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The use of cannabis for skin diseases and hair regrowth is at the preliminary stage., Legalization: Many countries have approved cannabis for medical use; however, four countries Canada, Uruguay, South Africa, and Georgia have legalized it for both medical and recreational purposes., The Endocannabinoid System: The endocannabinoid system may maintain skin homeostasis; two notable endocannabinoids include 2-Arachidonoylglycerol (2-AG) and N-arachidonoylethanolamine (AEA)., Routes of Administration and Pharmacokinetics: Topical cannabinoids can avoid the first-pass metabolism and reduce respiratory side effects; however, the high hydrophobicity of cannabinoids may hinder percutaneous absorption., Skin Disorders and Hair Growth: Human clinical studies suggest that cannabinoids may be used in eczema, acne, pruritus, and systemic sclerosis treatment. Cannabidiol (CBD) may enhance hair growth via multiple mechanisms., Safety: Topical cannabis may cause mild side effects such as pruritus, burning, erythema, and stinging; they are relatively safer than inhalation and oral cannabis. Cannabis use may be associated with allergic symptoms and reduced immune response to live vaccination., Cannabinoids in Practice: Despite growing interest, dermatologists should be cautious prescribing cannabinoids due to insufficient clinical data on both efficacy and safety., (© 2021 Wiley Periodicals LLC.)

The self-induced dermatoses represent about 2% of dermatology patient visits, and include the recurrent body-focused repetitive behaviors (BFRB) (skin-picking or excoriation disorder, trichotillomania, onychophagia and onychotillomania), dermatitis artefacta, and features of other psychiatric disorders, for example, secondary to excessive grooming in body dysmorphic disorder, skin picking in delusional infestation, or secondary to self-harm in depressive disease. Among the BFRBs, onychophagia and onychotillomania are most likely to be associated with lesions that mimic other dermatologic conditions (eg, nail psoriasis, lichen planus, vasculitis, onychomycosis, melanoma). Dermatitis artefacta (DA) describes lesions that are self-inflicted with the intention of assuming a sick role in the absence of obvious external rewards. DA lesions can be bizarre-appearing or may be created intentionally to mimic dermatologic disease (eg, Munchausen syndrome). The manipulation of the integument can have a focused obsessive-compulsive behavioral style which is more responsive to the standard behavior therapies, or an impulsive-dissociative style where patients have partial or no recollection of having self-induced their lesion; dissociative patients tend to have more severe BFRBs and DA, and greater psychopathology. Self-induced dermatoses may both imitate and co-occur with primary dermatologic disease, and may not be readily identified unless the clinician maintains an index of suspicion., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Several antiepileptic drugs (AEDs) are approved by the US Food and Drug Administration for the treatment of bipolar disorder (valproic acid, divalproex, lamotrigine, carbamazepine) and some cutaneous neuropathic pain syndromes (carbamazepine, gabapentin, pregabalin). The AEDs may be effective in the management of (1) chronic pruritus, including pruritus due systemic disease, including uremia, neuropathic pain, neuropathic pruritus, and complex cutaneous sensory syndromes, especially where central nervous system (CNS) sensitization plays a role; (2) management of emotional dysregulation and the resultant repetitive self-excoriation or other cutaneous self-injury in patients who repetitively stimulate or manipulate their integument to regulate emotions (prurigo nodularis, lichen simplex chronicus, skin picking disorder, trichotillomania); (3) management of dermatologic clinical manifestations associated with autonomic nervous system activation (hyperhidrosis, urticaria, flushing; these often occur in conjunction with psychiatric disorders with prominent autonomic activation and dysregulation, eg, social anxiety disorder, posttraumatic stress disorder); and (4) when certain anticonvulsants have a direct therapeutic effect (eg, in psoriasis); currently the use of AEDs for such cases is largely experimental. Gabapentin (dosage range 300-3600 mg daily) is the most widely studied AED mood stabilizer in dermatology and is especially effective in situations where CNS sensitization is a mediating factor. Further larger-scale controlled studies of AEDs in dermatology are necessary., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Antipsychotic drugs can be beneficial in dermatology because of their both central nervous system and peripheral effects. All antipsychotic drugs have a central postsynaptic dopamine D2 receptor blocking effect, which underlies their antipsychotic action. The antipsychotic drugs have varying degrees of histamine H1-receptor, cholinergic muscarinic receptor, and α1-adrenergic receptor blocking effects, which can affect cutaneous perception and the autonomic reactivity of the skin and can be potentially beneficial in the management of certain histamine or sympathetically mediated dermatologic manifestations (eg, urticaria, pruritus, hyperhidrosis). In addition to their antipsychotic effect, antipsychotic drugs also have a general anxiolytic effect related in part to their α1-adrenergic receptor blocking action, which can be of benefit in many dermatologic conditions, including pruritus. The antipsychotic drugs are most commonly used in dermatology for the management of a delusional disorder, somatic type, manifesting as delusional infestation, and as monotherapy or as augmentation therapy of selective serotonin reuptake inhibitor (SSRI) antidepressants, and for management of trichotillomania and skin-picking or excoriation disorder. There is earlier literature (1) on the possible beneficial effect of the phenothiazine antipsychotics in a wide range of pruritic dermatoses, and (2) the efficacy of pimozide as adjunctive therapy for metastatic melanoma, which both warrant further investigation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Obstructive sleep apnea (OSA) is present in at least 2% of women and 4% of men, and its prevalence is increasing, because a major predisposing factor for OSA is a high body mass index. Psoriasis has the most strongly substantiated link with OSA, where the relationship may be bidirectional. Dermatologic disorders may be comorbid with OSA due to several factors: (i) the heightened proinflammatory state in OSA, which can occur independent of body mass index, and may exacerbate inflammatory dermatoses; (ii) intermittent hypoxemia may promote neovascularization and tumor growth in certain cancers, such as melanoma; (iii) obesity, present in majority of OSA patients, can be associated with a heightened proinflammatory state; (iv) upper airway obstruction due to local tumors or soft tissue swelling due to physical urticaria or angioedema; (v) acute nasal congestion in the atopic patient with allergic rhinitis; (vi) dermatologic disorders associated with other OSA risk factors (eg, acanthosis nigricans and metabolic syndrome); and (vii) a high sympathetic tone (eg, in atopic dermatitis) and resultant sleep fragmentation contributing to upper airway instability during sleep. In many instances, the dermatology patient with OSA may have other medical and psychiatric comorbidities that are also associated with increased OSA risk., (Copyright © 2017 Elsevier Inc. All rights reserved.)

