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hyperpigmentation Archives | Skin of Color Update | Dermatology Conference | New York City

Black Male With Psoriasis and Dyspigmentation

Successful Management of a Black Male With Psoriasis and Dyspigmentation Treated With Halobetasol Propionate 0.01%/Tazarotene 0.045% Lotion: Case Report

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Introduction

Skin of color patients with psoriasis face unique challenges related to disease characteristics and treatment. Distribution and severity of psoriasis may be greater in patients with skin of color.1,2 Dyspigmentation—including postinflammatory hypo- and hyperpigmentation—also more frequently and severely affects patients with skin of color3,4 and remains a challenge for dermatologists to manage.5 Finally, Black and Hispanic/Latino patients have demonstrated worse health-related quality of life (QoL) compared with White patients, as assessed by the Dermatology Life Quality Index (DLQI)6; these differences are likely related to several factors, which include varying cultural perceptions of skin disorders and the greater negative impact of dyspigmentation in patients with skin of color.2,7 The treatment of psoriasis commonly involves the use of topical corticosteroids, such as the superpotent topical corticosteroid halobetasol propionate (HP).8,9 Corticosteroids are anti-inflammatory, immunosuppressive, antiproliferative, and vasoconstrictive; however, tachyphylaxis and adverse events following long-term use remain a concern.8-10 The topical retinoid tazarotene (TAZ) has several mechanisms of action that modulate pathogenic factors of psoriasis—including normalizing markers of differentiation, proliferation, and inflammation—though TAZ used alone may induce cutaneous irritation.10-13 The combination of HP with TAZ may enhance efficacy in the treatment of psoriasis, reduce side effects of both active drugs, and sustain treatment response.10,11

A fixed combination lotion of HP 0.01% and TAZ 0.045% (HP/TAZ; Duobrii,® Ortho Dermatologics, Bridgewater, NJ) was developed utilizing a novel polymeric emulsion technology, which allows for rapid and uniform distribution of HP and TAZ, humectants, and moisturizers on the skin.10 Phase 3 clinical data have demonstrated efficacy and tolerability of HP/TAZ lotion in patients with moderate-to-severe localized plaque psoriasis.14,15 Here, we present a case report of a Black male with moderate plaque psoriasis who was successfully treated with once-daily HP/TAZ lotion over 8 weeks, with resolution of skin dyspigmentation by week 12.

Psoriasis and Dyspigmentation in black male

 Click table to enlarge

Case Report

The patient was a 58-year-old, non-Hispanic, Black male with moderate psoriasis (Investigator’s Global Assessment [IGA]=3) and affected body surface area (BSA) of 10% at baseline (Table 1). The patient was enrolled in a phase 3, randomized, double-blind, vehicle-controlled study that assessed HP/TAZ lotion in participants with moderate-to-severe psoriasis (NCT02462070); detailed methodology and study results have been previously published.14,15 The patient, randomized to HP/TAZ for 8 weeks with a 4-week posttreatment follow-up, was instructed to apply a thin layer of HP/TAZ lotion once-daily over all affected areas. The target lesion (Figure 1), located on the upper right arm, was 99 cm2 in size at baseline; prominent keloid scars were also apparent. The patient also had an additional non-target lesion treated with HP/TAZ during the study (Figure 2). At baseline, both lesions appeared as classic psoriatic elevated plaques covered with white/silvery scales. By week 2 of HP/TAZ treatment, scales had diminished, though affected skin was hypopigmented in the center with hyperpigmentation at the border of the psoriatic plaque resolution. The degree of hypopigmentation appeared to be greatest at week 4, with skin pigmentation nearing normal by week 8. At 4 weeks posttreatment, the affected skin area had returned to normal with small regions of hyperpigmentation, the greatest around the periphery of the affected skin lesion.

FIGURE 1. Target lesion. Patient was treated with HP 0.01%/TAZ 0.045% lotion once daily for 8 weeks, with 4-week posttreatment follow-up at week 12.

Black Male With Psoriasis and Dyspigmentation

HP, halobetasol propionate; TAZ, tazarotene.

FIGURE 2. Additional lesion. Patient was treated with HP 0.01%/TAZ 0.045% lotion once daily for 8 weeks, with 4-week posttreatment follow-up at week 12.

Black Male With Psoriasis and Dyspigmentation

HP, halobetasol propionate; TAZ, tazarotene.

 

The patient achieved treatment success with HP/TAZ lotion, with an improvement to ‘almost clear’ at week 4 that was maintained posttreatment at week 12 (Table 1). Improvements in affected BSA and signs of psoriasis at the target lesion were also observed early following treatment with HP/TAZ lotion and maintained up to 4 weeks posttreatment. The patient had substantial improvements in QoL during the study, with DLQI score decreasing from 9 (“moderate effect” on life) at baseline to 1 (“no effect” on life) at weeks 4 and 8.

No adverse events were reported. Dryness was the only local skin reaction present at baseline (assessed as moderate by the investigator), which subsided at weeks 2–6 and returned to mild dryness by study end (Table 1). No itching was reported during HP/TAZ treatment until posttreatment follow-up, where it was assessed as moderate. The patient did not report burning/stinging at any study visit. Further, there were no instances of skin atrophy, striae, telangiectasias, or folliculitis—other known drug-related skin reactions.

