Linda Stocum

Acne vulgaris is a skin condition caused by the dysfunction of the pilosebaceous unit which causes red bumps on the face and truck. Commonly, adolescents battle with this skin condition, but this patient age group is also more susceptible to misinformation. A recent article looked into the issue of the amount of misinformation on the internet by compiling a qualitative review of misinformation and conspiracy theories in acne.

The reason why adolescents are often more likely to believe misinformation is due to age, stress about the condition, and the amount of time spent on the internet. The researchers performed a review in March 2022 of PubMed that used the terms ‘acne’ AND ‘misinformation’ OR ‘disinformation’ OR ‘conspiracy theory’ in which 1,024 abstracts were found and then analyzed to see if they should be included as misinformation. After the analysis, 5 were included. After, a Google search was conducted using combinations of the terms ‘acne’ and ‘misinformation’, ‘disinformation’ and ‘conspiracy theories’. After that, TikTok, Twitter, Facebook, and Instagram were also investigated.

The common categories of the false content were diet and other ‘causes’ of acne, distrust of traditional acne therapies, and the use of nonconventional treatments. The dietary causes of acne, in these misinformation posts, included exposure to dairy products, high-fat foods, and chocolate. Other supposed causes included poor hygiene, contagion, systemic infections such as Candida, and fluoridated water, the researchers explained. For cures, veganism was often cited along with natural topical treatments, and nutritional supplements like diindolylmethane.

The posts said treatments like antibiotics were poisonous, and isotretinoin was toxic and devasting to the patient. Other misinformation about common treatments included an over exaggeration of cases of depression, inflammatory bowel disease, organ failure, infertility, and sexual dysfunction.

The researchers found that the websites in which these pieces of content were found often were associated with companies that were selling products that were advertised to cure acne in a short amount of time.

“Dermatologists should be aware of the nature of acne-related misinformation available online, and be prepared to counter it with scientific principles and facts,” the researchers concluded.

O’Connor C, O’Grady C, Murphy M. Spotting fake news: a qualitative review of misinformation and conspiracy theories in acne vulgaris. 

. Published online April 18, 2022:ced.15222. doi:10.1111/ced.15222

Articles

Teenagers were the most likely to be affected by targeted misinformation.

Misinformation and acne

Most children will break out in/develop a rash at some point, but commonness does not make these skin conditions any less irritating or, in some cases, painful. Rashes are often caused by eczema or allergic contact dermatitis, which while similar, can be treated differently and recognizing the differences and causes is essential to making a correct diagnosis—the key to proper treatment and, ultimately, relief, according to JiaDe Yu, MD, FAAD.

Yu, director of the Contact Dermatitis and Occupational Dermatology Clinic and an assistant professor of adult and pediatric dermatology at Massachusetts General Hospital in Boston, detailed the fundamentals and latest approaches for both skin disorders in a presentation on pediatric AD at the 2022 American Academy of Dermatology Annual Meeting in Boston.

Eczema is frequently characterized by intense itching, which can damage skin and worsen the rash. AD is the most common form and typically presents early in life, with most patients developing the condition before their fifth birthday. Eczema can appear differently on skin of color—an important point because Black and Asian American children develop AD more often than their White counterparts, and Black children potentially have itchier, more severe eczema.

Eczema may resolve as a child grows up, but 50% of patients still will have it when they reach adulthood. Although there is no way to know if the condition will persist, early diagnosis and treatment can prevent severe disease, which can be harder to treat and is more likely to continue into adulthood.

Although it can be confused with eczema, allergic contact dermatitis can generate symptoms such as rash, tenderness, burning, and blisters. Metals such as nickel and cobalt, which can be found in toys, clothing accents, and costume jewelry, are likely allergens among children. Soaps, shampoos, and laundry detergents are sources of 2 other common allergens: fragrance and preservatives. Chemicals and dyes used to treat fabrics can also induce a reaction.

“Dermatologists are seeing 2 emerging allergens affecting children—adhesive allergens, which are commonly used in wearable blood glucose monitors, and acetophenone azine, linked to reactions associated with…an allergen from a chemical used in shin guards and footwear,” Yu noted.

Knowing a rash’s location and getting a thorough family history of skin conditions can help differentiate the conditions. Allergic contact dermatitis often arises in unusual locations—say, fingertips, eyelids, or lips—whereas eczema frequently presents on areas such as the wrist or back of knee. Because allergic contact dermatitis worsens eczema, children who have eczema should avoid common allergens when possible.

Yu suggested referring patients to a specialist for patch testing because it can reveal allergic contact dermatitis. “Patch testing is the gold standard for detection of allergic contact dermatitis in adults and children,” he said. “It is the belief of contact dermatitis experts that patients should be patch tested before starting a systemic immunosuppressive agent such as methotrexate, cyclosporine, [or] dupilumab [Dupixent; Sanofi and Regeneron Pharmaceuticals]…due to the potential for ‘curing’ their dermatitis with allergen avoidance alone.”