An assessment of suicidal behaviors in the dermatology patient may be necessary in several situations: (1) in the presence of psychiatric comorbidity (major depressive disorder, body dysmorphic disorder, substance use disorder, posttraumatic stress disorder), encountered in up to 30% of dermatology patients; (2) when dermatologic symptoms ("dysmorphophobia," dermatitis artefacta) represent psychiatric pathologic conditions; (3) when psychosocial stressors (bereavement, interpersonal violence) increase the risk of suicidal behavior and exacerbate stress-reactive dermatoses (psoriasis, acne); (4) in the presence of high disease burden (chronicity, increased disease severity); (5) in instances of significant pruritus or chronic sleep disruption; (6) in the presence of facial lesions or facial scarring; (7) when social exclusion or feelings of alienation arise secondary to the skin disorder; (8) with use of medications (retinoids, biologics) for which suicidal behavior has been implicated as a possible side effect; and (9) when treating psychiatric patients experiencing a serious reaction to psychotropic medications (eg, Stevens-Johnson syndrome and anticonvulsants). Suicide risk must be assessed within a demographic context because suicide rates rise rapidly in adolescents and young adults, among whom the prevalence of skin disorders associated with suicidal behaviors (acne, psoriasis, atopic dermatitis) is also high, and suicide rates are increasing among white men, who tend to be overrepresented in dermatology clinical trials., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Dermatologic symptoms can be associated with posttraumatic stress disorder (PTSD) in several situations: (1) as features of some core PTSD symptoms, such as intrusion symptoms manifesting as cutaneous sensory flashbacks, as autonomic arousal manifesting as night sweats and idiopathic urticaria, and as dissociation manifesting as numbness and dermatitis artefacta; (2) the cutaneous psychosomatic effects of emotional and physical neglect and sexual abuse (eg, infantile eczema, cutaneous self-injury, and body-focused repetitive behaviors such as trichotillomania and skin picking disorder) and eating disorders, which can have dermatologic effects; (3) the direct effect of physical or sexual abuse or catastrophic life events (eg, earthquakes) on the skin; and (4) as a result of significant alterations in hypothalamic-pituitary-adrenal and sympatho-adrenal medullary axes, which can affect neuroendocrine and immune functions, and can lead to exacerbations of stress-reactive inflammatory dermatoses such as psoriasis, chronic urticaria, and atopic dermatitis. Elevated levels of inflammatory biomarkers and impaired epidermal barrier function have been reported in situations involving sustained psychologic stress and sleep deprivation. Some PTSD patients show hypothalamic-pituitary-adrenal axis hyporesponsiveness and higher circulating T lymphocytes, which can exacerbate immune-mediated dermatologic disorders. PTSD should be considered an underlying factor in the chronic, recurrent, or treatment-resistant stress-reactive dermatoses and in patients with self-induced dermatoses., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Dissociation and conversion (defined as the somatic component of dissociation) can play an important mediating role in the exacerbation of the stress-reactive dermatoses (eg, psoriasis, idiopathic urticaria, atopic dermatitis), dermatoses that are exacerbated by excessive scratching (eg, lichen simplex chronicus, prurigo nodularis) and koebnerization, and the self-induced dermatoses (dermatitis artefacta, acne excoriée, skin picking disorder, trichotillomania, onychotillomania/onychophagia). Dissociative symptoms often coexist with obsessive-compulsive symptoms in the more severe cases of the self-induced dermatoses. Dissociation can play an important role in cutaneous sensory disorder (eg, scalp dysesthesia syndrome, stomatodynia/glossodynia, vulvodynia/scrotodynia, medically unexplained anesthesia). Dissociation typically occurs in the context of extreme psychosocial stress and a history of severe abuse/neglect during early life. Dissociative patients may experience a sense of detachment from their body and present in a state of extreme self-neglect, including denial of serious skin disorders. Amnesia is one of the core symptoms of dissociation; therefore, patients, who self-induce their skin lesions during a dissociative episode often deny self-inducing their lesions; it is important to recognize that this is distinct from malingering, and the lesions are not intentionally induced. Dissociation and conversion symptoms are typically present in the complex dermatology patient and should be assessed using a comprehensive biopsychosocial approach., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Increasing and inappropriate use of opioid analgesics (OA) have been declared a public health concern in the United States. There are no epidemiologic studies of OA use in skin disorders. We examined OA use in a nationally representative sample of US patient visits with only physician-diagnosed skin disorders., Methods: Retrospective cross-sectional study of 56 751 patient visits from 1995 to 2010 (International Classification of Diseases, 9th Revision, Clinical Modification codes 680-709 denoting "Diseases of the Skin and Subcutaneous Tissue"; 172, 173, 216 and 232 denoting malignant and benign skin neoplasms)., Results: An estimated 3.1% ± 0.2% of skin disorders visits were associated with OA use; 52.7% ± 5.4% were Schedule III opioids; 11.4% ± 1.4% of OA visits involved skin neoplasms and 45.4% ± 2.3% cellulitis and abscess. OA use increased from 1995 to 2010 (adjusted OR = 1.82, 95% CI: 1.49-2.22), even after controlling for increase in the frequency of skin infections from 1995 to 2010., Discussion: The most frequent use OA for cellulitis and abscess is entirely consistent with their Food and Drug Administration (FDA)-approved indications for pain management. The almost two-fold increase in OA use in skin disorders from 1995 to 2010 may suggest that OA are being considered for pain management earlier in therapy., Conclusions: Only a minority of patient visits with OA had primary dermatologic disease. OA are being used in dermatology primarily for FDA-approved indications.

