Medical Tests, Citing Dangers and Costs (NY Times, 11.24.15)

Opioids: By the numbers, a deadly epidemic

By Bob Dunn (The Berkshire Eagle, November 21, 2015)

Fatal opioid-related overdoses in Massachusetts have increased more than 300 percent since the beginning of the century, according to new figures from the Department of Public Health.
According to reports released last month, there were 338 confirmed unintentional opiate fatalities statewide in 2000. In 2014, that number jumped to at least 1,089, according to DPH. 

Full article: Download Opioid Deaths in Massachusetts

Senile Gluteal Dermatosis

Senile gluteal dermatosis: a clinical study of 137 cases.
Liu HN1, et. al. Int J Dermatol. 2014 Jan;53(1):51-5.
Abstract
BACKGROUND: Senile gluteal dermatosis (SGD) is a common genital dermatosis but has gained little attention before. A large-scale clinical study of this disease is lacking.

MATERIALS AND METHODS: We examined 162 consecutive outpatients with gluteal skin diseases of different causes. Fourteen skin biopsies were performed. Patient's age, gender, body mass index (BMI), way of sitting or lying, treatment response, and underlying systemic diseases were recorded.

RESULTS: About 137 (85%) patients could be defined as SGD. These patients, with a mean age of 79.4 ± 40.7 years and a mean BMI of 21.7 ± 10.8, presented with either partial (n = 43, 31%) or full-blown (n = 94, 69%) SGD lesions characterized by the sign of so-called "three corners of a triangle": brownish plaques on the gluteal cleft and each side of the buttocks. Male/female ratio was 130/7. Itching or pain of varying intensity was reported by 50 patients (36%) and 14 patients (10%), respectively. Eighty-six patients (53%) presented with horizontal hyperkeratotic ridges, a characteristic sign of SGD. Most patients spent most of the day sitting but reported no special way of sitting or lying. More than half of patients with SGD claimed no response to topical steroids and/or keratolytics. In comparison with patients with SGD, SGD-free patients were younger (61.3 ± 36 years, P = 0.0005) and heavier (BMI 26.2 ± 15.6, P < 0.0001) but showed no significant difference in the frequency of underlying systemic diseases.

CONCLUSIONS: SGD is a common dermatosis, mostly affecting the thinner elderly. Friction, pressures and long hours sitting seemed to be important factors to trigger this dermatosis.

Comment:  This is a common problem in the elderly.  The name here is unfortunate, but it is descriptive.  This is one of the only articles about this disorder. This has been also called "Sitter's Sign." Download Sitter's Sign

Introducing the Cloud Clinic

Sugata Mitra hit upon the idea of unsupervised learning by computers in an iconic study of slum children in India. This evolved into Self-Organised Learning Environments (SOLEs) where children search for answers to ‘big’ questions. Why not apply this idea to the medical environment? We envision a Consultative Cloud Clinic whose primary aim is to enhance diagnosis and therapy in the interest of patient care and autonomy.  See introduction to Cloud Clinic.

Rethinking Clean

Forgoing a shower, even for a day, makes some people want to hide from society and double up on the deodorant. For Dave Whitlock, this is simply life as usual.

The chemical engineer and MIT grad decided back in 2003 to stop showering after discovering that animals harness bacteria in mud to stay odor-free. Called Nitrosomonas, these bacteria break down ammonia, producing nitrite (a powerful antibacterial) and nitric oxide (a beneficial gas). Speaking with LiveScience, Whitlock said he theorized that colonies of Nitrosomonas on the skin could potentially reduce body odor and keep other nasty bacteria in check.

The biggest problem with these ammonia oxidizing bacteria (or AOB) is that they take a long time to colonize on the skin and are extremely susceptible to many modern soaps and shampoos. Whitlock also discovered that modern humans are the only animal that does not harbor this particular bacteria — a likely result of our clean-obsessed lifestyles.

