Vitiligo: causes, clinical features, diagnosis and general management

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Vitiligo is an acquired disorder of the skin characterized by well-circumscribed macules or patches of depigmentation. Vitiligo can be cosmetically disabling, especially in people of darker skin. It is caused by destruction of melanocytes in the skin, which are essential for the production of melanin. The etiology is thought to be due to an autoimmune process, triggered in people with certain genetic susceptibilities.  

Vitiligo can affect any part of the body, common sites are sun-exposed areas (face, neck and hands) and skin folds (armpits, groin). Vitiligo may appear following trauma to the skin, this is known as Koebner’s phenomenon. The pattern of depigmentation in Vitiligo is variable. It may affect a single patch of skin or it may involve multiple areas distributed throughout the body. Vitiligo lesions usually extend for a few months before stabilizing for variable periods. This cycle of pigment loss followed by stability of lesions may continue for years.

Vitiligo may be classified as segmental or non-segmental. In segmental vitiligo, there is usually a single patch of depigmented skin. This type also more commonly affects younger people and is more likely to be stable after the initial period of extension. Non-segmental vitiligo is characterized by lesions that are bilateral and symmetrical. Each of these types (Segmental and non-segmental) includes many other subtypes which are based on the distribution of lesions.

Vitiligo is typically a clinical diagnosis. Depigmented lesions are readily seen on Wood’s lamp examination. At times of diagnostic difficulty, a skin biopsy may be needed to rule out other possible causes of depigmentation. Blood tests such as thyroid function markers and Vitamin B12 levels may be ordered to check for possible co-existing autoimmune disorders.

General measures for the management of Vitiligo include preventing skin injury and wearing sunscreen. Specific treatment for Vitiligo may include topical medications such as steroids or Calcineurin inhibitors. Phototherapy is another option which aims at achieving re-pigmentation of the involved area. Systemic therapies for Vitiligo are available, examples include oral steroids, Methotrexate, and Cyclosporin. These all have immune-modulating properties and target the possible etiology of the disease. JAK2 inhibitors such as Ruxolitinib are currently being investigated for the treatment of Vitiligo and may be used in the future as a second-line medication. Depigmentation therapy may be an option for severely affected patients in whom other methods of treatment are not effective.

 

 

Written by: Turki Alsehli, Medical Student 

 

Resources:

www.DermNetNZ.org

www.UpToDate.com

Front Immunol. 2019 Dec 3;10:2847. doi: 10.3389/fimmu.2019.02847. eCollection 2019.

Emerging Topical and Systemic JAK Inhibitors in Dermatology. Solimani F, Meier K, Ghoreschi K.

The elusive connection between vitamin D and skin health

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Vitamin D is a fat-soluble vitamin that has an imperative role in health. It regulates calcium metabolism and homeostasis, but its scope of function extends beyond that, particularly the skin.

 

The production of vitamin D occurs in the skin in response to ultraviolet B radiation from sunlight. Once it is synthesized, it exerts an immunomodulatory effect on immune cells by dampening overactive signaling cells from secreting inflammatory mediators, in addition, vitamin D aids in the defense against opportunistic infections of the skin by upregulating antimicrobial gene expression, which collectively consolidates and maintains the integrity of the cutaneous barrier.

 

A myriad of studies in the literature have highlighted vitamin D’s potential therapeutic properties for a number of dermatological diseases, namely psoriasis, atopic dermatitis, vitiligo and many other skin maladies. One study elucidated that oral vitamin D conferred to an improvement of psoriasis in 88% of the patients. Another meta-analysis study demonstrated that the risk of vitiligo is inversely associated with vitamin D serum.

 

There are many sources in which you can ascertain vitamin D. Exposure to sunlight is remarkably efficient at converting vitamin D into its active form, followed by dietary supplementation, with negligible amount present in dietary intake, mostly in commercialized processed foods which has been fortified with essential compounds.

 

With a growing body of research on this matter and promising results, vitamin D has proven to be a quintessential vitamin for the skin. Insufficient levels are therefore associated with multiple dermatological disorders, and adequate sunlight exposure and supplementation with regular blood tests for vitamin D serum level are advisable for healthy skin.

 

 

Written by: Naif Alshaikh, Medical Student 

 

Resources:
Bergqvist C, Ezzedine K. Vitamin D and the skin: what should a dermatologist know? G Ital Dermatol Venereol 2019;154:669-80. DOI: 10.23736/S0392-0488.19.06433-2

 

Wadhwa B, Relhan V, Goel K, Kochhar AM, Garg VK. Vitamin D and skin diseases: A review. Indian J Dermatol Venereol Leprol 2015;81:344-55

 

Perez A, Raab R, Chen TC, Turner A, Holick MF. Safety and efficacy of oral calcitriol (1,25-dihydroxyvitamin D3) for the treatment of psoriasis. Br J Dermatol 1996;134:1070–8.