Objectives: Sleep deprivation can physically affect skin appearance, e.g. increase the cutaneous signs of aging. There are no studies of sleep disorders and subjective ratings of skin appearance or cutaneous body image (CBI). CBI is an important consideration in the treatment of cosmetically disfiguring dermatologic disorders. We examined the association of insomnia and CBI., Methods: As part of a larger study, community-based non-clinical participants completed ratings of insomnia and CBI (also measured 4-weeks post-baseline) using the Cutaneous Body Image Scale (CBIS)., Results: 301/311 adults (238 women; mean ± SD age 38.6 ± 14.7 years; 54.5% married; 94.2% "white") completed insomnia and CBI ratings at baseline; 243/301 completed CBI ratings 4-weeks post-baseline. A low CBIS score denotes greater dissatisfaction with CBI. Multiple regression analysis using CBI at baseline as dependent variable and insomnia, age and sex as independent variables revealed that insomnia (β = -0.24, p < 0.001) and female gender (β = -0.25, p < 0.001) but not age (β = -0.097, p = 0.07) were predictors of CBI dissatisfaction (adjusted R(2 )= 0.15, p < 0.001). A similar relationship was observed for CBI ratings 4-weeks post-baseline., Conclusions: CBI dissatisfaction was positively related to insomnia severity, especially among women. Underlying insomnia may confound an individual's self-assessment of their CBI, a finding that has important treatment implications in dermatology.

Several diagnoses in the new DSM-5 chapter on 'Obsessive-Compulsive and Related Disorders' directly relate to psychodermatology. The new excoriation (skin-picking) disorder (SPD) and trichotillomania (TTM) both manifest as recurrent body-focused repetitive behaviors that have compulsive and dissociative features, the latter being more prevalent in TTM than SPD. The DSM-5 refers to SPD and TTM occurring without full awareness or preceding tension, however does not specifically mention the possible role of dissociation. This has important treatment implications, as patients with high dissociative symptoms are not likely to respond to the standard treatments for obsessive-compulsive disorder. Body dysmorphic disorder (BDD), which is frequently associated with cutaneous body image (CBI) dissatisfaction, is present in 9%-15% of dermatology patients. Treatment guidelines in dermatology are increasingly considering the psychosocial morbidity related to CBI in their treatment outcome measures. The presence of BDD, if unrecognized, may therefore directly affect the dermatologic treatment regimens offered to the patient.

There are no large-scale studies ofpolypharmacy (PP) in dermatology. The authors examined trends in PP (simultaneous use of > or = 4 medications in our study) and associated clinical factors among a nationally representative sample of 46,273 (weighted count +/- standard error [SE]: 617,970,596 +/- 25,187,959) dermatology-related (International Classification of Diseases, Ninth Revision, Clinical Modification codes 680-709) patient visits from 1995 to 2009. Data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey were examined. The overall frequency (+/- SE) of PP was 8.9% +/- 0.4%. There was almost a doubling in the frequency of PP in dermatology from 1995 to 2009 (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.67-2.44, after controlling for comorbidities and sex). This increase was noted among patients with > 1 diagnoses, and all age groups including the younger than 25 age category (PP frequency +/- SE, 7.4% +/- 0.4%; OR, 1.45; 95% CI, 1.12-1.88), and not just among patients in the geriatric age range with multiple complex dermatologic problems. Some of the most frequent conditions in the PP group included acne, psoriasis, atopic dermatitis, and infections of the skin and subcutaneous tissue, conditions that are known to be affected by psychodermatologic factors. PP among these patients may in part be an indication of their complex presentation caused by psychosocial vs dermatopathologic factors.

Objective: Cutaneous body image (CBI) dissatisfaction, feelings of social exclusion and stigmatization have been associated with increased suicidality in dermatology patients. We examined the relation between CBI dissatisfaction and suicidal ideation in a non-clinical sample, and examined the possible mediating effect of interpersonal sensitivity (IS), a symptom dimension related to self-consciousness, feelings of inferiority and social exclusion., Methods: As part of a larger study, 312 community-based participants from London, Ontario, Canada (241 women, 71 men; mean±SD age: 38.4±14.9years) rated their CBI satisfaction, measured with the Cutaneous Body Image Scale (Gupta MA et al., 2004). The Brief Symptom Inventory (BSI) (Derogatis L et al.,1982) was used to measure the constructs of suicidal ideation (4 suicide-related items from the BSI) and IS (Interpersonal Sensitivity subscale of BSI)., Results: Assessing mediation using the Baron & Kenny (1986) model, CBI satisfaction had a significant negative effect on suicidal ideation [c=-0.316, t(296)=-5.73, p<0.001] and IS [a=-0.365, t(297)=-6.76, p<0.001]; when CBI satisfaction and IS were considered together, IS had a significant positive effect on suicidal ideation (b=.690, t(295)=15.80, p<.001) while the effect of CBI satisfaction on suicidal ideation was no longer significant [c*=-.063, t(295)=-1.44, ns]., Conclusion: Our findings suggest an inverse relationship between CBI satisfaction and suicidal ideation, which is mediated by IS. This relationship likely falls in a continuum between non-clinical and clinical situations, with suicide risk being greater when individuals experience greater CBI dissatisfaction and social alienation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Cutaneous sensory disorder (CSD) represents a heterogeneous clinical situation where the patient presents with either disagreeable skin sensations (ie, itching, burning, stinging) or pain (ie, allodynia) and/or negative sensory symptoms (ie, numbness, hypoaesthesia). These patients have no apparent diagnosable dermatologic or medical condition that explains the cutaneous symptom, and typically have negative findings upon medical workup. Skin regions that normally have a greater density of epidermal innervation tend to be more susceptible to the development of CSD. CSDs can affect any body region but generally tend to be confined to the face, scalp and perineum, and have been referred to in the literature with region-specific terms such as burning mouth syndrome, glossodynia and vulvodynia. Symptoms such as pruritus with unexplained hyperhidrosis may occur during sleep, as a result of heightened sympathetic tone. Sleep deprivation and insomnia can play a moderating role in CSD. Somatization and dissociation can play a central role in the pathogenesis of CSDs. A review of the literature suggests that CSDs represent a complex, and often poorly understood interplay between neurobiological factors associated with neuropathic pain, neuropathic itch and neurologic/neuropsychiatric states (eg, radiculopathies, stroke, depression and posttraumatic stress disorder). These neurologic/neuropsychiatric states can modulate pain and itch perception by potentially affecting the pain and itch pathways at a structural and/or functional level.

