Chronic Itch: Clinical Pearls

Gil Yosipovitch, MD

Dr Yosipovitch provides us with key takeaway points for managing patients with chronic itch…

  • Chronic itch is a disease on its own right and requires adequate treatment.
  • Anti histamines in most cases do not work for chronic itch
  • There are different types of chronic itch that include dermatologic, neuropathic systemic and psychogenic that require different treatment approaches.
  • Chronic itch is associated with peripheral and central nerve sensitization.
  • There is an imbalance of Mu opioids that over expressed versus kappa opioids in chronic itch and therefore drugs that are kappa opioid agonists and mu antagonists are effective for severe cases of itch.
  • Drugs that reduce nerve fiber sensitization such as gabapentin and pregablin and Selective serotonin and neuroepinephrine re- uptake inhibitors are effective for treatment of chronic itch.
  • Stress aggravates chronic itch and treatments that reduce stress including holistic approaches are important adjunct therapies for chronic itch.

More Clinical Pearls on Psoriasis

Joel Gelfand, MD

What about common comorbidities associated with psoriasis? Dr Gelfand highlights important clinical pearls…

  • The risk of comorbidities generally increases with the severity of psoriasis, patients with more severe disease have a 5 year reduction in life expectancy
  • Well established comorbidities associated with psoriasis include Heart Attack, Stroke, CV death, Metabolic syndrome, Diabetes, Psoriatic arthritis, Mood Disorders (anxiety, depression, suicide), Crohn’s Disease, and T cell lymphoma (rare)
  • Emerging comorbidities associated with psoriasis include Sleep apnea, Nonalcoholic steatohepatitis (NASH), Chronic obstructive pulmonary disease (COPD), Adverse infectious disease outcomes, Chronic and end stage renal disease, Peptic ulcer disease
  • Perform a skin biopsy if the diagnosis is not certain or if the patient is not responding appropriately to treatment. Connective tissue diseases and cutaneous T cell lymphoma can mimic psoriasis and may be exacerbated by psoriasis treatments
  • Putting a patient on an immune suppressive medication? Be sure to consider age appropriate cancer screening and vaccinations to lower the risk of complications

Social Media: Clinical Pearls

Jeffrey Benabio, MD

How does social media impact the clinician? How can we better utilize social media. Dr Benabio gives us some important insights…

  • Simply put, social media, refers to digital technologies that allow people to connect and to share information.
  • Over 60% of US adults read online reviews when seeking a new doctor, and 44% of those consider Yelp the most trusted review site.
Facebook, the behemoth of social networks, has 1.35 billion monthly active users.
  • 60% of social media users are likely to trust content posted by physicians online.
  • 18 to 24-year-olds are twice as likely than 45 to 54-year-olds to use social media for healthcare-related discussions.
  • Senior citizens are one of the fastest growing segments who use social media for their health information.
  • 90% percent of adults ages 18-24 say they would trust medical information shared by others in their social networks.
YouTube, which has over 1 billion unique visitors a month, reaches more US adults ages 18-34 than any cable network.

Pruritis: Clinical Pearls

Matthew J. Zirwas, MD

What are the key issues we should remember when managing an itchy patient? Dr Zirwas provides his clinical pearls…

  • Don’t go crazy with labs – they very rarely give an answer.
  • In itch with an underlying systemic cause, the underlying systemic is usually either obvious or is diagnosed prior to itch onset.
  • If you don’t have a definite diagnosis, address each entity in your differential one at a time.
  • Every adult with new onset severe itch and a non-specific rash should be treated for scabies, regardless of results of scabies prep.
  • Peppermint extract is cheap, available at most grocery stores, and can be mixed into any moisturizer or topical steroid to give immediate, short term itch relief.
  • Gabapentin is pretty reliably effective, but often need 600 mg tid to 900 mg tid.
  • Mirtazapine is very good for night-time itch but can cause significant weight gain.
  • Butorphanol nasal spray is VERY effective, but is a controlled substance because it has opioid effects.


Nail Disease: Clinical Pearls

Nat Jellinek, MD

Clinical Pearls from Dr Jellinek discussing an in-depth range of nail topics…

  • Longitudinal melanonychia may represent a heterogeneous group of conditions, from primary melanocytic causes to fungal/bacterial infections, hemorrhage, and exogenous causes, among others.  The dermatologist’s job is to diagnose nail melanoma.
  • Too often early nail melanoma, presenting as longitudinal melanonychia, is observed rather than biopsied.  Clinically differentiating benign from malignant is difficult.  Biopsy and pathologic examination remains the gold standard for diagnosis.  Earlier biopsies diagnose earlier melanoma.
  • Digital myxoid cysts represent ganglions from the DIPJ.  Most treatments, one way or another, involve scarring the stalk that extends from the joint to the tissues around the nail.
  • Nail squamous cell carcinoma is usually associated with HPV-16.  It is difficult to clinically differentiate refractory-to-treatment ungual/periungual warts from carcinoma.  Only biopsy with depth can make this diagnosis reliably.
  • Midline nail dystrophies are often confusing, with habit tic deformity and median canaliform dystrophy occasionally demonstrating overlap features.  Careful examination can usually distinguish the two.