Discussion

Racial and ethnic differences in epidemiology, clinical features, genetic predisposition, and response to treatment of psoriasis are important to address given our increasingly diverse patient population.7 Here we report the management of psoriasis in a Black male enrolled in a clinical trial who was randomized to treatment with HP 0.01%/TAZ 0.045% lotion once daily for 8 weeks, with a 4-week posttreatment follow-up at week 12.

HP/TAZ was efficacious in this patient, who achieved an IGA score of 1 (almost clear) within 4 weeks and maintained treatment success at weeks 8 and 12. Affected BSA decreased 50% from baseline to week 8. Quality of life was improved in this patient, whose DLQI score by week 8 indicated “no effect” of psoriasis on the patient’s QoL, a substantial and clinically meaningful16 improvement from the “moderate effect” observed at baseline. A clinical feature of this patient was the presence of prominent keloid scars, which are benign fibrous growths resulting from an abnormal connective tissue response.17 While the cause of the keloids in this patient is not known, the presence of keloids is not unexpected, as there are racial differences in prevalence, with Black individuals forming keloids more often than White individuals.17

The patient experienced dyspigmentation of the affected skin during the trial, which is also not unexpected, given that resolution of psoriasis in darker skin is associated with both hypo- and hyper-pigmentation.18 Dyspigmentation is of particular concern, as it can have significant psychosocial impacts, contribute to greater negative emotions, and even be more bothersome than the psoriasis itself in patients with skin of color.2,4,7 Hypopigmentation was primarily experienced from weeks 2-8, with the greatest degree at week 4. By week 12 the affected skin area had returned to normal, with only small regions of hyperpigmentation, primarily around the periphery of the lesion. This relatively fast time to resolution is notable given that dyspigmented patches can take between 3 and 12 months to resolve.2

Skin color is primarily due to the presence of melanin, a pigment formed by immune cells called melanocytes. Melanin formation, or melanogenesis, is a complex process of melanin synthesis, transport, and release to keratinocytes, which occurs within organelles of melanocytes called melanosomes.19 The mechanisms and pathogenesis of postinflammatory hypo- and hyperpigmentation in psoriasis are not fully elucidated, though multiple hypotheses have been suggested. Inflammation-associated hypopigmentation may be a result of rapid turnover of keratinocytes during hyperplasia, which can interfere with melanosome transfer.18 Cutaneous inflammation, through signaling of growth factors and pro-inflammatory cytokines such as IL-17 and TNF-α, can also lead to hypopigmentation through inhibition of melanogenesis, 18,20 with more severe inflammation potentially leading to permanent pigmentary changes through loss or death of melanocytes.20 Interestingly, it has been observed that while hypopigmentation often accompanies active inflammation, patients are at risk of developing hyperpigmentation once the inflammation has resolved, potentially due to increased numbers and activity of melanocytes.18,21 This too may be the result of cytokine signaling during inflammation. For example, IL-17 and TNF-α can simultaneously suppress melanogenesis while also stimulating the proliferation of melanocytes; as such, upon resolution of inflammation, the increased number of melanocytes in lesional skin (without concurrent suppression of melanogenesis) will produce excess melanin, leading to postinflammatory hyperpigmentation.18

The fixed combination of HP and TAZ used to treat psoriasis in the patient from this case report resulted in psoriasis lesion clearance with self-limited postinflammatory hypopigmentation and low levels of hyperpigmentation observed by week 12. Topical corticosteroids, a mainstay of treatment for psoriasis,8 are used as first-line therapy for hyperpigmentation when combined with hydroquinone and topical retinoids.5,22 Corticosteroids are thought to be effective by decreasing cellular metabolism, thereby inhibiting melanin synthesis.22 Corticosteroids have also been shown to minimize the risk of postinflammatory hyperpigmentation after laser resurfacing.23 Topical retinoids are effective in treating postinflammatory hyperpigmentation with other agents as described above or as monotherapy.22 For example, TAZ 0.1% gel and cream have demonstrated efficacy in acne-related postinflammatory hyperpigmentation, significantly improving pigmentation intensity versus vehicle24,25; TAZ was also more effective than adapalene 0.3% gel in reducing hyperpigmentation.25 Tazarotene 0.1% cream is approved as an adjunctive treatment in the mitigation of facial mottled hyper- and hypopigmentation. Retinoids are thought to reduce hyperpigmentation through multiple mechanisms, including: stimulating keratinocyte turnover (promoting loss of melanin), reducing/inhibiting melanosome transfer to keratinocytes, and interrupting melanin synthesis.22,26 TAZ has also been shown to downregulate markers of cell proliferation and inflammation such as IL-6,12,13 which is known to have hypopigmenting effects.18