Sleep is an active process that occupies about one-third of the lives of humans; however, there are relatively few studies of skin disorders during sleep. Sleep disruption in dermatologic disorders can significantly affect the quality of life and mental health of the patient and in some situations may even lead to exacerbations of the dermatologic condition. Sleep and skin disorders interface at several levels: (1) the role of the skin in normal sleep physiology, such as thermoregulation, core body temperature control, and sleep onset; (2) the effect of endogenous circadian rhythms and peripheral circadian "oscillators" on cutaneous symptoms, such as the natural trough in cortisol levels during the evening in patients with inflammatory dermatoses, which most likely results in increased pruritus during the evening and night; (3) the effect of symptoms such as pruritus, hyperhidrosis, and problems with thermoregulation, on sleep and sleep-related quality of life of the patients and their families; (4) the possible effect of primary sleep disorders, such as insomnia, sleep apnea, sleep deprivation, and circadian rhythm disorders, on dermatologic disorders; for example, central nervous system arousals from sleep in sleep apnea can result in increased sympathetic neural activity and increased inflammation; and (5) comorbidity of some dermatologic disorders with stress and psychiatric disorders, for example, major depressive disorder and attention deficit hyperactivity disorder (ADHD) that are also associated with sleep-related complaints. Sleep loss in atopic dermatitis (AD) is likely involved in the pathogenesis of ADHD-like symptoms in AD. Scratching during sleep, which may be proportional to the overall level of sympathetic nervous activity during the respective stages of sleep, usually occurs most frequently during non-rapid eye movement (NREM) stages 1 and 2 (vs stages 3 and 4 which are the deeper stages of sleep), and in rapid eye movement (REM) sleep, where the severity of scratching is similar to stage 2 sleep. Patient and parental reports of nocturnal itch and scratching in AD typically do not correlate with objective measures of scratching., (Copyright © 2013. Published by Elsevier Inc.)

It is well recognized that the clinical course of many dermatologic disorders is the result of a complex and sometimes reciprocal interaction between biological, psychiatric/psychological, and social factors that can have a predisposing, precipitating, and/or perpetuating role for the dermatologic disorder. Assessment of psychiatric and psychosocial comorbidity, which can be present in up to 30% of dermatology patients, is an important component of the overall clinical evaluation of the patient. This paper discusses a practical approach to the assessment of psychosocial and psychiatric factors, including suicide risk and parasuicidal behaviors in the dermatology patient. The approach further classifies these factors as predisposing, precipitating, and/or perpetuating, in order to aid the clinician with the possible secondary and tertiary prevention of some dermatologic disorders by management of their psychosocial and psychiatric comorbidity., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Cutaneous body image (CBI), defined as the individual's mental representation of his or her skin, hair, and nails, is an important clinical factor in dermatologic disorders and often the primary consideration in deciding whether to proceed with cosmetic procedures or institute treatment in some skin disorders such as acne. CBI is a highly subjective construct that can be significantly confounded by cultural, psychosocial, and psychiatric factors. Assessment of CBI in the dermatology patient is best accomplished using a biopsychosocial model that involves (1) evaluation of concerns about the appearance of the skin, hair, and nails, (2) assessment of comorbid body image pathologies, especially body dysmorphic disorder, and (3) assessment of other psychiatric comorbidities such as major depressive disorder that can confound the presentation of the CBI complaint. Depending on the psychiatric comobidities, an assessment of suicide risk may have to be done, and if necessary, a referral made to a mental health professional. The clinician should consider the patient's developmental stage (eg, body image concerns are likely to be much greater in the adolescent patient independent of his or her dermatologic disorder) and sociocultural background (eg, a desire for lighter skin in some ethnic groups), factors that can also have a major effect on CBI., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The occurrence of depression in association with dermatologic disease is common. Psychiatric disturbance is reported in approximately 30% of dermatology patients. Depression can have varied presentations and is more relevant clinically in dermatology patients during critical psychosocial periods of development. Early recognition and treatment of depression associated with skin disorders can lead to improved therapeutic outcomes and may avert disastrous outcomes, including suicide.

Over one third of dermatologic disorders have significant psychiatric comorbidity. The impact of the skin disorder on quality of life, the role of psychosocial stressors, and use of substances should be assessed. Major depressive disorder is the most frequently encountered psychiatric disorder in dermatology and is often associated with suicide risk. Other psychiatric syndromes comorbid with dermatologic disorders include obsessive-compulsive disorder, social phobia, posttraumatic stress disorder associated with dissociation and conversion symptoms, body image pathologies, delusional disorder, and a wide range of personality disorders. This article reviews psychiatric guidelines that may be used to assess psychopathology in the dermatology patient.

