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Introduction Psoriasis (Pso) is a common, immune-mediated, chronic-relapsing, inflammatory skin disease. While a great deal is known about Pso and its treatment, there remain several treatment scenarios unaddressed by clinical studies. To be effective, treatment for Pso must alter the activity of one or more immunological pathways important in the pathogenesis of the disease. While the benefit of blocking these pathways may be apparent, there remain uncertainties regarding safety, such as infections, malignancies, and the potential for off-target effects. Existing guidelines and treatment recommendations rely primarily on clinical trial or observational data, none of which adequately address specific clinical challenges. This document describes a methodological framework for generating practical and clinically relevant guidance for situations where direct evidence is rare or absent. Guidelines implementing this framework are currently ongoing. Methods We develop a knowledge synthesis approach to guideline development, utilizing clinical trial data where available, and a formalized inferential decision-making process that considers indirect data coupled with structured expert opinion and analysis. This approach is best suited for situations where direct, high-level evidence is lacking. Support for each resultant recommendation is expressed as a quantified assessment of confidence. Results The topics to be addressed by this set of guidelines are ranked by clinicians and patients as areas of concern, with an emphasis on topics where high-level evidence may have limited availability. Conclusion Through this novel approach, we will derive practical, informative recommendations using the best evidence available in combination with structured expert opinion to guide best practices in complex, real-world settings. Supplementary file2 (MP4 98653 kb) Supplementary Information The online version contains supplementary material available at 10.1007/s13555-021-00642-5., Plain Language Summary Clinical guidelines aim to assist doctors in managing their patients’ medical conditions. A limitation of current guidelines is that they are frequently based on randomized clinical research trials—often considered the gold standard in medical research. Clinical trials are designed to estimate the safety and effectiveness of treatment. Outside of clinical trials, doctors encounter a range of patient cases excluded from clinical trials. Our group aims to create guidelines for those clinical scenarios not adequately addressed by clinical trials. Examples include patients excluded from clinical trials, the elderly, patients with human immunodeficiency virus (HIV), and pregnant or breastfeeding women. When clinical trial data is limited, doctors must make decisions nonetheless. In certain clinical situations they are left to their own resources to consult with experts, review the data, and make inferences based on the limited data available. Instead of concluding that there is no data, the topic of interest can be broken down into components that are answerable by different types of research studies. This inference-based approach uses expert opinion and indirect evidence to support an inference-based position on topics where direct clinical data is sparse or insufficient to answer the question. This approach can be used as a complement to clinical trial data informing disease management guidelines. Supplementary Information The online version contains supplementary material available at 10.1007/s13555-021-00642-5.

Extracorporeal photopheresis (ECP) is an immunomodulatory therapy that has been used for over 35 years to treat numerous conditions. ECP was initially approved by the US FDA in 1988 for the treatment of Sézary syndrome, a leukemic form of cutaneous T-cell lymphoma (CTCL). Although CTCL remains the only FDA-approved indication, ECP has since been used off-label for numerous other conditions, including graft-versus-host disease (GvHD), systemic sclerosis, autoimmune bullous dermatoses, Crohn's disease, and prevention of solid organ transplant rejection. In Canada, ECP is mainly used to treat CTCL, acute and chronic GvHD, and in some instances systemic sclerosis. Herein, we review the current concepts regarding ECP mechanism of action, treatment considerations and protocols, and efficacy.

Background Since its legalization in Canada, cannabis use has expanded to include commercially available topical formations. Several scientifically unsupported claims regarding the therapeutic efficacy of topical cannabis are also being made. Developing an understanding of the consumer uses of topical cannabis is important for clinicians to provide appropriate counseling and inform potential areas of therapeutic development. We are examining the prevalence, purpose of use, and sources of information regarding topical cannabis in the Canadian population, with a focus on dermatologic uses. Method A cross-sectional, anonymous electronic, voluntary survey was developed to assess the use of topical cannabis amongst adults in Canada. Results Cannabis was used topically at least once by 24.3% of respondents who started the survey. The commonest form of topical cannabis were creams (26.2%). The most common dermatologic conditions being treated with topical cannabis included atopic dermatitis (25%), acne (19%), and anti-aging (16%); for non-dermatologic conditions, common uses were for joint stiffness or tendonitis (30%) and headaches and migraines (27%). Topical cannabis was reported to be most effective for joint stiffness and tendonitis, general muscular soreness, headaches, eczema, pruritus, acne, and psoriasis. Most respondents obtained and received information about topical cannabis from dispensaries. Conclusion Canadians use topical cannabis for a broad range of systemic and dermatologic purposes, most of which have limited evidence. Future clinical studies are required to elucidate the therapeutic efficacy and safety of topical cannabis. Dermatologists should screen their patients for topical cannabis use and be aware of the limited evidence of therapeutic potential.