COVID-19: how is it related to the skin?

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In December 2019 unexplained pneumonia cases started arising in Wuhan, China due to a new pathogen called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and thus the disease was named Coronavirus Disease 2019 (COVID-19). Cases started spreading rapidly around the globe and on March 12th World Health Organization (WHO) declared it as a pandemic. Some of the clinical signs associated with it are fever, fatigue and dry cough. In addition to presenting symptoms and signs, nasopharyngeal and oropharyngeal swab can aid in diagnosis.

 

There are very limited data in literature about the cutaneous manifestation of COVID-19 so far, however, data collected from 88 patients in Lecco, Italy in which 14 of them presented with skin rash mostly affecting the trunk region. In addition, three patients presented with urticaria and one patient had chickenpox-like vesicles. It was concluded that the skin symptoms observed in COVID-19 were frequently seen in common viral infections. Furthermore, the severity of the skin symptoms did not seem to correlate with the severity of the disease. Due to additional infection prevention steps taken by first-line healthcare workers, 97% of them reported having skin damages, some of which are dryness and desquamation. Sites involved were mainly the nasal bridge, hands, cheek, and forehead. Therefore, preventive measures must be taken which include emollients, barrier creams, and moisturizers especially before applying personal protective equipment. Further steps should be taken to maintain hand hygiene and moisturization such as using unscented soap and avoiding using too much. Additionally, washing hands with warm water instead of hot water and applying moisturizers immediately after drying hands.

 

In conclusion, further studies should be done on the specific skin symptoms associated with COVID-19 infection. Skin damage and dryness are common conditions, especially with frequent hand washing during the pandemic, therefore, additional measures need to be taken to prevent such conditions.

 

Written by: Khalid Al Dakheel, Medical Student @ KSU

 

 

Resources:

https://www.researchgate.net/publication/340477835_Review_Review_Coronavirus_COVID-19_and_Relevance_for_Dermatologists_-Are_We_Ready_for_the_Battle

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102542/

https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.16387

https://www.uclahealth.org/body.cfm?id=1397&action=detail&ref=5741&fr=true

The unexpected correlation between BMI index and acne vulgaris

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It’s common knowledge that a healthy diet can improve skin condition greatly
as there are many products and food supplements that claim to refresh and
nourish the skin while preventing acne, but exactly how much can a conscious
diet affect our skin?

The most common form of acne is Acne Vulgaris which is “a chronic
inflammatory skin disease of pilosebaceous unit“ that many Adolescents
suffer from and deal with on a daily basis which is detrimental to their
mental and psychological health.

Many studies conducted in the last decade show a notable correlation
between different dietary factors (like dairy consumption and high glycemic
load diet) and acne vulgaris as they are thought to increase sebum
production which leads to blocking hair follicles hence causing acne and
spots.

In 2019 a new article published by The Journal of The American Academy of
Dermatology proposed a new idea into the table, that the BMI index level may
have an association with the risk of developing Acne Vulgaris.

The results suggest that in Youths, high BMI index and Obesity are “inversely
associated with acne in a dose-dependent manner” which is odd as a high
calorie diet doesn’t necessarily reflect a healthy nor desirable approach to
reduce acne vulgaris risk but is surely interesting.

The connection between acne vulgaris and the BMI index remains unclear
which provides space for future research to improve the current
understanding.

 

Written by: Bayan Alhazmi, Medical Student @ KSU

Resources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884775/

https://www.jaad.org/article/S0190-9622(19)30589-4/pdf

A brief outline on the management of Psoriasis

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Psoriasis is a chronic inflammatory skin condition characterized by well-defined, erythematous scaly plaques. Psoriasis can occur at any age, and is usually a lifelong disease with fluctuations in severity and extent. There are many subtypes of Psoriasis including Small Plaque Psoriasis, characterized by plaques less than 3 cm in size, Chronic Plaque Psoriasis, in which the plaques are larger than 3 cm in size, Palmoplantar Psoriasis which mainly affects the palms and soles, and many other types that vary in distribution and severity.

There are many modalities in the management of Psoriasis which usually depend on the severity of the disease at time of treatment initiation. These include simple lifestyle modifications such as smoking cessation and maintaining a healthy weight. Mild Psoriasis may be managed by topical drugs, such as Salicylic acid, Topical corticosteroids, Calcineurin inhibitors (tacrolimus,pimecrolimus). Management of more severe disease may include systemic agents such Methotrexate, Cyclosporin and Azathioprine. Systemic corticosteroids should be avoided as they can precipitate a flare of Psoriasis. Recently, there has been great interest in the use of biologic agents, some of these include Tumor Necrosis Factor inhibitors such as Infliximab and Etanarcept, The IL-12,23 antagonist Ustekinumab, and Guselkumab, a systemic anti-IL-23p19 agent. These biological agents are usually reserved for refractory disease which doesn’t respond to the conventional drugs.