The fixed combination HP 0.01%/TAZ 0.045% lotion used by the patient in this case report has additional efficacy and safety benefits. The new polymeric emulsion technology used to develop HP/TAZ lotion allows for efficient permeation of the active ingredients into the dermal layers, at around half the concentration of traditional topical formulations.10 Further, HP/TAZ lotion has demonstrated synergistic activity, with efficacy greater than that which would be predicted from the individual active ingredients.10 The maintenance of therapeutic effect seen in this patient—who sustained disease reduction 4 weeks posttreatment—is likely due to the mechanism of action of TAZ in psoriasis, which restores skin to a quiescent, prelesional status.27 However, when used alone, TAZ can cause cutaneous irritation; HP alone can also result in AEs that limit long term use. These safety limitations can be minimized when combining HP with TAZ.10,11 The patient in this case report did not report any adverse events—including any application or irritation events—and local skin reactions were limited. Though the patient was limited to 8-weeks of HP/TAZ treatment as part of the clinical trial design, treatment with HP/TAZ for up to 1 year (maximum 24 weeks of continuous use) in an open-label, long-term study (NCT02462083) has demonstrated a favorable safety profile.28

Conclusion

In conclusion, this case report in a Black male patient demonstrates that this new formulation of HP 0.01%/TAZ 0.045% lotion was efficacious in the treatment of psoriasis, with treatment success achieved early and maintained 4 weeks posttreatment. Hypopigmentation was evident during resolution of disease, though had completely resolved by week 12 with minimal hyperpigmentation observed. These results indicate that HP/TAZ may be a treatment option for patients with skin of color, who are disproportionally affected by postinflammatory dyspigmentation.

Disclosures

Seemal Desai has served as a research investigator and/or consultant for Skinmedica, Ortho Dermatologics, Galderma, Pfizer, Dermavant, Almirall, Dermira, and Watson.

Andrew F. Alexis has received grant/research support (funds to institution) from Leo, Novartis, Almirall, Bristol-Myers-Squibb, Celgene, Menlo, Galderma, Bausch Health, and Cara; and has served as a consultant/advisory board member for Leo, Novartis, Menlo, Galderma, Pfizer, Sanofi-Regeneron, Dermavant, Unilever, Celgene, Beiersdorf, L’Oreal, BMS, Menlo, Scientis, Bausch Health, UCB, and Foamix.

Abby Jacobson is an employee of Ortho Dermatologics and may hold stock and/or stock options in its parent company.

Acknowledgements

The studies were funded by Ortho Dermatologics. Medical writing support was provided by Prescott Medical Communications Group (Chicago, IL) with financial support from Ortho Dermatologics. Ortho Dermatologics is a division of Bausch Health US, LLC.

References

1. Gelfand JM, Stern RS, Nijsten T, et al. The prevalence of psoriasis in African Americans: Results from a population-based study. J Am Acad Dermatol. 2005;52(1):23-26.
2. Alexis AF, Blackcloud P. Psoriasis in skin of color: Epidemiology, genetics, clinical presentation, and treatment nuances. J Clin Aesthet Dermatol. 2014;7(11):16-24.
3. Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: A comparative practice survey. Cutis. 2007;80(5):387-394.
4. Davis EC, Callender VD. Postinflammatory hyperpigmentation: A review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3(7):20-31.
5. Desai SR. Hyperpigmentation therapy: a review. J Clin Aesthet Dermatol. 2014;7(8):13-17.
6. Shah SK, Arthur A, Yang YC, et al. A retrospective study to investigate racial and ethnic variations in the treatment of psoriasis with etanercept. J Drugs Dermatol. 2011;10(8):866-872.
7. Kaufman BP, Alexis AF. Psoriasis in skin of color: Insights into the epidemiology, clinical presentation, genetics, quality-of-life impact, and treatment of psoriasis in non-White racial/ethnic groups. Am J Clin Dermatol. 2018;19(3):405-423.
8. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009;60(4):643-659.
9. Uva L, Miguel D, Pinheiro C, et al. Mechanisms of action of topical corticosteroids in psoriasis. Int J Endocrinol. 2012;2012:561018.
10. Tanghetti EA, Stein Gold L, Del Rosso JQ, et al. Optimized formulation for topical application of a fixed combination halobetasol/tazarotene lotion using polymeric emulsion technology. J Dermatolog Treat. 2019:1-8.
11. Tanghetti E, Lebwohl M, Stein Gold L. Tazarotene revisited: Safety and efficacy in plaque psoriasis and its emerging role in treatment strategy. J Drugs Dermatol. 2018;17(12):1280-1287.
12. Duvic M, Nagpal S, Asano AT, Chandraratna RA. Molecular mechanisms of tazarotene action in psoriasis. J Am Acad Dermatol. 1997;37(2 Pt 3):S18-24.
13. Duvic M, Asano AT, Hager C, Mays S. The pathogenesis of psoriasis and the mechanism of action of tazarotene. J Am Acad Dermatol. 1998;39(4 Pt 2):S129-133.
14. Gold LS, Lebwohl MG, Sugarman JL, et al. Safety and efficacy of a fixed combination of halobetasol and tazarotene in the treatment of moderate-to-severe plaque psoriasis: Results of 2 phase 3 randomized controlled trials. J Am Acad Dermatol. 2018;79(2):287-293.
15. Sugarman JL, Weiss J, Tanghetti EA, et al. Safety and efficacy of a fixed combination halobetasol and tazarotene lotion in the treatment of moderate-to-severe plaque psoriasis: A pooled analysis of two phase 3 studies. J Drugs Dermatol. 2018;17(8):855-861.
16. Basra MK, Salek MS, Camilleri L, et al. Determining the minimal clinically important difference and responsiveness of the Dermatology Life Quality Index (DLQI): Further data. Dermatology. 2015;230(1):27-33.
17. Kelly AP. Keloids. Dermatol Clin. 1988;6(3):413-424.
18. Wang CQF, Akalu YT, Suarez-Farinas M, et al. IL-17 and TNF synergistically modulate cytokine expression while suppressing melanogenesis: Potential relevance to psoriasis. J Invest Dermatol. 2013;133(12):2741-2752.
19. Wasmeier C, Hume AN, Bolasco G, Seabra MC. Melanosomes at a glance. J Cell Sci. 2008;121(Pt 24):3995-3999.
20. Vachiramon V, Thadanipon K. Postinflammatory hypopigmentation. Clin Exp Dermatol. 2011;36(7):708-714.
21. Abdel-Naser MB, Liakou AI, Elewa R, et al. Increased activity and number of epidermal melanocytes in lesional psoriatic skin. Dermatology. 2016;232(4):425-430.
22. Vashi NA, Kundu RV. Facial hyperpigmentation: Causes and treatment. Br J Dermatol. 2013;169 Suppl 3:41-56.