Consequently, he decided to isolate the bacteria into a spray and stop showering completely. Twice a day, he would apply the odorless spray to his body in an effort to build up a concentration of the bacteria on his skin. To his surprise, he discovered that not only did he not smell as time passed, but that his lack of showering had no ill effect on his health. Now 12 years later, he's still continuing the regimen –– but with a focus on only those parts he's recently washed.

"I only wash my hands," he told Motherboard. "In terms of the rest of my body, it’s basically already in a steady state. The bacteria on my skin are in a very stable, long-term state. I only need the spray on the parts of my body that I wash with water, because there the good bacteria gets washed away. If I took a normal shower, I’d have to use the spray all over my body after."

Armed with more than a dozen years of evidence that his spray harbors benefits for human skin, Whitlock recently helped launch a skin microbiome company called AOBiome. The startup's first products under the brand name Mother Dirt include not only the AO+ Mist (containing the live, beneficial Nitrosomonas bacteria), but also a biome-friendly face and body wash and shampoo.

"AOB were once a crucial part of the skin's ecosystem, but they've been lost due to modern chemistry in today's products and our lifestyles," Jasmina Aganovic, president of AOBiome, said in a statement. "With Mother Dirt, we're creating products that enhance and protect the skin biome."

According to Aganovic, users who incorporated the daily spray into their cleansing routines reported less dependence on deodorants, moisturizers and other personal care products. "They also found their skin was calmer, more hydrated, less oily, and generally more balanced," she added.

As for Whitlock, he says he's experienced another big benefit in the form of a better outlook; something he says may have something to do with the Nitrosomonas bacteria's production of nitric oxide.

"Well this is a bit speculative, but, according to science journals, nitric oxide is a very important psychological parameter," he told Motherboard. "It controls a lot of brain functions, for example. Stress is the result of low levels of nitric oxide. So if you have higher levels of nitric oxide, then it acts as an anti-stress mechanism."

The company is quick to add that you don't need to eschew showering to enjoy the benefits of a healthy skin biome.

"It’s not necessary that people stop showering or give up their soaps and shampoos," they state. "Our research shows that daily application along with normal showering in regular tap water produces a sustained level of AOB on skin. We recommend applying AO+ Mist daily as part of your usual personal hygiene routine."

Check out Aganovic speaking about AOBiome's breakthrough products at a recent IDEAS Boston conference below. (See YouTube of backstory.)

Keratoacanthoma

“Keratoacanthoma is a skin lesion that erupts in sun damaged skin, rather like a little volcano. It grows for a few months, then will usually shrink and resolve by itself. Keratoacanthoma is considered to be a variant of the keratinocytic or non-melanoma skin cancer, squamous cell carcinoma (SCC). Since it cannot be clinically reliably distinguished from more serious forms of skin cancer, keratoacanthomas are usually treated surgically.”

Most older dermatologists recognize keratoacanthomas (KAs) clinically. However, the trend these days is for dermatopathologists to label KAs “squamous cell carcinoma, well-differentiated.” This makes sense since dermatopathologists want to cover their bets, but it leaves the patient with a malignant diagnosis. KA, in the past, was also known as “benign self-healing epithelioma.” Since procedure codes for malignant lesions are higher than for benign ones, most clinicians will happily code these lesions as malignant when, in reality, the majority were destined to behave benignly.

Reference: Keratoacanthoma: A distinct entity?
Gleich T, et. al. Exp Dermatol. 2015 Oct 17. doi: 10.1111/exd.12880.
Abstract: Keratoacanthoma (KA) are common but exceptional benign tumors, often appearing on sun-exposed areas of light skinned people and showing spontaneous resolution. The goal of this study was to review existing literature, to point out the etiologic complexity of KA biology and to answer the controversial debate if or not KA is a distinct entity or a variant of squamous cell carcinoma (SCC). Relying on recent results, we highlight that KA is an individual lesion with a unique molecular signature caused by alterations in the TGFβ signaling pathway. These recent findings will help to understand the nature of KA and to develop new reliable diagnostic tools, simplifying the discrimination of the histologically similar KA and SCC.