Background: Imiquimod is a topical immunomodulator that is indicated for the treatment of external genital and perianal warts. This drug has been recently approved for the treatment of actinic keratoses and superficial basal cell carcinoma. There is a growing body of evidence for its effectiveness in treating a variety of other skin conditions., Objective: This review examines the role of imiquimod 5% cream in the treatment of skin diseases such as actinic keratoses, basal cell carcinoma, Bowen's disease, lentigo maligna, and extramammary Paget's disease., Methods: Published literature containing the words "Imiquimod" or "Aldara" was reviewed and summarized., Results: This agent has demonstrated indirect antiviral and antitumor effects in animal models. Although the exact mechanism of action is unknown, imiquimod is an agonist for toll-like receptor (TLR) 7 and is thought to act by inducing cytokines, such as interferon alpha (IFN-alpha), interleukin-12 (IL-12), and tumor necrosis factor alpha (TNF-alpha). These cytokines trigger the immune system to recognize the presence of a viral infection or tumor and the associated lesion is ultimately eradicated. Side effects are generally well tolerated with local skin reactions reported most frequently., Conclusion: Imiquimod has been shown to be a safe and effective treatment for a variety of skin conditions.

Sulfur has antifungal, antibacterial, and keratolytic activity. In the past, its use was widespread in dermatological disorders such as acne vulgaris, rosacea, seborrheic dermatitis, dandruff, pityriasis versicolor, scabies, and warts. Adverse events associated with topically applied sulfur are rare and mainly involve mild application site reactions. Sulfur, used alone or in combination with agents such as sodium sulfacetamide or salicylic acid, has demonstrated efficacy in the treatment of many dermatological conditions.

Background: Infliximab is a chimeric monoclonal antibody that binds specifically to human tumor necrosis factor-alpha (TNF-alpha), decreasing the effect of the cytokine in inflammatory diseases., Objective: The aim of this study was to review the efficacy and safety of infliximab in the treatment of dermatological diseases., Methods: A MEDLINE search (1966-January 2003), using the keyword "infliximab" was performed to find relevant articles pertaining to the use of infliximab in dermatology., Results: Infliximab has been used in the following dermatological diseases: psoriasis, Behcet's disease, graft versus host disease, hidradenitis suppurativa, panniculitis, pyoderma gangrenosum, SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome, sarcoidosis, subcorneal pustular dermatosis, Sweet's syndrome, toxic epidermal necrolysis, and Wegener's granulomatosis. There is a generally good safety profile for infliximab, which is similar to that when it is used to treat Crohn's disease and rheumatoid arthritis., Conclusion: Although not approved for use in dermatological diseases, there have been numerous reports of the efficacy of infliximab in cutaneous inflammatory diseases. The most promise lies in those diseases that have increased amounts of TNF-alpha in the cutaneous lesions, such as psoriasis.

Photodynamic therapy is a non-invasive technique used in the treatment of skin diseases which has various advantages, one being the ability to localize treatment to the area being treated, which is common among most photosensitizers. Aminolevulinic acid is a prodrug that is metabolized intracellularly to form the photosensitizing molecule protoporphyrin IX (PpIX). When PpIX is activated by light, cytotoxic reactive oxygen species and free radicals are generated. This phototoxic effect may cause malignant and non-malignant hyperproliferative tissue to be destroyed, to decrease in size, and to eventually disappear. The application of topical aminolevulinic acid 20% followed by the use of a blue light photodynamic therapy illuminator is indicated in the US for the treatment of non-hyperkeratotic actinic keratoses of the face or scalp. There are data suggesting that aminolevulinic acid/photodynamic therapy may also be beneficial in acne vulgaris, verrucae, psoriasis, mycosis fungoides, and human papillomavirus. This treatment modality has also proven effective in the management of skin cancer such as, Bowen disease and basal cell carcinoma. Further experience in the use of photodynamic therapy will help define its utility in the management of actinic keratosis and other dermatoses.

Psychiatric and psychological factors play an important role in at least 30% of dermatologic disorders. In many cases the impact of the skin disorder upon the quality of life is a stronger predictor of psychiatric morbidity than the clinical severity of the disorder as per physician ratings. Furthermore, in certain disorders such as acne and psoriasis, the psychiatric co-morbidity, which can be associated with psychiatric emergencies such as suicide, is an important measure of the overall disability experienced by the patient. The severity of depression and increased suicide risk are not always directly correlated with the clinical severity of the dermatologic disorder. Consideration of psychiatric and psychosocial factors is important both for the management, and for some aspects of secondary and tertiary prevention of a wide range of dermatologic disorders. It is useful to use a biopsychosocial model which takes into account the psychological (e.g. psychiatric comorbidity such as major depression and the impact of the skin disorder on the psychological aspects of quality of life) and social (e.g. impact upon social and occupational functioning) factors, in addition to the primary dermatologic factors, in the management of the patient. Some dermatology patients are likely to benefit from psychotherapeutic interventions and psychotropic agents for the management of the psychosocial comorbidity, in addition to the standard dermatologic therapies for their skin disorder.