Originally published in the Journal of Drugs in Dermatology in October 2020. 

Desai, S. R., Alexis, A. F., & Jacobson, A. (2020). Successful Management of a Black Male With Psoriasis and Dyspigmentation Treated With Halobetasol Propionate 0.01%/Tazarotene 0.045% Lotion: Case Report. Journal of drugs in dermatology: JDD, 19(10), 1000-1004. https://jddonline.com/articles/dermatology/S1545961620P1000X

Content and images republished with permission from the Journal of Drugs in Dermatology.

Adapted from original article for length and style.

The Journal of Drugs in Dermatology is available complimentary to US dermatologists, US dermatology residents, and US dermatology NP/PA. Create an account on JDDonline.com and access over 15 years of PubMed/MEDLINE archived content.

Did you enjoy this case report? You can find more here.

SKIN OF COLOR UPDATE PRE-CONFERENCE VIRTUAL SYMPOSIUM

By | Medical Dermatology, Sessions, Skin of Color Update Agenda | No Comments
SKIN OF COLOR UPDATE PRE-CONFERENCE VIRTUAL SYMPOSIUM
A Case-Based Conversation with The Experts: Treating Pigmentary Disorders in Skin of Color Patients
SKIN OF COLOR UPDATE PRE-CONFERNECE VIRTUAL SYMPOSIUM
TUESDAY, AUGUST 3RD | 6:00PM ET – 9:00PM ET
The Skin of Color Update invites you to join its pre-conference symposium where co-chairs Drs. Andrew Alexis and Eliot Battle will host an interactive, case-based conversation with pigmentary disorders experts. Faculty will review treatment options for common as well as challenging and less frequently discussed pigmentary conditions in skin of color patients. Through a detailed review of each case, panelists will provide guidance and evidence-based treatment protocols as well as practical pearls drawn from their clinical experience. You will walk away from this session armed with clinical pearls immediately useful in your practice. In addition, all panelists will participate in live Q&A sessions to answer your most pressing questions about treating pigmentary disorders in SOC.
AGENDA
6:00-6:05 PM – Welcome & Introductions from Symposium Moderators – Andrew F. Alexis, MD, MPH & Elliot F. Battle, MD
6:05-6:20 PM – A Challenging Case of Melasma – Heather Woolery-Lloyd, MD
6:20-6:35 PM – A Case of Vitiligo Treated with Pulsed Corticosteroids/JAK-Inhibitor – Seemal Desai, MD
6:35-6:50 PM – Post-Inflammatory Hyperpigmentation(PIH) Topical & Procedural Treatment – Neelam Vashi, MD
6:50-7:00 PM – Live Audience Q&A
7:00-8:00PM – For Patients with Plaque Psoriasis: An Oral, Non-Biologic Therapy With Data on Clearer Skin and Symptoms – Paul Wallace, MD, MPA (Non-CE Workshop)
8:00-8:05 PM – Welcome & Introductions from Symposium Moderators – Andrew F. Alexis, MD, MPH & Elliot F. Battle, MD
8:05-8:20 PM – A Challenging Case of Erythema Dyschromicum Perstans – Nada Elbuluk, MD, MSc
8:20-8:35 PM – A Case of Hypopigmented Mycosis Fungoides – Eva Kerby, MD
8:35-8:50 PM – Lichen Planus Pigmentosus – Mukta Sackdev, MD
8:50-9:00 PM – Live Audience Q&A
SYMPOSIUM CO-CHARIS
Andrew F. Alexis, MD, MPH
Eliot F. Battle, MD
EXPERT FACULTY
Seemal R. Desai, MD, FAAD
Nada Elbuluk MD, MSc
Eva Kerby, MD
Heather Woolery-Lloyd, MD
Mukta Sachdev, MD
Neelam Vashi, MD
Pemphigus Foliaceus

Psoriasiform Pemphigus Foliaceus in an African American Female: An Important Clinical Manifestation

By | Case Reports, SOC Manuscripts | No Comments

JDD authors document and highlight this atypical psoriasiform presentation of Pemphigus Foliaceus in a patient with skin of color to raise awareness and improve diagnosis and outcomes.