Introduction An estimated 2–4% of Western populations are thought to have psoriasis, with a regional incidence ranging from 0.09% to 11.43%. Variance in estimates is a result of differences in study populations, methodology, regional differences, and definitions of disease. Reliable prevalence estimates of plaque psoriasis are challenging to establish. Further, the distribution of psoriasis severity in the population is unknown. This study aims to establish the utility of expert elicitation (EE) as a method for estimating unknown parameters in dermatology by (1) estimating the prevalence of psoriasis in the adult population, and (2) estimating previously unknown disease severity distribution. Methods An expert panel of 11 Canadian dermatologists with demonstrated expertise in psoriasis was formed. A proof-of-concept EE exercise estimated psoriasis prevalence in the general population in Canada, followed by estimation of psoriasis disease severity distribution by body surface area (BSA). Expert estimates were consolidated using Bayesian methods to statistically model the data and represent uncertainty. Results The median prevalence of psoriasis in the adult population using the Bayesian estimate was 3.0% (95% credibility interval, 2.7–3.3%), compared with the estimated mean prevalence of 3.4% (95% confidence interval, 2.2–4.9%). By EE, the estimated cumulative distribution of disease severity assessed by BSA suggests that approximately 50% of patients have a BSA of 50%. Conclusion The EE approach resulted in prevalence estimates that had a narrow distribution and were consistent with published literature, supporting its value in dermatology as a complementary method to help guide decision-making in areas where evidence is scarce or uncertain. Supplementary Information The online version contains supplementary material available at 10.1007/s13555-021-00518-8., Plain Language Summary Psoriasis is a common skin disease that affects 2–4% of the population. Prevalence estimates vary depending on factors such as study type and population studied. The distribution of disease severity (what proportion of patients have mild, moderate, or severe psoriasis) is not known. In this study, 11 dermatologists with expertise in psoriasis used an approach called expert elicitation to make educated guesses about prevalence and disease severity distribution in the real world. Using a statistical approach called Bayesian estimation, experts can represent the level of certainty in what they know and do not know and make inferences or assumptions about a population. Bayesian estimates are not based on the amount of data; rather, each datum contributes to a statistically meaningful result. The median prevalence of psoriasis in the adult population using the Bayesian estimate was 3.0%, which is in the expected range based on prior literature and supports the use of this expert elicitation method. This study provides the first expert estimate of disease severity distribution in the population assessed by body surface area affected by psoriasis. Approximately 50% of psoriasis patients have mild disease (

Idiopathic chilblains is a cold-induced inflammatory condition that causes significant morbidity. When preventative measures alone are inadequate, oral nifedipine is generally recommended as first-line pharmacologic therapy. Given the natural course of this spontaneously remitting/relapsing condition, controls are needed to critically appraise studies and determine the value of treatments. We report a systematic review of placebo-controlled or comparative therapeutic trials for the treatment of idiopathic chilblains. Our search of PubMed, Embase, and Cochrane databases, identified 11 studies that met our inclusion criteria for a combined study population n = 576. Therapies included nifedipine, pentoxifylline, tadalafil, topical glyceryl trinitrate (GTN), topical minoxidil, diltiazem, corticosteroids, and vitamin D. There was moderate evidence to support the use of nifedipine and pentoxifylline in the treatment of severe or refractory cases of idiopathic chilblains, while other therapies had inadequate evidence or nonsignificant results compared to placebo.