Very recently (November 2019), new evidence emerged on the use Guselkumab for treatment-resistant Palmoplantar Psoriasis, the clinical trial found that guselkumab improved disease severity scores for PPP refractory to conventional treatment, it also supported that Guselkumab was well-tolerated with infrequent adverse effects.

In conclusion, Psoriasis is a life-long disease which may be debilitating without treatment. The discovery of new biological agents shows promise in controlling even the most severe forms of the disease with great success.

 

 

Written by: Turki Alsehli

Sources:

UpToDate.com, Dermnetnz.org, PubMed

Efficacy and Safety of Guselkumab in Japanese Patients With Palmoplantar Pustulosis: A Phase 3 Randomized Clinical Trial. Terui T, Kobayashi S, Okubo Y, Murakami M, Zheng R, Morishima H, Goto R, Kimura T

JAMA Dermatol. 2019

Probiotics and the skin

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Probiotics are live microorganisms administered for their beneficial effects. WHO (World Health Organization) defines them as live microorganisms that “when administered in adequate amounts, confer to a health benefit on the host”. Lactobacillus and Bifidobacterium are the most commonly used species. Probiotics are mainly used for gastrointestinal diseases however, some research suggests they could be beneficial to some skin conditions such as atopic dermatitis, acne and wound healing.

 

As far as healthy skin goes, few studies were done on the matter, it does however, suggest that probiotics have beneficial effects on skin’s hydration and elasticity. Some research has shown the role of probiotics in prevention and improvement in the symptoms of atopic dermatitis in children. In one study, a combination of probiotics was given to children suffering from atopic dermatitis in which their symptoms were alleviated by 56%. In addition, another study was done where pregnant women were given probiotics four weeks before delivery and 6 months after delivery showed a noticeable reduction in the risk of developing atopic dermatitis in the first few years of life. A small number of studies were done on the role of probiotics in the prevention of acne, in one study, the side effects of minocycline were alleviated with the administration of probiotics while still maintaining its potency. Furthermore, Probiotics and Minocycline both demonstrated a synergistic anti-inflammatory effect against acne vulgaris. Probiotics could also influence wound healing; a study was done where burn wounds were given a type of yeast called Saccharomyces cerevisiae and the wound exhibited an improvement in the healing process. In addition, there was an increase in the levels of collagen and TGF beta 1.

 

In conclusion, probiotics could potentially have positive results on normal skin, however, the use of probiotics as means of prevention and/or treatment of some skin conditions requires further studies as the exact mechanism to how they exhibit their effects is still not fully understood.

Written by: Khalid Al Dakheel, Medical Student @ KSU

Source

Electronic cigarettes and dermatological manifestations

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Electronic cigarette usage has become quite frequent in the last couple of years, mainly due to it being marketed as a substitute for traditional cigarettes. There’s a lot of controversy revolving around whether it is truly a safe substitute to traditional cigarettes. However, some harmful dermatological manifestations have been linked with e-cigs.

 

Some of the dermatological manifestations associated with the usage of e-cigs are contact dermatitis, thermal injury, and oral mucosal lesions. Contact dermatitis usually affects the dominant hand, and it’s caused by the release of nickel from the heating coil, which is the component that vaporizes the liquid. Thermal, blast and chemical injuries reported were due to overheating, leakage and/or explosion of lithium-containing batteries used in e-cigs. There is also an increased prevalence of oral mucosal lesions such as nicotine stomatitis, hyperplastic candidiasis, and black hairy tongue among consumers of electronic cigarettes.

 

In conclusion, the increased consumption of electronic cigarettes is due to it being advertised as a safer alternative to tobacco cigarettes. However, electronic cigarettes can cause some harmful skin-related conditions outlined above. Currently, electronic cigarettes are not a safe alternative and further studies are needed on the topic.

 

Written by: Khalid Al Dakheel, Medical Student @ KSU

Source

Pattern hair loss: What causes it? How can it be treated?

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Baldness or “Alopecia” is a common condition, it has many types and causes, but the most common type is pattern hair loss, which is what will be addressed here. Hair loss has a lot of psychological impact on affected individuals, especially when it occurs at a young age. A common misconception is that every old person suffers from baldness which is false, hair loss does NOT only occur with age. Another misconception is that shampoo causes hair loss, which is just a myth. when you wash your hair, you’re just washing off already dislodged hair.