Background: The use of psychological therapies in dermatology is being increasingly recognized because stress and negative emotions are major factors in a wide range of dermatologic disorders. Eye movement desensitization and reprocessing (EMDR) is a relatively new psychological intervention which was first described to be effective in post-traumatic stress disorder, a condition associated with extremely stressful life situations., Objective: We evaluated the efficacy of EMDR in primary dermatologic disorders where psychological stress plays an important part in the pathogenesis of the disorder, and in clinical situations where the dermatologic symptom is the feature of a stress-related psychiatric disorder., Methods: Four patients (two patients with atopic dermatitis and psoriasis, respectively, whose symptoms were exacerbated by stress, one patient with acne excoríee associated with body image pathology as a result of childhood emotional abuse, and one patient with generalized urticaria associated with post-traumatic stress disorder) were treated using the standard EMDR protocol with 3-6 sessions for a period ranging from 4 to 12 weeks, and followed up for 6-12 months after the end of EMDR therapy., Results: All 4 patients experienced a marked improvement in their symptoms after 3-6 sessions of EMDR, within a period of

The recent emergence of monkeypox poses a life-threatening challenge to humans and has become one of the global health concerns after COVID-19. Currently, machine learning-based smart healthcare monitoring systems have demonstrated significant potential in image-based diagnosis including brain tumor identification and lung cancer diagnosis. In a similar fashion, the applications of machine learning can be utilized for the early identification of monkeypox cases. However, sharing critical health information with various actors such as patients, doctors, and other healthcare professionals in a secure manner remains a research challenge. Motivated by this fact, our paper presents a blockchain-enabled conceptual framework for the early detection and classification of monkeypox using transfer learning. The proposed framework is experimentally demonstrated in Python 3.9 using a monkeypox dataset of 1905 images obtained from the GitHub repository. To validate the effectiveness of the proposed model, various performance estimators, namely accuracy, recall, precision, and F1-score, are employed. The performance of different transfer learning models, namely Xception, VGG19, and VGG16, is compared against the presented methodology. Based on the comparison, it is evident that the proposed methodology effectively detects and classifies the monkeypox disease with a classification accuracy of 98.80%. In future, multiple skin diseases such as measles and chickenpox can be diagnosed using the proposed model on the skin lesion datasets. [ABSTRACT FROM AUTHOR]

Methicillin-resistant Staphylococcus aureus (MRSA) infections occurring within communities are increasing and can affect healthy individuals who have had little to no experience with hospital or healthcare settings (community-associated MRSA, CA-MRSA). CA-MRSA infections have multiple presentations which can make diagnosis and timely treatment difficult yet often manifest as a skin and soft tissue infection (SSTI) requiring dermatological intervention. There is emerging evidence of multiple environmental sources of bacteria that may contribute to recurrence. As with other infections, preventing transmission and recurrence depends on adherence to hand-washing and personal hygiene practices. Pharmaceutical intervention should be culture- rather than empirically-guided. The goal of this review is to provide dermatologists with a brief summary of the diagnostic features of CA-MRSA infections and updated strategies for management and prevention of transmission and recurrence of CA-MRSA infections, infections likely to present to dermatology offices. [ABSTRACT FROM AUTHOR]

In December of 2002, the FDA approved azelaic acid 15% gel for the topical treatment of inflammatory papules and pustules of mild to moderate rosacea. Azelaic acid is a saturated dicarboxylic acid, which is naturally occurring and has been used in the treatment of rosacea, acne, and melasma. The 15% gel has a high efficacy and is generally well tolerated, with the local irritation (burning, stinging, itching, and scaling) being typically mild and transient. Azelaic acid 15% gel is considered effective and safe as a therapy for inflammatory papulo-pustular rosacea and is suitable for use on all skin types. [ABSTRACT FROM AUTHOR]

Background: Rosacea is a common chronic skin and ocular condition. It is unclear which treatments are most effective. We have conducted a Cochrane review of rosacea therapies. This article is a distillation of that work. Objective: We sought to assess the evidence for the efficacy and safety of rosacea therapies. Methods: Multiple databases were systematically searched. Randomized controlled trials in people with moderate to severe rosacea were included. Study selection, assessment of methodologic quality, data extraction, and analysis were carried out by two independent researchers. Results: In all, 29 studies met inclusion criteria. Topical metronidazole is more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95-12.06). Azelaic acid is more effective than placebo (odds ratio 2.45, 95% confidence interval 1.82-3.28). Firm conclusions could not be drawn about other therapies. Limitations: The quality of the studies was generally poor. Conclusions: There is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. More well-designed, randomized controlled trials are required to provide better evidence of the efficacy and safety of other rosacea therapies. [Copyright &y& Elsevier]

Abstract: Objective: We examined the relation between medically unexplained cutaneous symptoms and dissociation [measured by the Dissociative Experiences Scale, or DES; Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986;174:727–35] among participants with no history of primary dermatologic disorders. Methods: Three hundred sixty consenting participants (44 psychiatric outpatients and 316 nonclinical participants from the community at large) rated the severity of nine medically unexplained cutaneous symptoms (sum of all ratings comprised the Cutaneous9 variable) and completed the DES. Results: The Cutaneous9 variable correlated significantly (Pearson r=.56, P<.001) with DES scores. Stepwise multiple regression analysis using the nine cutaneous symptoms as independent variables revealed that Pain, Itching, and Numbness were the best predictors of the DES scores (adjusted R 2=.34, P<.001). Conclusion: Our findings have empirically shown that itching, like pain and numbness, may be a symptom of somatoform dissociation. Second, even milder degrees of dissociation in the nonclinical range may play a role in the genesis of unexplained cutaneous sensory symptoms. [Copyright &y& Elsevier]

Abstract: The human and animal pathogenic yeast genus Malassezia has received considerable attention in recent years from dermatologists, other clinicians, veterinarians and mycologists. Some points highlighted in this review include recent advances in the technological developments related to detection, identification, and classification of Malassezia species. The clinical association of Malassezia species with a number of mammalian dermatological diseases including dandruff, seborrhoeic dermatitis, pityriasis versicolor, psoriasis, folliculitis and otitis is also discussed. [Copyright &y& Elsevier]