Background Indoor tanning (IT) in fitness facilities encourages a misleading positive relationship between tanning and health. While IT in Canadian fitness facilities has been studied, American literature regarding this topic is lacking. Objectives The objective of this study is to evaluate availability, cost, reported risks, and adherence to legislation of IT in American fitness clubs. Methods This was a cross-sectional study utilizing a telephone questionnaire to survey gyms across all 50 states. The key term “fitness club” was searched in the Yellow Pages and 20 facilities from each state were randomly included into the study. Data were described descriptively and Pearson χ2 tests were used to compare IT prevalence and rates of noncompliance between population groups. Regression analysis examined potential relationship between cost and prevalence of IT. Results Of the 1000 fitness clubs surveyed, 44.4% (444/1000) offered IT. The overall noncompliance rates for age, rest time, and eye protection were 13.8% (54/390), 26.0% (20/77), and 27.8% (85/225), respectively. The most common risk reported was skin cancer (61.6%), but many facilities were unsure of risks (27.0%) and some described no risk associated with IT (3.2%). The average cost for monthly unlimited tanning was 33 ± 13.96 USD. A state-to-state comparison showed a statistically significant inverse relationship between mean cost and prevalence of IT ( P = .013, [ r]= −0.35). Conclusion The prevalence and noncompliance rates of IT in fitness clubs contradict the healthy lifestyles they are working to promote. To limit harms, legislations should be standardized and more strictly enforced. Additionally, public education on IT risks and the use of higher costs may help minimize IT use.

Background Dermatological conditions are commonly seen in the emergency department and inpatient wards. The ability to access dermatology on-call services improves the accuracy of diagnosis and management of common and sometimes life-threatening conditions. Limitations of dermatologist availability led to the suspension of the dermatology on-call service for 3 months in Ottawa, Canada. Objectives Our objective was to assess the impact of this call suspension on patient care and the need for a dermatology on-call service at our hospital, as perceived by nondermatologist physicians at our center. Methods A survey was sent to all departments at The Ottawa Hospital, addressed to staff physicians and residents. Participation was entirely voluntary. Descriptive statistics were used to analyze survey responses. Results A total of 105 physicians completed the survey including staff physicians (85%) and resident trainees (15%). The most represented specialties were emergency medicine ( N = 21), general internal medicine ( N = 19), nephrology ( N = 17), neurology ( N = 13), and plastic surgery ( N = 13). Over half of the respondents felt that the lack of dermatology on-call service impacted the care of their patients by a moderate or great extent. Over half reported performing dermatology-related clinical work during the call suspension and two-thirds of these individuals reported feeling uncomfortable or very uncomfortable doing so. Most (94%) participants felt that an on-call dermatology service was useful and 57% deemed it essential. Conclusion Our survey results demonstrate a significant impact of the suspension of a dermatology on-call service, as perceived by nondermatologist physicians. Hospitals need to recognize the importance of on-call dermatology consultations and provide support for divisions to enable this service to continue.

As part of an in-depth review of the specialty for the Royal College of Physicians and Surgeons of Canada (RCPSC), the Dermatology Working Group (DWG) was tasked with leading a comprehensive and objective analysis of the current state of Dermatology practice and training patterns in Canada. Preliminary research for the report was conducted in 3 areas: a jurisdictional analysis, a literature review, and a landscape overview. The results of this research were published in the spring 2019 edition of the Journal of Cutaneous Medicine and Surgery. Various factors impacting the discipline were explored, including trends in the workforce, population needs, accessibility, and wait times, as well as issues in undergraduate and postgraduate medical education. The DWG, supported by the RCPSC’s Office of Specialty Education, used information gained from the reviews, a national survey, and stakeholder perspectives to develop recommendations that address the current challenges and build upon opportunities for advancement in the specialty.

IntroductionVaccines for SARS-CoV-2 have been accessible to the public since December 2020. However, only 58.3% of Americans are fully vaccinated as of 5 November 2021. Numerous studies have supported YouTube as a source of both reliable and misleading information during the COVID-19 pandemic. Misinformation regarding the safety and efficacy of COVID-19 vaccines has negatively impacted vaccination intent. To date, the literature lacks a systematic evaluation of YouTube’s content on COVID-19 vaccination using validated scoring tools. The objective of this study was to evaluate the accuracy, usability and quality of the most widely viewed YouTube videos on COVID-19 vaccination.MethodsA search on YouTube was performed on 21 July 2021, using keywords ‘COVID-19 vaccine’ on a cleared-cache web browser. Search results were sorted by ‘views’, and the top 150 most-viewed videos were collected and analysed. Duplicate, non-English, non-audiovisual, exceeding 1-hour duration, or videos unrelated to COVID-19 vaccine were excluded. The primary outcome was usability and reliability of videos, analysed using the modified DISCERN (mDISCERN) score, the modifiedJournal of the American Medical Association(mJAMA) score and the COVID-19 Vaccine Score (CVS).ResultsApproximately 11% of YouTube’s most viewed videos on COVID-19 vaccines, accounting for 18 million views, contradicted information from the WHO or the Centers for Disease Control and Prevention. Videos containing non-factual information had significantly lower mDISCERN (pConclusionAs the COVID-19 pandemic evolves, widespread adoption of vaccination is essential in reducing morbidity, mortality, and returning to some semblance of normalcy. Providing high-quality and engaging health information from reputable sources is essential in addressing vaccine hesitancy.