Approximately 40% of pediatric patients with AD have a relevant positive allergen that may contribute to their dermatitis, Yu continued. Lack of awareness of the potential allergen can lead to unnecessary long-term treatment with topical steroids or systemic immunosuppressants.

Dermatologists have a wide range of choices for treatment. Although dupilumab has shown efficacy for AD in the pediatric population, Yu said, some patients fail treatment. In these cases, options include tralokinumab (Adbry; LEO Pharma)—the agent specifically binds to and inhibits the cytokine IL-13—and Janus kinase (JAK) inhibitors such as abrocitinib (Cibinqo; Pfizer) and upadacitinib (Rinvoq; AbbVie). Upadacitinib is FDA approved for patients 12 years and older with moderate to severe AD, whereas abrocitinib is approved only for adults.

According to Yu, tralokinumab has an adverse event (AE) profile similar to that of dupilumab, but JAK inhibitors are still being explored.

“In children, we always try to be more cautious, and therefore most pediatric dermatologists would likely offer safer treatment options like dupilumab or tralokinumab prior to novel JAK inhibitors until more is known about the [AE] profiles in children with atopic dermatitis,” Yu said.

The drugs’ ease of dosing and delivery is an important discussion point with patients. If a therapy requires multiple doses a day, adherence may be difficult; if it causes pain, the patient may be resistant. “In my experience, once children see the significant benefit a particular medication has on their skin, they are more likely to adhere to the dosing regimen,” Yu said.

In addition to allopathic medicine, which is a system in which physicians and other healthcare professionals treat symptoms and diseases using drugs, radiation, or surgery, alternative regimens may benefit pediatric patients with eczema, according to Yu. Integrative approaches to consider, in his view, include acupuncture, behavioral therapy, and relaxation techniques, which may help reduce stress, a factor that worsens eczema and AD. For at-home help, apps such as Calm can Headspace offer breathing exercises, but these may not be as suitable for younger patients.

“Natural therapies such as sunflower oil, extra virgin coconut oil, and safflower oil have the most evidence for being effective,” Yu said. “However, I make sure to avoid products for which I don’t know the ingredients, given risk for contact dermatitis.”

This article was originally published by sister publication Dermatology Times.

1. What’s causing your child’s itchy rash? American Academy of Dermatology. March 25, 2022. Accessed March 26, 2022. 

https://www.aad.org/news/cause-childrens-itchy-rash

2. Kaufman B, Alexis A. Eczema in skin of color: what you need to know. National Eczema Association. February 16, 2018. Updated July 15, 2022. 

https://nationaleczema.org/eczema-in-skin-of-color/

3. Reeder M, Atwater AR. Acetophenone azine: The 2021 American Contact Dermatitis Society allergen of the year. 

 2021;107(5):238-240. doi:10.12788/cutis.0252.

4. U.S. FDA approves Rinvoq (upadacitinib) to treat adults and children 12 years and older with refractory, moderate to severe atopic dermatitis. AbbVie. Press Release. Published January 14, 2022. Accessed January 17, 2022. 

https://news.abbvie.com/news/press-releases/us-fda-approves-rinvoq-upadacitinib-to-treat-adults-and-children-12-years-and-older-with-refractory-moderate-to-severe-atopic-dermatitis.htm?view_id=6943

5. Breaking news: FDA approves Cibinqo (Abrocitinib). National Eczema Association. Published January 14, 2022. Accessed January 17, 2022. 

https://nationaleczema.org/cibinqo-approval/

Allergic contact dermatitis and atopic dermatitis are common causes of rashes in the pediatric population. Patch testing can help demystify the cause of such skin conditions and determine treatment. 

Using integrative, allopathic approaches to treat atopic dermatitis

The American Academy of Dermatology (AAD) has released their survey results of more than 1,000 Americans. The Academy found that responders did rate themselves higher for sun protection and said that sun protection is more important to them now than 5 years ago. However, many have a lack of knowledge on how to protect themselves from the sun and the risks of sun exposure, like skin cancer.

Other results include, 62% of responders rating themselves an overall grade of excellent or good for sun protection in 2021, but 63% reported getting a tan, which is an increase of 9% from 2020. About 30% of survey takers reported getting a sunburn, which is an increase from 25% in 2020.

“If you are getting a tan, you are definitely not doing a good job of protecting yourself from the sun,” said board-certified dermatologist Mark D. Kaufmann MD, FAAD, president of the AAD, in the release. “There is no such thing as a safe tan. Every time you tan or burn, you are also damaging the DNA in your skin. The more you damage your DNA, the greater your risk of getting skin cancer.”