Actinic keratosis lesions occur frequently on sun-exposed skin of Caucasians. They become more prevalent with advancing age and are important in identifying the risk factor of those people possibly predisposed to invasive squamous cell carcinoma. Topical therapies are useful alternatives to cryotherapy for treating diffuse actinic damage and a number of preparations have been developed for treating actinic keratosis. A cumulative meta-analysis was performed to determine the efficacy of imiquimod 5% cream, which presents a new alternative topical therapy for actinic keratosis, and to compare it to 5-fluorouracil for the treatment of actinic keratosis lesions of the face and scalp. We searched MEDLINE (1966 to October 2004) for relevant studies evaluating the efficacy of actinic keratosis topical agents imiquimod and 5-fluorouracil (0.5%, 1%, and 5%). Studies included in this meta-analysis required a dosage regimen that was not significantly different from that approved by Health Canada and the U.S. FDA. Studies also required a well-defined treatment duration and followup period, with the primary efficacy variable being the complete (100%) clearance of all actinic keratosis lesions defined as the proportion of patients at followup with no clinically visible lesions in the treatment area. To determine the average efficacy rate for both drugs, the data from each study were combined for that drug. Ten studies were included in the analysis. The average efficacy rate for each drug (with 95% confidence interval) was 5-fluorouracil, 52 ± 18% ( n = 6 studies, 145 subjects) and imiquimod, 70 ± 12% ( n = 4 studies, 393 subjects). The results of this meta-analysis show that both imiquimod and 5-fluorouracil are effective methods for the treatment of actinic keratosis and provide a useful alternative to cryotherapy. However, this analysis suggests that imiquimod may have higher efficacy than 5-fluorouracil for actinic keratosis lesions located on the face and scalp and therefore provides another option to dermatologists. [ABSTRACT FROM AUTHOR]

Actinic keratosis is the third most common reason for dermatologist visits in the US. Treatments include local excision or destruction by means of cryotherapy or curettage, chemical destruction by topical fluorouracil cream and solution, photodynamic therapy with aminolevulinic acid, immunotherapy using imiquimod cream, or using the NSAID, diclofenac gel. A Medline search from 1966 to March 2003 was performed using the search terms ‘solar keratosis’, ‘senile keratosis’, ‘senile hyperkeratosis’, and ‘actinic keratosis’, to identify clinical trials and review papers. This review provides an overview of the literature focussing on clinical trials and the efficacy of the following fluorouracil formulations currently approved by the US FDA: 0.5% cream, 2% solution, and 5% cream and solution. Treatments with fluorouracil may evoke the characteristic inflammatory reaction and irritation which includes erythema, burning, and dryness. The degree and duration of these adverse effects can vary with the formulation, the application regimen, and the patient. Each of the fluorouracil formulations, photodynamic therapy and 3% diclofenac, are effective and safe in the management of actinic keratosis. The topical therapies present viable treatment alternatives for actinic keratosis lesions. Conventional surgical methods are still the most popular treatment among physicians, however, surgery has its disadvantages and is better suited for certain cases, such as for hyperkeratotic or discrete lesions. Studies designed to follow patients treated with topical fluorouracil cream for ≥1 year post-treatment are needed to evaluate the regression, recurrence and appearance of new actinic keratosis lesions. [ABSTRACT FROM AUTHOR]

Provides information on the pathogenesis of psoriasis. Activation of several types of leukocytes that control cellular immunity; T-cell dependent inflammatory processes in skin that accelerate the growth of epidermal and vascular cells in psoriasis lesions; Longer-lasting remission provided by mechanisms that reduce T-cells in skin lesions; Quality of life and cost issues associated with psoriasis; Ways to assess the severity of the disease; Elements of the psoriasis area and severity index (PASI); Reduction of disability associated with psoriasis.

Background: Topical steroids have been a popular choice for treating various cutaneous disorders; however, the potential for significant local and systemic adverse events, like skin atrophy and hypothalamic-pituitary-adrenal (HPA) axis suppression, has limited their use. Objective: This article reviews the topical steroid prednicarbate through its mechanism of action, clinical efficacy, and adverse events profile. Methods: Published literature containing the word ‘prednicarbate’ was examined anti summarized. Results: Prednicarbate is a nonhalogenated, double-ester derivative of prednisolone that has been used in the treatment of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses such as atopic dermatitis. It has a favorable benefit risk ratio, low skin atrophy potential, and high and-inflammatory action. Conclusion: These characteristics make prednicarbate an ideal alternative agent for children, elderly patients, and those who require long-term intermittent treatment. [ABSTRACT FROM AUTHOR]

To investigate the distribution of Malassezia species on four body sites (scalp, forehead, chest and back), we employed contact plates filled with Leeming-Notman agar to sample 245 clinically healthy subjects, representing six age groups (AG) (AG I, 0-3 years; AG II, 4-14 years; AG III, 15-25 years; AG IV, 26-40 years; AG V, 41-60 years; AG VI, over 60 years). The number of colony forming units was recorded for every plate positive for Malassezia species, and the species were identified. Younger individuals (<14 years) yielded a culture positive for Malassezia significantly less frequently than did older individuals (≥15 years). M. globosa was cultured at significantly elevated frequency on younger subjects. M. sympodialis was present at low frequency on younger subjects, but was found in higher amounts on the skin of adolescents and adults. The amount and kind of Malassezia species that can be recovered from human skin varies with age and body site. [ABSTRACT FROM AUTHOR]