Bullous pemphigoid is an acquired autoimmune subepidermal blistering disease that can arise following exposure to systemic medication, referred to as drug-induced bullous pemphigoid. Drug-induced bullous pemphigoid is a rare but potentially serious immune-related adverse event that should be considered in patients with advanced malignancies undergoing immunotherapy, with immune checkpoint inhibitors emerging in particular as a well-documented drug association in drug-induced bullous pemphigoid. We present a 74-year-old female with recurrent metastatic programmed cell death-ligand 1–positive squamous cell carcinoma of the head and neck area who developed drug-induced bullous pemphigoid in the setting of immunotherapy with a novel immunoglobulin-like transcript 4 inhibitor (MK-4830) in combination with pembrolizumab. Treatment with upadacitinib, a Janus-associated kinase-1 inhibitor, was pursued for significantly disabling disease that was recalcitrant to standard therapies and ultimately transition to palliative care. Follow-up at 4 weeks demonstrated good response. This is the first report describing the use of a Janus-associated kinase inhibitor for the treatment of bullous pemphigoid.

Background and objective East Asians exposed to the urate-lowering drug allopurinol have a predilection for severe cutaneous drug reactions such as drug-induced hypersensitivity syndrome or drug reaction with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). Screening is recommended in patients of East Asian descent for the presence of HLA-B*58:01 prior to allopurinol initiation to avoid these complications. Utilization rates of the HLA-B*58:01 predictive screening test within the Greater Vancouver area, which has a population composed of 40.1% people of East Asian descent, are unknown. Measures We identified cases of DRESS or SJS/TEN due to allopurinol using the Vancouver General Hospital dermatology consult service database. We next compared the frequency in which the HLA-B*58:01 screening test was ordered since 2012 to the estimated frequency of new prescriptions for allopurinol prescribed for the management of gout among the East Asians. Results We report 5 cases of East Asian patients exposed to allopurinol for management of gout between 2012 and 2016, who developed DRESS (4 patients) or SJS/TEN (1 patient). All were of HLA-B*58:01 genotype, representing preventable cases. The HLA-B*58:01 test was ordered 6 times in 2012, whereas the estimated number of new cases of allopurinol-prescribed gout among patients of East Asian descent during that time period was 13. For 2012, testing was ordered for only 46% of at-risk patients. Conclusion We continue to observe cases of severe cutaneous drug reactions among high-risk individuals due to allopurinol exposure. The HLA-B*58:01 screening test for allopurinol hypersensitivity is underutilized in our geographic area.

The specialty of dermatology is constantly changing to meet the medical needs of our society. The discipline is in flux because of a variety of factors such as growing population needs, technological advancements, fiscal restraint, and demographic changes. As part of an in-depth review of the specialty, the Dermatology Working Group (DWG) for the Royal College of Physicians and Surgeons of Canada sought to determine whether the current training configuration is suitably preparing graduates to meet the societal health needs of dermatology patients. In this first of a 2-part series, the authors conducted comprehensive literature and historical reviews and a jurisdictional analysis to understand the current state of dermatology practice in Canada. Herein, they explore trends in the dermatology workforce, population needs, accessibility, and wait times, as well as issues in undergraduate and postgraduate medical education. In a subsequent publication, the DWG will utilize information gained from this historical analysis and jurisdictional review, stakeholder perspectives, and a national survey to shape the future of dermatology training in Canada.