Case Report

A 50-year-old African-American woman presented to the dermatology clinic with a pruritic eruption of 3 years’ duration that began as discrete plaques on the inframammary folds and subsequently spread towards the mid-chest, ears, back, elbows, knees, and scalp. Past treatments by other clinicians included clotrimazole cream and a topical corticosteroid of unknown potency without significant improvement. She denied any new medications and was taking aspirin, divalproex, mirtazapine, cetirizine, venlafaxine, atorvastatin, and omeprazole.

On clinical examination, the patient had well-demarcated, pink, atrophic plaques and superficial erosions over the inframammary folds and mid-chest (Figures 1). She also had well-demarcated, hyperpigmented, hyperkeratotic scaly plaques over the abdomen, suprapubic region, elbows, knees, and back with sporadic small superficial blisters (Figure 2). Complete blood count, complete metabolic panel, rheumatoid factor, and antinuclear antibody were within normal limits. Rapid plasma reagin test was negative. Erythrocyte sedimentation rate was elevated at 54 millimeter/hour (reference range 0-22 millimeter/hour). A punch biopsy of the right abdomen was performed and revealed psoriasiform epidermal hyperplasia, focal parakeratosis, and acantholysis throughout the superficial spinous and granular layers (Figure 3). Only a sparse inflammatory infiltrate was present in the underlying dermis. These clinical and histological findings supported the diagnosis of pemphigus foliaceus (PF). Patient was started on 50 mg oral dapsone daily.

Pemphigus Foliaceus

FIGURE 1. Well-demarcated, scaly plaques over the mid-chest and inframammary folds, with a single superficial erosion on the right medial chest.

Pemphigus Foliaceus

FIGURE 2. A plaque from the abdomen demonstrates “corn flake-like” scale.

Pemphigus Foliaceus

FIGURE 3. Composite photomicrograph, hematoxylin, and eosin, original magnification x200.

 

Discussion

Herein, we present a case of Pemphigus Foliaceus with a psoriasiform clinical presentation in an African-American patient. PF is an autoimmune skin disease caused by antibodies against the desmosomal glycoprotein, desmoglein 1.¹ Desmogleins, members of the cadherin family, serve to anchor epidermal desmosomes between adjacent keratinocytes and assist in epithelial differentiation.² Antibodies targeting desmoglein 1 result in acantholysis in the upper epidermis with limited separation in the basal layers and minimal mucosal involvement as desmoglein 1 is primarily expressed in the granular layer of the non-mucosal epidermis.¹ Patients present with scaly plaques on an erythematous base and fragile shallow blisters which are infrequently found intact; rarely, the condition can progress to exfoliative erythroderma.1,3 Initially, PF usually presents on the trunk, face, or scalp, but may subsequently involve other regions of the skin.1 Diagnosis may be confirmed with biopsy and direct immunofluorescence with intercellular IgG and C3 limited to the upper epidermis. Treatment includes oral and topical steroids, azathioprine, dapsone, and rituximab. The differential diagnosis for PF may include systemic lupus erythematosus, bullous impetigo, psoriasis, and seborrheic keratosis depending on the presentation.1

Physical exam findings in this patient were suggestive of PF due to the presence of superficial secondary erosions and “corn flake-like” scales, but psoriasis was included in the differential diagnosis due to the presence of discrete plaques with an erythematous border. PF is a relatively rare condition with a prevalence of less than 1 case per 100,000 and is about 5 to 10 times less common than pemphigus vulgaris.4 In contrast, psoriasis impacts approximately 2-4% of people in the United States.5 An endemic form of PF, fogo selvagem, has been reported in Brazil, Colombia, Peru, and Tunisia, while pemphigus vulgaris is more common in Mediterranean and Ashkenazi Jewish populations.4

We hypothesize that patients with psoriasiform presentations of PF may be misdiagnosed with plaque psoriasis. One author (JJ) has previous significant clinical experience with patients with skin of color and has seen other skin of color patients present with a psoriasiform manifestation of PF. PF and psoriasis share similar treatments including topical corticosteroids and immunosuppressants, and this may lead to underreporting of PF with psoriasiform manifestations. It is important to distinguish between these findings as there is evidence that ultraviolet light, a common treatment for psoriasis, may exacerbate PF.6,7 We performed a search of the published literature and identified one article that describes three patients with pemphigus erythematosus, a variant of PF, which was misdiagnosed as psoriasis.8 No identified articles described cases of PF with a psoriasiform presentation in patients with skin of color. We document and highlight this atypical psoriasiform presentation of PF in a patient with skin of color to raise awareness and improve diagnosis and patient outcomes.