Association of halo nevus/i and vitiligo in childhood

Association of halo nevus/i and vitiligo in childhood: a retrospective observational study.

Patrizi A, et. al. J Eur Acad Dermatol Venereol. 2013 Feb;27(2):e148-52.

Abstract
BACKGROUND: Although halo nevus (HN) is frequently observed, the relationship between vitiligo and HN in children has rarely been investigated.

OBJECTIVES: To investigate the association between HN and vitiligo in children and understand if HN/HNi might be a risk factor for vitiligo.

METHODS: Ninety-eight patients with only HN/HNi and 27 with HN/HNi and vitiligo were investigated for number and localization of HN/HNi, family history for HN/HNi and vitiligo and personal and family history for autoimmune or other diseases. A follow-up telephone interview was performed to investigate the evolution of HN/HNi and the possible onset of vitiligo and/or other diseases.

RESULTS: In the HN/HNi and vitiligo group, HN/HNi and vitiligo had started almost simultaneously in 11 children; in nine, the onset of HN/HNi was followed by vitiligo after 6 months to 5 years; seven patients presented vitiligo first and HN/HNi after 3-9 years. Patients with associated vitiligo had, significantly more often, multiple HNi and a positive personal and/or family history of autoimmune thyroiditis compared with those with only HN/HNi. Follow-up longer than 5 years was available in 54/98 patients with only HN/HNi; two of them, both with multiple HNi, developed vitiligo. After follow-up, multiple HNi were noticed in 18/52 patients without vitiligo and in 9/11 of those in whom HN/HNi heralded vitiligo (s.s.).

CONCLUSIONS: In patients with multiple HNi, the risk of vitiligo and other autoimmune diseases seems to be higher than in pediatric patients with a single HN; clinicians should pay particular attention to children with multiple HNi and personal or family history of autoimmune diseases.

The Neurology of Itch

The neurology of itch.
Dhand A1, Aminoff MJ. Brain. 2014 Feb;137(Pt 2):313-22
Abstract: Research over the past 15 years has helped to clarify the anatomy and physiology of itch, the clinical features of neuropathic itch syndromes and the scientific underpinning of effective treatments. Two itch-sensitive pathways exist: a histamine-stimulated pathway that uses mechanically insensitive C-fibres, and a cowhage-stimulated pathway primarily involving polymodal C-fibres. Interactions with pain continue to be central to explaining various aspects of itch. Certain spinal interneurons (Bhlhb5) inhibit itch pathways within the dorsal horn; they may represent mediators between noxious and pruritic pathways, and allow scratch to inhibit itch. In the brain, functional imaging studies reveal diffuse activation maps for itch that overlap, but not identically, with pain maps. Neuropathic itch syndromes are chronic itch states due to dysfunction of peripheral or central nervous system structures. The most recognized are postherpetic itch, brachioradial pruritus, trigeminal trophic syndrome, and ischaemic stroke-related itch. These disorders affect a patient's quality of life to a similar extent as neuropathic pain. Treatment of neuropathic itch focuses on behavioural interventions (e.g., skin protection) followed by stepwise trials of topical agents (e.g., capsaicin), antiepileptic drugs (e.g., gabapentin), injection of other agents (e.g., botulinum A toxin), and neurostimulation techniques (e.g., cutaneous field stimulation). The involved mechanisms of action include desensitization of nerve fibres (in the case of capsaicin) and postsynaptic blockade of calcium channels (for gabapentin). In the future, particular histamine receptors, protease pathway molecules, and vanilloids may serve as targets for novel antipruritic agents. Free Full Text.

Updae on the management of Rosacea

This is a helpful review with special reference to isotretinoin.  It is available free full text.

Abstract. Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Also see:  All About Rosacea.