Introduction Hidradenitis Suppurativa (HS) is a chronic inflammatory disordercommonly affecting body folds. It can significantly impair quality of life due to the physical, psychological, and socialturmoil experienced by patients. Treatment remains a challenge.Limited data on the HS patient experience, such as self-treatment exists. Methods This was a single-center cross-sectional study, utilizing a paper-based survey. Surveys were mailed out to all HS patients from the dermatology clinic and completed on a voluntary basis. Demographics, disease characteristics, medical and family history, treatments tried, and life quality were documented. Results The response rate was 49.4% (41/83), with a female predominance (26/41). Eighty-five percent (35/41) were Caucasian with an average age and BMI of 39.0 ± 16.78 and 30.71 ± 7.02, respectively. In total, 24.4% (10/41), 56.0% (23/41), and 19.5% (8/41) had Hurley I, II, and III, respectively. Lesions affected the genital region (75.6%), thigh/groin (68.2%), and axilla (46.3). Almost half (49%) of patients experienced an average of 1-2 flares per month. The most bothersome symptoms were pain (92.7%), discharge (68.3%), malodor (63.4%), and itch (61%). Depression (53.7%), severe facial acne (14.6%), and hypertension (14.6%) were the most common co-morbidities. Treatments used included antibiotics (82.9%) and surgical excision (34.2%) were. Over 90% of patients reportedself-treatment of lesions by squeezing (80.5%), soaking (53.7%), and lancing (41.4%). Conclusions This study provides insight into the patient perspective of HS. We identify itch as a symptom that is not frequently associated with HS and reveal how commonly patients utilize various types of self-treatment in their experience of disease.

Immune-mediated diseases and immunotherapeutics can negatively impact normal immune functioning and consequently vaccine safety and response. The COVID-19 pandemic has incited research aimed at developing a novel SARS-CoV-2 vaccine. As SARS-CoV-2 vaccines are developed and made available, the assessment of anticipated safety and efficacy in patients with immune-mediated dermatologic diseases and requiring immunosuppressive and/or immunomodulatory therapy is particularly important. A review of the literature was conducted by a multidisciplinary committee to provide guidance on the safety and efficacy of SARS-CoV-2 vaccination for dermatologists and other clinicians when prescribing immunotherapeutics. The vaccine platforms being used to develop SARS-CoV-2 vaccines are expected to be safe and potentially effective for dermatology patients on immunotherapeutics. Current guidelines for vaccination of an immunocompromised host remain appropriate when considering future administration of SARS-CoV-2 vaccine., The safety and efficacy of SARS-CoV-2 vaccines in patients with immune-mediated dermatologic diseases requiring immunotherapeutics is unknown. The SARS-CoV-2 vaccines approved and distributed are expected to be safe for patients on immunotherapeutics with some variability in efficacy, depending on the degree of immunosuppression and type of vaccine given.

UNSTRUCTURED Research Letter

Dupilumab is the only biologic therapy currently approved in Europe and the United States for severe atopic dermatitis in patients 6 years of age or older. Off-label use is rationalized in younger children with severe atopic dermatitis. Decisions about vaccination for children on dupilumab are complex and depend on both the child’s current treatment and the type of vaccination required. To achieve consensus on recommendations for vaccination of pediatric patients with atopic dermatitis treated with or planning to start dupilumab, a review of the literature and a modified-Delphi process was conducted by a working group of 5 panelists with expertise in dermatology, immunology, infectious diseases and vaccination. Here, we provide seven recommendations for vaccination of pediatric patients with atopic dermatitis treated with or planning to start dupilumab. These recommendations serve to guide physicians’ decisions about vaccination in children with atopic dermatitis treated with dupilumab. Furthermore, we highlight an unmet need for research to determine how significantly dupilumab affects cellular and humoral immune responses to vaccination with live attenuated and inactivated vaccines. Supplementary Information The online version contains supplementary material available at 10.1007/s40257-021-00607-6.

Coronavirus disease 2019 (COVID‐19) is caused by SARS‐CoV‐2, a novel RNA virus that was declared a global pandemic on 11 March 2020. The efficiency of infection with SARS‐CoV‐2 is reflected by its rapid global spread. The SARS‐CoV‐2 pandemic has implications for patients with inflammatory skin diseases on systemic immunotherapy who may be at increased risk of infection or more severe infection. This position paper is a focused examination of current evidence considering the mechanisms of action of immunotherapeutic drugs in relation to immune response to SARS‐CoV‐2. We aim to provide practical guidance for dermatologists managing patients with inflammatory skin conditions on systemic therapies during the current pandemic and beyond. Considering the limited and rapidly evolving evidence, mechanisms of action of therapies, and current knowledge of SARS‐CoV‐2 infection, we propose that systemic immunotherapy can be continued, with special considerations for at risk patients or those presenting with symptoms.