Disclosures

The authors have no relevant disclosures. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. This material is the result of work supported with resources and the use of facilities at the Sacramento VA Medical Center.

 

References

  1. James KA, Culton DA, Diaz LA. Diagnosis and clinical features of pemphigus foliaceus. Dermatol Clin. 2011;29(3):405-412, viii.
  2. Simpson CL, Patel DM, Green KJ. Deconstructing the skin: cytoarchitectural determinants of epidermal morphogenesis. Nat Rev Mol Cell Biol. 2011;12(9):565-580.
  3. Kershenovich R, Hodak E, Mimouni D. Diagnosis and classification of pemphigus and bullous pemphigoid. Autoimmun Rev. 2014;13(4):477-481.
  4. Meyer N, Misery L. Geoepidemiologic considerations of auto-immune pemphigus. Autoimmun Rev. 2010;9(5):A379-A382.
  5. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70(3):512-516.
  6. Ruocco V, Ruocco E, Schiavo AL, Brunetti G, Guerrera LP, Wolf R. Pemphigus: Etiology, pathogenesis, and inducing or triggering factors: Facts and controversies. Clin Dermatol. 2013;31(4):374-381.
  7. Aghassi D, Dover JS. Pemphigus foliaceus induced by psoralen-UV-A. Arch Dermatol. 1998;134(10):1300-1301.
  8. Oktarina DA, Poot AM, Kramer D, Diercks GF, Jonkman MF, Pas HH. The IgG “lupus-band” deposition pattern of pemphigus erythematosus: association with the desmoglein 1 ectodomain as revealed by 3 cases. Arch Dermatol. 2012;148(10):1173-1178.

Originally published in the Journal of Drugs in Dermatology in April 2018. 

Evan Austin BS, Jillian W. Millsop MD, Haines Ely MD, Jared Jagdeo MD MS, and Joshua M. Schulman MD (2018). Psoriasiform Pemphigus Foliaceus in an African American Female: An Important Clinical Manifestation. Journal of Drugs in Dermatology, 17(14), 471-473. https://jddonline.com/articles/dermatology/S1545961618P0471X 

Content and images republished with permission from the Journal of Drugs in Dermatology.

Adapted from original article for length and style.

The Journal of Drugs in Dermatology is available complimentary to US dermatologists, US dermatology residents, and US dermatology NP/PA. Create an account on JDDonline.com and access over 15 years of PubMed/MEDLINE archived content.

Did you enjoy this case report? You can find more here.

Ethnicity Matters: Medical Dermatology Concerns Across Ethnic Groups

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Wendy Roberts Presenting at SOCU

Source: Dermatology News

This is an excerpt from Dermatology News’ coverage of Skin of Color Update 2019.

For women with pseudofolliculitis barbae, an empirically-based strategy of microdermabrasion, laser treatment, emollients, and maintenance retinoids has been found highly effective, Wendy Roberts, MD, reported at the Skin of Color Update 2019.

“We didn’t have great treatments for this problem in the past, but the technology has evolved, and you can now get most women clear,” Dr. Roberts, a dermatologist who practices in Rancho Mirage, Calif., said at the meeting.

This approach is appropriate in all women, but Dr. Roberts focused on her experience with black patients, for whom an antioxidant cream is added to address the inflammatory-associated hyperpigmentation that often accompanies pseudofolliculitis barbae, a chronic inflammatory skin condition typically characterized by small, painful papules and pustules.

Start with microdermabrasion to treat the hypertrophic hair follicles and address keratin plugs, Dr. Roberts said. The microdermabrasion smooths the skin and increases penetration of subsequent creams and topics, she said.

“In the same session, I treat with Nd-YAG 1064 nm laser using short pulses,” she noted. For black women, she makes four passes with the laser at a level of moderate intensity. For those with lighter skin, she might perform as many as six passes with the laser set higher.

The microdermabrasion is repeated monthly for three or four treatments, but can be extended for those with persistent symptoms, Dr. Roberts pointed out. She presented a case of a patient who required seven treatments to achieve a satisfactory response.

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Long-Term Benefits of Daily Photo-Protection With a Broad-Spectrum Sunscreen in United States Hispanic Female Population

By | Aesthetic Dermatology, Medical Dermatology | No Comments
Image of photo aging

Source: JDD Online

The following is an excerpt from the Journal of Drugs in Dermatology article, Long-Term Benefits of Daily Photo-Protection With a Broad-Spectrum Sunscreen in United States Hispanic Female Population.