Other misconceptions the survey found were:

Responders believing that SPF 30 is twice as protective as SPF 15 (67%)

Often forgetting to reapply sunscreen (65%)

Unaware that shade protects a person from UV rays (43%)

Patients understanding the difference between SPF numbers and what the measures mean is an essential part of sun protection. The AAD recommends that everyone, in order to reduce the risk of skin cancer, should seek shade, wear sun-protective clothing, and apply a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

“It’s great that 82% of respondents say protecting their skin from the sun is more important to them now than it was five years ago,” said Kaufmann in the release. “However, it’s important that people use sun protection now so they can prevent premature skin aging and reduce their risk of skin cancer before they start seeing the damaging effects of the sun on their skin.”

As a way to help educated the public, the AAD will be starting its SPOT Skin Cancer campaign on May 2nd, Melanoma Monday, as May is melanoma awareness month. The Academy has also awarded 20 shade structure grants to public schools and non-profit organizations this year for the installation of permanent shade structures for outdoor locations that are not protected from the sun, such as playgrounds, pools, or recreation spaces, according to the release. Since the start of the Shade Structure Grant program in 1999, the Academy has awarded 480 shade structure grants that protect an estimated 3.6 million people from overexposure to the sun each day. The AAD also has a youth education program called the Good Skin Knowledge, that teaches common skin, hair, and nail conditions to children and adolescence.

“As we head into summer, it’s important that the public practices safe sun to reduce their risk of skin cancer,” Kaufmann concluded. “If you have any questions about how to protect yourself from the sun or notice new or suspicious spots on your skin or any spots that are changing, itching or bleeding, make an appointment to see a board-certified dermatologist.”

New American Academy of Dermatology survey reveals most Americans say sun protection is more important now than five years ago, yet many misunderstand how to protect themselves. April 26, 2022. Accessed April 28, 2022. 

https://www.aad.org/news/new-aad-survey-reveals-growing-importance-sun-protection

The American Academy of Dermatology’s survey finds more Americans say sun protection is more important than 5 years ago, but don’t understand how to protect themselves.

Sun protection misundersunderstood by many Americans

Jonathan Silverberg, MD, associate professor of dermatology at The George Washington University School of Medicine and Health Sciences in Washington, DC, highlighted a 6-week study on a multi-disciplinary, digital therapeutic approach to help with education, treatment adherence, lifestyle changes, and overall self-efficacy for patients with atopic dermatitis (AD). This was presented at the 4th annual Revolutionizing Atopic Dermatitis (RAD) conference held from April 9 to 11 in Baltimore, Maryland.

The goal of this study was to investigate the feasibility of the digital program to help patients. There were 21 patients enrolled in this study, all of which had baseline clinical assessments, and then participated in the 6-week clinical intervention. After the 6 weeks, their follow up visit was held.

“With any kind of digital intervention, whatever it might be, we always think about ‘how do people engage with that intervention?’ ‘how often can they stick with it?’” Silverberg said. “This is a very important part, and we have good numbers here.”

Of the 21 patients examined for the intervention, 20 completed the study intervention. The platform saw that the average weekly active days on the app was 6.5 days, the median active days were 39.0 days, the average daily mission interactions were 8.9, and 95% of participants used the medication reminders and the disease education opportunities.

All of the patients reported that they used topical mediations, with the most common being corticosteroids (19 users), and 4 of the participants used the topical treatments in addition to oral therapies. There were patients who also reported using moisturizers and more, which Silverberg stated, is something to expect with the average patient with AD using multiple therapeutic approaches.

There were multiple outcome measures used during the study to determine the amount of skin disease improvement. A significant improvement from treatment was observed in both the SCORing Atopic Dermatitis (SCORAD) score and Patient-Oriented Eczema Measure (POEM), along with an increase the Dermatology Life Quality Index (DLQI). When the severity of the disease was categorized, it showed a shift toward milder symptoms over time, and the differences observed in clinical outcomes and quality of life (QOL) were large overall. While there was some degree of fluctuation in these results, Silverberg explained, there was a shift in the mild direction.

The SCORAD score has a mean decrease of -25.79 points with a standard deviation (SD) of 19.94 (

 < .001; 1.3 [1.2-1.9, 95% CI]). The POEM mean decrease was -7.50 with a SD of 6.96 (

 < .001; 1.0 [0.5-1.6, 95% CI]) and the mean DLQI score decreased to -3.67 with a SD of 2.50 (

In terms of treatment adherence, Silverberg said, “We have to have this conversation [about adherence]. We should be having this conversation in every field of dermatology, but we are not.” Those patients who had high treatment adherence tended to have higher engagement and compliance with the platform. There was also a shift to better adherence to other behaviors that can help control AD, like using skin care or trigger avoidance, according to Silverberg.