 

Pattern hair loss occurs in both males and females, but it’s more common in males. You might ask what is the cause of pattern hair loss?  The cause of it is a combination of hair follicles being more sensitized to androgens, and androgens’ effect on them. It occurs at any time in genetically predisposed people after puberty, however it’s usually fully expressed in 40’s. There’s a lot of frustration with progressive hair loss, so before you pull out your hair out of frustration, there are a few options for the treatment of such a condition. The easiest would be to just wear a hairpiece, however if treatment using medications is preferred minoxidil and finasteride can be used. There’s also the option of getting a hair transplant where androgen-insensitive hair is taken and implanted into the scalp.

 

Finally, pattern hair loss is common and there are a lot of misconceptions associated with it. It has a psychological impact on those who suffer from it. It can be treated using both medical and surgical methods.

 

 

Written by: Khalid Al Dakheel, Medical Student @ KSU
Reference: Fitzpatrick Color Atlas and Synopsis of Clinical
Dermatology

3rd Riyadh Derm Forum

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Riyadh Derm Forum is a scientific forum conducted twice a year by the Saudi Society of Dermatology and Dermatologic Surgery and organized by the students’ club under the supervision of the society. The 3rd Riyadh Derm Forum took place in the Ritz-Carlton hotel on November 22nd, 2019 from 5:30 to 9:30 PM. It was directed by Dr. Yousef Binamer and Dr. Hind Alshehri.

The 3rd Riyadh Derm Forum consisted of 2 sessions, the first was a set of lectures which included, Immunological Aspect of Urticaria presented by Dr. Rand Arnaout consultant immunologist, and Cutaneous Manifestation of Rheumatic disease presented Dr. Ahmed Alshaikh consultant rheumatologist. The second session discussed 14 interesting clinical cases from regional, national and international hospitals. By the end of the session a nomination of best clinical case presentation was placed by the attendees. This year’s best clinical case presentation awards with a prize of 5000 SR went to Dr. Lama Altawil and Dr. Ayman Abdelmaksoud.

Also, in its support of research and residents the society congratulated and rewarded the top three resident projects presented on September 24th, 2019 at the residents’ research day. The residents were Dr. Rama Alhallaf, Dr. Rahaf Bashihab and Dr. Albatool Alammari, with a prize of 7000 SR, 5000 SR and 3000 SR respectively.

Finally, we thank all the attendees for their constant attention and interaction with the presentations, and all the organizers for their excellent and impeccable teamwork and work ethic.

We look forward to seeing you all in the upcoming forum!

 

Your skin your health campaign

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Your skin your health is an annual campaign supervised by the Saudi Society of Dermatology and Dermatologic Surgery, directed at the general population to shed some light on common skin conditions. It was held on November 15th, 2019 in Granada center from 4 PM to 10 PM. There were 32 health promoting volunteers and 6 corners, each addressing a common skin condition. The different subjects discussed were warts, psoriasis, acne, eczema, hair loss and sun protection.

There were many interactions between volunteers and visitors of Granada center, and a lot of questions concerning common skin conditions were answered, and visitors of each corner were given a pamphlet containing information about that specific skin condition. Some misconceptions such as acne being caused by uncleanliness or eczema being contagious were also addressed in the campaign.

 

 

Eczema in a nutshell

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   October is eczema awareness month, which is a month-long campaign directed at people and families of those who suffer from eczema all over the world. The main goals of the campaign are to raise awareness, reduce stigma and show the impact of eczema. Because not only does eczema affect the skin, it also has psychological effects such as depression and anxiety.

    When we say eczema (dermatitis) we’re not referring to one disease, there are many types of eczema, so when we talk about it here, we’re merely “scratching” the surface. What people usually mean by eczema is the atopic type, which is the most common type, the hallmark of this disease is pruritus, which is basically just a fancy word for “itching”. There isn’t one single cause for atopic dermatitis, a few hypotheses have been suggested but they all revolve around the patient’s genetical tendency to develop allergic diseases, a term called “atopy”, there is also strong association with asthma, hay fever and other allergic diseases. Atopic dermatitis is usually diagnosed at childhood, but it could be diagnosed later in life. Educating the patient to stop scratching and to avoid triggers such as soaps with certain chemicals is important. Topical treatment is also initially used (steroids, tacrolimus), phototherapy and systemic steroids are usually reserved for non-responsive cases.

     In conclusion, eczema is a serious autoimmune disease affecting the skin, which has both physical and psychological impact. Eczema awareness month is there to shed some light on these issues and the impact of it on individuals.

Happy Eczema Awareness Month!

 

Written by: Khalid Al Dakheel, Medical Student @ KSU

Reference: Fitzpatrick Color Atlas and Synopsis of Clinical
Dermatology (Vienna) By Klauss Wolff and
Richard Allen Johnson. (6th Edition)