Background. Antifungal agents are beneficial in the treatment of onychomycosis in the general population, as well as in children, the elderly, and immunocompromised individuals. Special patient populations can be more difficult to treat due to such factors as drug interactions with concomitant medications, adverse events, and poor compliance. In addition, there is limited information about the use of antifungal agents in special populations, e.g., children. Objective. The pros and cons of oral and topical antifungal agents are discussed, with focus on special patient populations. Methods. We searched MedLine (1966 to April 2003) for clinical studies evaluating the efficacy of oral and topical antifungal agents to treat onychomycosis. The key words used in conjunction with “onychomycosis” include: “terbinafine,” “itraconazole,” “fluconazole,” “amorolfine nail lacquer,” “ciclopirox nail lacquer,” “HIV,” “transplant patients,” “diabetes,” “children,” and “elderly.” Studies were excluded if published in a language other than English. Results. Studies have shown that antifungal agents can be of benefit in treating the elderly, children, and immunocompromised individuals (e.g., transplant patients, Down’s patients, HIV patients, and diabetics) with onychomycosis. Conclusion. The treatment modality of onychomycosis in special patient populations should take into account the clinical presentation of the onychomycosis, the causative organism, patient and physician preference, the concomitant medications that the patient is on, and the potential for adverse events for that patient if antifungal therapy is undertaken. [ABSTRACT FROM AUTHOR]

Objective: The quality of original clinical trial publications pertaining to the use of oral antifungal agents to treat onychomycosis was evaluated using predetermined criteria. Methods: The list of studies included in this analysis was determined by conducting a search in Medline. For each clinical trial, two independent reviewers each determined a composite score by evaluating a list of criteria that were felt to represent a good study, for example, randomization and blinding, prior sample size calculated, and treatment regimen clearly explained. A citation count was performed to determine whether higher-quality papers were cited more often than lower-quality papers. Results: Forty-five studies were included in this quality analysis of study design. Of these, 27 were considered to be “high quality” (score greater than or equal to 11 out of 20). A significant correlation coefficient of 0.997 was found between the two reviewers (P < 0.00001). Higher-quality papers were cited significantly more often than lower-quality papers (P = 0.03). Conclusion: The scale that we use to evaluate the quality of onychomycosis studies has high interrater reliability. According to this scale, many published studies (18 out of 45) pertaining to treatments for onychomycosis do not meet the criteria required to be considered “high quality.” [ABSTRACT FROM AUTHOR]

Focuses on dermatological complications associated with eating disorders. Skin diseases arising from disordered eating behavior; Skin complications brought about by self-induced vomiting; Complications associated with drugs consumed to lose weight.

AbstractBackground Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV). Objective To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed. Method One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded. Results Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34.7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 × 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 × 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mm/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group. Conclusions A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection. [ABSTRACT FROM AUTHOR]

Tumor promoting phorbol esters, such as 12-0-tetradecanoylphorbol-13-acetate (TPA), when applied topically to mouse skin cause inflammation and hyperplasia. The major cellular phorbol ester receptor is a calcium and phospholipid dependent protein kinase, protein kinase C (PK-C). PK-C is directly activated by TPA and most of the responses of cells to TPA appear to be mediated by PK-C. This suggests that PK-C may play a key role as a mediator of inflammation and growth in TPA treated mouse skin. Sphingosine has been reported to be a potent inhibitor of PK-C in vitro and in intact leukocytes. We therefore have investigated the effects of sphingosine upon TPA-induced inflammation, hyperplasia, induction of ornithine decarboxylase (ODC) activity and ODC mRNA, and activation of PK-C in mouse skin. The results demonstrate that sphingosine is a potent inhibitor of all of the TPA-induced responses examined. These data are compatible with the hypothesis that PK-C is a major mediator of the phorbol ester response in mouse skin. Furthermore, PK-C inhibitors may have therapeutic potential in inflammatory skin diseases such as psoriasis. [ABSTRACT FROM AUTHOR]

The impact of psoriasis upon the quality of life contributes significantly to the overall morbidity associated with the disease. The impact of psoriasis on the quality of life con- tributes significantly to the morbidity associated with the disease and may in turn adversely affect its course. The psychosocial morbidity associated with psoriasis has been rated by patients as the worst feature of their condition. The authors propose, that the chronologically older patients as a group, had a more extensive life-experience than patients with early onset psoriasis, which resulted in better emotional adjustment and mitigated the psychosocial impact of their disease.

In a randomized, double-blind, placebo-controlled study, patients received 10 fish or olive oil capsules three times daily for the whole study in addition to applying betamethasone diproprionate to their psoriatic plaques for the first 3 weeks. Most patients gradually worsened upon discontinuation of corticosteroids. Using survival analysis methods, no significant difference was found between the fish and olive oil groups. The authors attempt to put the role of fish oil in the therapy of psoriasis into perspective and discuss the efficacy of fish oil when used alone versus in combination therapy. [ABSTRACT FROM AUTHOR]

Canthaxanthin is used as a food-coloring agent, a photoprotective agent in certain photodermatoses, a tansimulating agent, and a pigment to darken vitiliginous skin. This article reviews the current literature on canthaxanthin and reports the evaluation of oral canthaxanthin as an artificial pigment for the management of vitiligo. Fifty-six patients were studied, using serum canthaxanthin levels, pre- and post-treatment photographs with standard conditions, physician assessment, and patient questionnaires evaluating treatment results. Canthaxanthin was rated ‘very satisfactory’ by 10%, ‘satisfactory’ by 35%, and ‘unsatisfactory’ by 54% of patients. In light-skinned individuals, self-reports were ‘very satisfactory’ in 27%, ‘satisfactory’ in 45%, and ‘unsatisfactory’ in 27%. In dark-skinned individuals, the treatment was less effective. Women were happier with the results than men. Major side effects were red stools and orange palms and soles. Canthaxanthin can be taken orally, is easy to use, and can be a cosmetically acceptable therapy in selected cases of vitiligo. [ABSTRACT FROM AUTHOR]

Atrophie blanche can be a chronic condition for which there is no satisfactory treatment. Two patients with atrophie blanche who had not responded to various therapeutic modalities were given a trial of sulfasalazine 1 g three times daily. The ulcers healed within 3 months in both cases. In view of these positive results, patients should be treated with sulfasalazine to determine the efficacy of this drug is atrophie blanche. [ABSTRACT FROM AUTHOR]