An otherwise healthy 42-year-old woman presented to the emergency department with a 1-week history of subjective fever, worsening headache, blurry vision, photophobia, nausea and epiphora ([Figure 1A][1]). On physical examination, the patient was afebrile but had a widespread asymptomatic

Background Hidradenitis suppurativa (HS) is associated with comorbidities that contribute to poor health, impaired life quality, and mortality risk. Objective To provide evidence-based screening recommendations for comorbidities linked to HS. Methods Systematic reviews were performed to summarize evidence on the prevalence and incidence of 30 comorbidities in patients with HS relative to the general population. The screening recommendation for each comorbidity was informed by the consistency and quality of existing studies, disease prevalence, and magnitude of association, as well as benefits, harms, and feasibility of screening. The level of evidence and strength of corresponding screening recommendation were graded by using the Strength of Recommendation Taxonomy (SORT) criteria. Results Screening is recommended for the following comorbidities: acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma gangrenosum, depression, generalized anxiety disorder, suicide, smoking, substance use disorder, polycystic ovary syndrome, obesity, dyslipidemia, diabetes mellitus, metabolic syndrome, hypertension, cardiovascular disease, inflammatory bowel disease, spondyloarthritis, and sexual dysfunction. It is also recommended to screen patients with Down syndrome for HS. The decision to screen for specific comorbidities may vary with patient risk factors. The role of the dermatologist in screening varies according to comorbidity. Limitations Screening recommendations represent one component of a comprehensive care strategy. Conclusions Dermatologists should support screening efforts to identify comorbid conditions in HS.

Delusional infestation (DI) is a rare delusional disorder in which individuals have a false belief that they are infested with bugs, parasites, or insects, despite the lack of medical evidence that such an infestation exists. Data on the effectiveness of antipsychotics for DI are limited.We conducted a systematic review using EMBASE, MEDLINE, PsycINFO, and Cochrane Central Register of Controlled Trials from inception of the databases up until July 20, 2018. Studies examining typical or atypical antipsychotics for primary DI were included.A total of 51 relevant articles were identified, primarily case reports/series. Overall response was favorable for both typical and atypical antipsychotics, but there was no strong evidence to suggest that any one antipsychotic agent was preferable to other agents. Pimozide (1-16 mg/day) and risperidone (0.5-8 mg/day) were the most commonly studied typical and atypical antipsychotics, respectively. Inconsistent reporting of treatment outcomes and variability in study designs limited the overall evaluation of the data.There remains a lack of sound data supporting the effectiveness of antipsychotic treatment for primary DI. Further research is required to establish more definitive conclusions about the relative clinical utility of antipsychotic agents for DI.

Pyoderma gangrenosum is a challenging disease to manage, due in part to the lack of approved treatment therapies. Recently, the emergence of biologic agents has expanded treatment options, with tumour necrosis factor alpha inhibitors being the best supported in the literature. In our report, we present a 50-year-old female with pyoderma gangrenosum who was successfully treated with the anti-interleukin-17 biologic agent, secukinumab, after failing other systemic therapies.

Background Surgical excision is considered standard treatment for nodular basal cell carcinoma (nBCC). However, patients who reject or are unsuited for surgery may benefit from imiquimod (IMQ) 5% cream as an alternative treatment. Objectives The objective of this study was to conduct a systematic review on the efficacy and safety of IMQ for the treatment of nBCC. Materials and Methods The terms basal cell carcinoma AND imiquimod OR Aldara were searched on Ovid-MEDLINE, EMBASE, and Cochrane Library databases. Articles were included if they reported the efficacy or side effects of IMQ for nBCC. Primary outcomes included clearance (clinical and histological), recurrence rates, and adverse events. Number of lesions/subjects, treatment regimens, length of treatment, and time to recurrence were secondary outcomes. Results Thirty-nine publications, totaling 738 lesions, revealed a 77.4% (335/433 lesions) clinical and 72.9% (390/535 lesions) histological clearance rate. Regimens ranged from once daily 2 days a week to twice daily 7 days a week. Average treatment duration was 8.81 (±3.49) weeks. There was a 1.80% recurrence rate after an average follow-up period of 13.03 (±15.09) months. Common adverse effects included erythema (77.2%), crusting (50.5%), pruritus (34.1%), tenderness/irritation (27.3%), ulceration (25.4%), burning (22.1%), and erosion (21.7%). Unforeseen side effects included conjunctivitis, keratitis, depigmentation, comedone formation, and ruptured epidermoid cysts. Conclusion Imiquimod showed clinical and histological clearance rates of over 70% for nBCC, with a recurrence rate of 1.80%. Although clearance rates are lower than surgery, IMQ can be considered as a treatment option for nBCC in those who decline or are unfit for surgical intervention.