Silverberg emphasized that treatment adherence matters. When looking at the patients in the study, those who had the increased treatment adherence saw a much greater improvement in disease severity than those who did not. He continued to clarify the type of treatment was not as important in this study. The real focus was how a physician can maximize its impact on AD in these patients no matter what treatment they are on.

“I think this is a revolution as we think about digital medicine interventions,” Silverberg concluded.

Silverberg, J. A Novel digital therapeutic intervention to improve symptoms of atopic dermatitis: a feasibility study. Presented at: Revolutionizing Atopic Dermatitis (RAD); April 9-11, 2022; Baltimore, MD.

What role will digital therapeutic agents have in the coming years of atopic dermatitis treatment? It’s still being studied, but Jonathan Silverberg, MD, reviewed an interventional study that may provide key insights into what’s to come.

How can digital therapeutic interventions improve symptoms of atopic dermatitis?

Investigators in a recent study aimed to determine which mental disorders affect pediatric patients with atopic dermatitis (AD) and compare it with the risk of their siblings without a skin condition.

In a cross-sectional, prospective study, theyused a risk assessment instrument for mental disorders in pediatric patients with AD vs their siblings from September 2016 to June 2018. The evaluation instrument used to assess the risk of mental disordersin AD patients was the Child Behavior Checklist (CBCL). The Wilcoxon-Mann-Whitney, Pearson's χ2 test with Yates correction and Fisher's exact test were used, considering a significance level of 5%, the article continued.

It was found thatthe risk of mental disorders in pediatric patients with AD was 63%compared to 36% in the healthy siblings (p < .01). There was also a greater risk forpatients with AD to experiencesleep problems, thought problems, and somatic complaints when compared to their siblings. Parental concerns on socialization and bullying were also more frequent for participants with AD when compared to siblings.

“Children and adolescents with AD present a high risk of [mental disorders], and their healthy siblings also present impairment in their mental health” the authors concluded.“In both cases, this impairment is higher than the one expected in the Brazilian general pediatric population (24.6%) and global pediatric population (22.4%).”

1. Muzzolon M, Muzzolon SRB, Lima M, Canato M, Carvalho VO. Mental disorders and atopic dermatitis in children and adolescents. 

. 2021;38(6):1099-1104. doi:10.5114/ada.2021.112280

What is the relationship between mental disorders and atopic dermatitis? Investigators from a recent study endeavored to find out.

Examining the risk of mental disorders in patients with atopic dermatitis

There have been efforts in dermatology research clinics to improve representation of patient sex, race, and ethnicity, but data on theresults of this endeavor have been sparse. In response, researchers aimed to characterize the diversity of patients in dermatologic trials conducted in the United Statesby comparing patient participation datafrom 2015 to 2020 vs 2010 to 2015, relating to common dermatologic conditions affecting all demographics.

The systematic literature review was populated by PubMed searching for randomized clinical trials published between July 1, 2015, and July 1, 2020. The keywords alopecia areata, acne, atopic dermatitis, lichen planus, psoriasis, seborrheic dermatitis, and vitiligo were used and the data collected included distribution of participant demographic characteristics, funding source, and journal type information.

To emulate the United States census data, studies were defined as unrepresentative of race and ethnicity if they included less than 20% ethnically or racially diverse patients or unrepresentative of sex if they included less than 45% female participants, according to the article. Python was used for statistical analysis by χ2 tests or Fisher exact tests.

In total, 392 randomized clinical trials were used in data collection. Comparing the period from 2010 to 2015 vs 2015 to 2020, the reporting rate for race and ethnicity in United States studies has increased from 59.8% to 71.9% (P = .05). Yet, the proportion of reporting articles including at least 20% non-Caucasian representation remained unchanged at 38.1% with 37 of 97 reporting randomized clinical trials in 2010 to 2015 and 53 of 139 reporting randomized clinical trials in 2015 to 2020 (P = .99), the article continued. Out of all the dermatologic conditions, psoriasis studies included the least diversity, with 12.1% of studies recording at least 20% non-Caucasian participants and 29.5% of studies recording at least 45% female participants.

“The findings of this systematic review suggest that reporting racial and ethnic data since 2010-2015 has become more transparent,” the researchers wrote. “However, inclusion of representative patient populations may still be considered inadequate, particularly in psoriasis studies.”

1. Chen V, Akhtar S, Zheng C, Kumaresan V, Nouri K. Assessment of changes in diversity in dermatology clinical trials between 2010-2015 and 2015-2020: a systematic review. 

. Published online January 26, 2022. doi:10.1001/jamadermatol.2021.5596

An article in examines if any changes have been made to the diversity of dermatologic clinical trials conducted from 2010 to 2015 compared to 2015 to 2020. 