Acne and Rosacea: Clinical Pearls

Guy Webster, MD, PhD

What you need to know about treating acne and rosacea…

  1. Isotretinoin absorption is very food dependent. An empty stomach causes a nearly 50% reduction in blood level.
  2. Antibiotic resistance has made macrolides useless in acne.
  3. Limiting antibiotic usage is critical for preserving antibiotic sensitivity.
  4. Use of topical retinoids early in acne therapy will allow withdrawal of antibiotics after a few months in many patients.
  5. Spironolactone and isotretinoin are two alternatives to antibiotics in severe acne.

Psoriatic Arthritis: Clinical Pearls

Arthur Kavanaugh, MD

Do you manage patients with psoriatic arthritis (PsA)? Dr Kavanaugh, a Rheumatologist at the University of California San Diego, highlights some important information in the area of PsA….

  • There is increasing evidence that early diagnosis and treatment of PsA results in improved outcomes.
  • There exists a large gap and unmet need in PsA, with many patients not being evaluated by doctors or receiving appropriate therapy.
  • Because skin manifestations usually precede joint involvement, often by years, Dermatologists play a key role in PsA diagnosis. However, this can present challenges.
  • New guidelines for PsA treatment are under development, and may provide some assistance to clinicians.
  • TNF inhibitors have allowed improved outcomes in PsA, and there continues to be great interest in optimizing therapy with these agents.
  • There is great interest in new targets and agents for the treatment of PsA. Recently revealed data with IL-17 inhibition show promise for treatment of all the various domains of PsA, including peripheral arthritis, skin and nail disease, enthesitis and dactylitis, and axial/spinal arthritis.
  • The IL-12/23 inhibitor ustekinumab was approved last year in PsA and has been shown to be effective across domains of disease.
  • The PDE4 inhibitor apremilast received FDA approval for PsA 3/21/14 and for psoriasis 9/23/14. Its use is increasing in the clinic, for diverse PsA patients. Safety is a particularly attractive feature of this drug.
  • Additional agents are in development for PsA.
  • Optimal management of PsA depends on the levels of activity and severity across the various domains of disease.

Psoriasis Update–Current Therapies: Clinical Pearls

Bruce Strober, MD, PhD

Below are some important clinical pearls from Dr Strober’s update on psoriasis:

  • Apremilast achieves PASI 75 in approximately 30% of patients after 16 weeks of therapy.
  • Apremilast has FDA-approval for the treatment of both psoriasis and psoriatic arthritis.
  • Apremilast also has been shown to provide improvement for nail and scalp psoriasis, and the reduction of pruritus.
  • Apremilast is associated with a >5% weight loss in between 10-20% of treated patients.
  • Data from the clinical trials of apremilast for the treatment of psoriasis do not convincingly support the contention that treatment with this drug causes depression and/or suicide.
  • Multiple independent registry studies show ustekinumab having the best durability of use, with patients remaining on this drug longer than other biologic and systemic drugs.
  • Rates of hospitalized infectious events are very low and fairly comparable between the various modalities, systemic and biologic, used to treat psoriasis.

Infectious Disease Update: Clinical Pearls

Stephen Tyring, MD, PhD, MBA

Dr Stephen Tyring provides us with key takeaway points from his presentation on Infectious Disease…

  • The recently approved HPV vaccine protects against 9 HPV types.
  • Helicase/primase inhibitors are safe and effective against HSV strains that have developed resistance to nucleoside inhibitors.
  • Therapeutic HSV vaccines are showing promise in clinical trials.
  • Coxsackievirus A6 is causing hand-foot-mouth disease in adults and producing more severe symptoms than in children.
  • Onychomadesis is a unique late sign of Coxsackievirus A6 infection.
  • Ebolavirus is a potentially lethal filovirus that produces mucocutaneous signs, e.g. ecchymoses and petechiae, late in the clinical course.
  • Ebolavirus is transmitted via infected body fluids.
  • Several new drugs and vaccines are being studied to manage ebola.
  • Chikungunya is a togavirus carried by mosquitoes that has spread rapidly throughout the Caribbean, southern United States and northern Latin America in the past year.
  • The most important symptoms of chikungunya are extreme joint pain and fever, and the most common cutaneous sign is erythematous macules.


Dermoscopy: Clinical Pearls

Ashfaq Marghoob, MD

Dermoscopy Clinical Pearls:

  • The presence of leaf-like and spoke wheel-like structures seen with dermoscopy is 100% specific for the diagnosis of basal cell carcinoma.
  • The presence of vessels arranged in a string of pearls pattern seen under dermoscopy is 100% specific for the diagnosis of clear cell acanthoma.
  • The presence of white blotches and strands within the same lesion seen with polarized dermoscopy is highly suggestive of basal cell carcinoma
  • Angulated lines forming a zigzag pattern or forming polygonal shapes is suggestive of pigmented actinic keratosis or lentigo maligna
  • The presence of any of the 10 melanoma specific structures in a melanocytic lesion should prompt consideration for a biopsy