Background: Although a variety of medical and surgical interventions exist for the treatment of hidradenitis suppurativa (HS), it remains a challenging disease to manage because of its variable presentation and unpredictable clinical course. Apart from the combination of clindamycin and rifampin, the success of other combination therapies is largely unknown. Objectives: The goal of our study was to examine the clinical utility of various combination therapies for the treatment of HS. Methods: We conducted a qualitative retrospective chart review of 31 patients with dermatologist-diagnosed HS who were seen at an academic teaching hospital between 2014 and 2018. Demographic data, disease location, disease severity, and treatment protocol were retrieved for analysis. Hurley stage was used to classify disease severity on initial presentation, and the International Hidradenitis Suppurativa Severity Score System (IHS4) was used to track changes across visits. Results: Of the 31 patients (Mage = 37.7 years; 67.7% female) included in the study, 6 (19.4%), 11 (35.5%), and 14 (45.2%) patients were classified as Hurley stages I, II, and III, respectively. Although no statistical results are provided because of the small sample size, we have identified several drug combinations that show promising clinical response for patients with HS based on their IHS4 score, such as isotretinoin/spironolactone for mild disease, isotretinoin or doxycycline with adalimumab for moderate disease, and cyclosporine/adalimumab for severe disease. Conclusions: This preliminary work demonstrates that HS treatment with combination therapy appears to be a promising method of disease management.

As part of an in-depth review of the specialty for the Royal College of Physicians and Surgeons of Canada (RCPSC), the Dermatology Working Group (DWG) was tasked with leading a comprehensive and objective analysis of the current state of Dermatology practice and training patterns in Canada. Preliminary research for the report was conducted in 3 areas: a jurisdictional analysis, a literature review, and a landscape overview. The results of this research were published in the spring 2019 edition of the

Background: Schizophrenia is a debilitating neuropsychiatric condition that affects 0.5% of the North American population. Skin disease in schizophrenia has not been well described. Identifying skin diseases that are commonly comorbid with schizophrenia may help clinicians address the burden of skin disease in patients with schizophrenia. Summary: We conducted a nonsystematic review of the literature to identify skin diseases that may be associated with schizophrenia. We searched MEDLINE, EMBASE, and PsycINFO for articles published in English from December 2000 through April 2020 using the key words “skin disease” or “dermatological” or “dermatology” and “schizophrenia.” Based on our results, we further refined the search terms to include more specific skin diseases. Schizophrenia appears to be associated with a number of skin diseases, including inflammatory dermatoses, autoimmune diseases, and certain genodermatoses. Limitations include being a nonsystematic review and the relative paucity of more rigorous clinical research using longitudinal study designs.

This document is a concise, current, and practical guide for dermatologists and other health care providers managing adult patients with moderate-to-severe atopic dermatitis (AD). The recommendations made here are based on a consensus of specialists with extensive experience managing patients with AD. Topics reviewed in this publication include AD pathophysiology, assessment, comorbidities, and treatment options.

There is a growing interest in the use of medical cannabis for a variety of dermatologic conditions. Despite the lack of evidence to validate the effectiveness and safety of marijuana, it is approved to treat a variety of dermatologic conditions in the United States. Furthermore, medical cannabis dispensaries have been making unsubstantiated claims about medical cannabis. It is important for dermatologists to know about the purported use of medical cannabis to help patients navigate this new treatment option, particularly as cannabis becomes legal in Canada in October 2018. We collected and tabulated the dermatologic indications for medical cannabis from Canada, the United States, and Europe. In the United States, dermatologic-approved indications vary by state but include psoriasis, lupus, nail-patella syndrome, and severe pain. Health Canada has listed psoriasis, dermatitis, and pruritus as potential therapeutic uses for cannabis but does not endorse its use for therapeutic purposes. We also surveyed the websites of dispensaries in Canada, the United States, and Europe and found that numerous unsubstantiated claims were being made and advertised to consumers. Dermatologic uses of medical cannabis, as claimed by dispensaries, included treating acne, aging, allergic contact dermatitis, chronic pain, herpes, dermatitis, lupus, Lyme disease, nevi, psoriasis, epidermolysis bullosa, and melanoma. Psoriasis, dermatitis, and chronic pain were the most commonly cited indications for medical cannabis listed by dispensaries. Our data indicate that the suggested and advertised uses of medical cannabis are largely unsubstantiated. Further research is necessary to validate the indications, effectiveness, and safety of medical cannabis.