Introduction
The demographics of the United states are evolving with a large increase in racial and ethnic diversity driven by international migration of Hispanic, African, and Asian populations leading to a minority-majority shift in ~2050 towards persons of color (Fitzpatrick III, IV, V, and VI).1 Specifically, the Hispanic population is projected to be among the fastest growing population in the US, projected to increase from 55 million in 2014 to 119 million in 2060, a change of +115%.1

Subjects with skin of color are heterogeneous with multiple shades and tones and different reactions to intrinsic and extrinsic aging factors due to structural and physiologic differences.2,3 Skin of color individuals have fewer visible signs of aging (deep wrinkles, fine lines, rough surface texture, and sun spots). However, darker skin tones are more susceptible to certain skin conditions including post-inflammatory hyperpigmentation (may occur after acne, eczema, injury, laceration, melasma, post-inflammatory hypopigmentation, pityriasis alba (round, light patches covered with fine scales), dry or “ashy” skin, dermatosis papulosa nigra, and/or greater risk of keloid development.2,3 The incidence of skin cancer among US Hispanics has also increased 1.3% annually from 1992 to 2008.4

Photodamage is characterized histologically by degeneration of the connective tissue and abnormalities in keratinocytes and melanocytes. Clinically, it manifests primarily with wrinkles, dyschromia, texture changes, and, in more severe cases skin cancer.5 Formulations containing broad spectrum sunscreens against both UVA and UVB play an essential role in the prevention of photodamage and UV-induced skin cancers.6,7,8 However, the majority of clinical research on photoprotection has been conducted on subjects with Fitzpatrick types I to III skin and have reported improvements in signs associated with skin aging and texture.9,10 Verschoore et al was the first to conduct a short-term clinical study in India with Phototype IV and VI subjects, and provided first evidence on the effectiveness of daily sunscreen use on skin tone and radiance.11 Similar benefits were observed in an 8-week study in US.12

Although sun protection is highly recommended by dermatologists for skin cancer risk-reduction and the prevention of premature aging or pigmentary disorders, adherence to the recommendations is not commonly observed among US Hispanics.13 Moreover, a large number of US Hispanics reside in areas with high UV index with a high degree of sun seeking behavior. Among Hispanic adults who report engaging in sun protection, they do so mostly by staying in the shade (53.7%) rather than use of sunscreen (32.3%) or wearing sun protective clothes (18.1%); while 36.7% of the subjects surveyed indicated that they never use sunscreen.14,15 There are sociodemographic factors that contribute to the adherence to safe sun behaviour such as education, age, and gender, etc, therefore there is a need to raise awareness of skin cancer risks, advocate for preventive measures and educate on benefits of sunscreen and sun protection among US Hispanics.16

The benefits of topical agents for reversal of sun damage has been well established. Use of retinoic acid and its derivatives or other drugs to reverse and improve sun damaged skin has been demonstrated in many studies.17,18 Long-term sunscreenuse along with other topical agents have also been shown to prevent photodamage and hyperpigmentation in fair-skinned subjects.19 For effective photoprotection, sunscreen products containing both SPF and PPD are essential to battle the harmful UVB (skin cancer risks) and UVA (photo-aging risks).20 Daily use of a broad-spectrum sunscreen (SPF 30) over a one-year period has also been demonstrated to improve clinical parameters of photodamage in phototype I-III subjects.10 However, a comprehensive long-term sunscreen use study in skin of color is lacking. Therefore, this study was designed to assess the benefits of sunscreen of SPF30/PPD 20 in Hispanic women of Fitzpatrick skin types IV and V over 12 months in comparison to a real-life observational group with subjects who did not use sunscreen regularly.

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Discussions and Conclusions
Effective photoprotection is critical for healthy skin, in preventing skin cancers, reducing photodamage, and improving aesthetic appearance. A broad spectrum sunscreen protecting against both UVA and UVB irradiation is essential. Protecting against the UVA spectrum needs special attention, especially under daily diffused exposure, as UVA is more penetrating and less affected by seasonality and impacts photoaging and skin oxidative stress.22 It has been reported that in order to receive effective photoprotection on skin, a PPD value of 18 is desired.20 In this study, the investigational product with SPF 30/PPD 20 is considered sufficient for daily activity without prolonged direct sun exposure when applied properly. Concerning skin of color population, the use of sunscreen is lower than in Caucasians despite high prevalence of sun-related pigmentary disorders and rising rates of cutaneous cancers.4 This study provides strong evidence to educate and advocate for daily use of a proper sunscreen product for populations with high phototype skin.

The clinical evaluation demonstrated significant visible improvement in sunscreen group starting from 3 months and progressive increased over time. Benefits on multiple facial areas and body sites were visible (upper, mid- and lower face, neck, and hands), not only on pigmentary-related concerns (skin tone evenness, overall hyperpigmentation, dark spots, and blotchiness), but also on aging parameters such as fine lines, skin texture, and overall skin quality. This suggests that beyond the preventative benefits, long-term persistent use of a proper sunscreen may also allow the photodamaged skin to self-heal and repair over time.

Histological observations further supported the clinical findings. The observation that the real-life group had higher tendency for pigmentation incontinence is of strong research interest. It has been reported that UV irradiation can destabilize and damage the dermal-epidermal junction (DEJ), which facilitates the entrapment of melanin in the dermis.23 The dermal melanin is extremely difficult to remove, often resulting in stubborn hyperpigmentation.24 This is especially important for skin of color population in whom dermal hyperpigmentation lesions are common and can be worsened with excessive sun exposure. This study provides the first evidence that effective daily photoprotection can be a strategy to prevent dermal melanin formation by protecting the DEJ. A larger sample size study with DEJ biomarkers will help to further elucidate this hypothesis. Infiltration of CD68-positive Macrophages is a hallmark of the inflammatory response after UV irradiation. In the dermis, 2 out of 3 of the real-life biopsy samples showed significant increase in CD68 positive macrophage cells at 12 months compared to baseline, while such change was not observed in the sunscreen group. This suggests the potential preventative benefits of sunscreen in subclinical skin inflammation induced by chronic exposure to UV. In all of the histological evaluations, thegeographical location in which the study was conducted (Los Angeles versus Washington, DC) was not a strong contributing factor to any of the observed differences. However, the histological findings in this study are limited by the small number of biopsies obtained.

In summary, this 12-month study on long-term persistent use of an SPF30/PPD20 sunscreen on phototype IV and V subjects demonstrated significant improvement in skin quality and improvement in skin color and photoaging parameters. To our knowledge, this is the first study of this kind in skin of color and Hispanic population. This study confirms that effective sunscreen use is not only protective and beneficial for light skin population but is also critical in improving skin condition for skin of color patients. Overall, the study demonstrates that daily use of sunscreen can protect skin from photo related damage and even reverse some of the photo-damage that has already occurred in skin. In addition to previous studies that demonstrated the photo-protective properties of sunscreen use in normal and diseased skin states7,8,9,10 and in view of the fact that good photoprotection behaviors are not common among Hispanics,14,15,16 studies of this type can help educate and stress the importance of daily use of sunscreen and other sun protection behaviors in Hispanic and other skin of color populations.

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Annual Skin of Color Issue from the Journal of Drugs in Dermatology (JDD)

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US Dermatologists, Dermatology Residents and Dermatology NP and PAs can create a free account on JDDonline.com to read the following Skin of Color annual issue highlights:

Patient-focused Solutions in Rosacea Management: Treatment Challenges in Special Patient Groups by Ahuva Cices MD and Andrew F. Alexis MD MPH aims to expand awareness of the impact of rosacea on QoL of patients of all ages, genders, and skin types. (CE credit is available)

Myths and Knowledge Gaps in the Aesthetic Treatment of Patients With Skin of Color, Andrew Alexis, MD et al.,  identifies knowledge gaps and myths concerning facial aesthetic treatment in individuals with SOC.

An online study was designed to survey facial aesthetic concerns, treatment priorities, and future treatment considerations in 2 companion articles, Understanding the Female Hispanic and Latino American Facial Aesthetic Patient and Understanding the Female Asian American Facial Aesthetic Patient.

In Vitro and In Vivo Efficacy and Tolerability of a Non-Hydroquinone, Multi-Action Skin Tone Correcting Cream Pearl Grimes, MD evaluates an alternative to HQ for improving skin tone.

A Survey-Based Comparison of Sun Safety Practices in a Representative Cohort of the General Public Versus Attendees of a Skin Cancer Screening examines sun-protection practices.

Topical Ozenoxacin Cream 1% for Impetigo: A Review explores the challenges of treating impetigo and growing concern of antimicrobial resistance.

Uncommon localizations of PLEVA pose a diagnostic challenge in An Atypical Presentation of PLEVA: Case Report and Review of the Literature

 

Skin of Color Update Co-Chair Dr. Eliot Battle Shares Insights into 2019 Faculty and Topics

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Skin of Color Update Co-Chair, Dr. Eliot Battle, discusses the elite faculty lineup and topics planned this year including hair loss, keloids, rosacea, acne, lasers, aesthetic treatments, skin cancer, medical dermatology, melasma, hyperpigmentation, vitiligo, inflammatory diseases and much, much more!

Skin of Color Update 2019 (previously Skin of Color Seminar Series) is the largest CE event dedicated to trending evidence-based research and new practical pearls for treating skin types III – VI. Attendees leave with critical annual updates and fresh practical pearls in skin of color dermatology.

Join us this year in New York City, September 7-8, 2019! Register today at https://skinofcolorupdate.com/registration-hotel-2019/

Co-Chair Dr. Alexis Shares the Exciting 2019 Program Highlights

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Skin of Color Update 2019 (previously Skin of Color Seminar Series) is the largest CE event dedicated to trending evidence-based research and new practical pearls for treating skin types III – VI. Attendees leave with critical annual updates and fresh practical pearls in skin of color dermatology. Earn CE in New York City with direct access to elite experts and an experience unmatched by any other event in dermatology.

Medical Updates in Skin of Color

Medical Updates in Skin of Color

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During the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference, ANGELO LANDRISCINA, MD had the pleasure of taking part in the Resident Career Development Mentorship Program (a program supported by an educational grant from Sun Pharmaceutical Industries, Inc.). and was paired with Dr. Andrew Alexis, Co-Chair of the Skin of Color Update.

Dr. Alexis lectured on new developments in the treatment of skin of color focusing on two prevalent conditions: hyperpigmentation and central centrifugal cicatricial alopecia (CCCA). Below are Dr. Landriscina’s takeaways and pearls from this lecture.

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