Background Stevens–Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are mucocutaneous hypersensitivity reactions, usually to drugs or their metabolites. TEN is the most severe involving greater than 30% of the total body surface area (TBSA). Management of these patients usually benefits from a large multidisciplinary team for both wound and medical management. Treatment of these patients varies between centers and physicians and there is lack of a standardized treatment protocol in the medical literature. Objectives To review the literature and complete a retrospective review of patients treated at Vancouver General Hospital over a 11-year period. Methods A retrospective chart review of all patients diagnosed with SJS/TEN and treated at Vancouver General Hospital from 2001 to 2011 was completed. Data collected include patient demographics, time to transfer to a burn center, SCORTEN calculation, suspected cause of TEN, %TBSA involved, length of stay in hospital and ICU, medications, dressings, infections/cultures, fluids, mucosal involvement, teams involved, associated complications, morbidity and mortality. Data is reported quantitatively. Results A total of 67 patients were identified (28 SJS, 21 SJS/TEN overlap, 18 TEN). In SJS/TEN overlap and TEN patients, oral mucosa and trunk were the primary sites involved. SCORTEN calculations were highest in the TEN group. Plastic surgery was consulted in 53% of TEN cases, 52% of SJS/TEN cases and 25% of SJS cases. Patients were admitted to a burn unit in 74% of TEN cases, 57% of TEN/SJS cases and 21% of SJS cases. Time from symptoms to diagnosis and transfer to a burn unit was highest for TEN patients. Time from presentation to diagnosis was highest in SJS/TEN overlap. Triggers were identified in 67-82% of cases. Treatment varied widely. Patients were treated conservatively, with steroids, IVIg, and cyclosporine alone or in combination. Observed mortality was higher than predicted by SCORTEN for patients treated with IVIg and lower for those treated with Cyclosporin. Dressings varied greatly and were often changed throughout a patients stay. Total mortality was 20.9% being the highest in the TEN group (35%). Conclusions SJS and TEN are a spectrum of severe mucocutaneous reactions that have unclear treatment recommendations within the literature and within our Level 1 hospital. Information gleaned from this research will help educate physicians involved in the treatment and management of patients with these diagnoses and has resulted in development of treatment guidelines in our hospital.

Background: Atopy is a genetic predisposition to the development of allergic reactions and the increased production of immunoglobulin E (IgE) upon exposure to environmental antigens. Clinical manifestations of atopy include asthma, atopic dermatitis (AD), and allergic rhinoconjunctivitis (ARC). Objective: To determine if cutaneous delayed hypersensitivity reactions (CDHRs) as assessed by patch testing are higher among patients with a history of atopy and with a familial predisposition to atopy. Methods: For this study, we reviewed the patch test database of the UBC Contact Dermatitis Clinic over a 4-year time span. A personal history of asthma, AD, and ARC was recorded. In addition, a family history was obtained and manifestations of atopy in family members were noted. Results: A total of 1515 patients were included in this study. Our data show that the odds ratio (OR) of a positive patch test with a personal history of atopy was 1.39, while the OR of a positive patch test with a family history of atopy was 1.69. Conversely, a personal history of respiratory atopy did not significantly affect the probability of a positive patch test, with an OR of 1.03. Conclusion: We conclude from our study that patients with a personal or family history of atopy have an increased risk of allergic contact dermatitis (ACD). These results provide further evidence for the link between atopy and ACD and suggest that children of atopic parents should avoid potential contact allergens and would likely benefit from prophylactic emollient use.

Hidradenitis Suppurativa (HS) is a chronic debilitating skin condition that impairs the productivity and the quality of patients` lives. HS has recently drawn lots of attention among scholars to further expand their knowledge but it still loads with uncertainties and gaps to be explored. This publication addresses these uncertainties, and provides a road-map for researchers, scholars and clinicians from different disciplines for their future studies about HS. This is a proceeding report of the first Symposium on Hidradenitis Suppurativa Advances (SHSA), and it reviews the scientific sessions about the epidemiology, pathophysiology, presentations, and management of HS. This symposium was a great opportunity for experts in the HS field to exchange their knowledge, and improve their mutual understanding of this disease.