Dr Rosen covered HIV, noting two new vaccines: emtricitabine and tenofovir alafenamide (Descovy), and emtricitabine and tenofovir disoproxil fumarate (Truvada). A 2019 study in The Lancet conclusively supported the theory of “undetectable = untransmittable” by demonstrating zero HIV transmissions over a 2-year period when an HIV+ partner reliably took antiretroviral therapy.
The measles outbreak, a hot topic in media, has spread globally. Statistics from the World Health Organization have shown a 300% increase in the first half of 2019 compared with the same period in 2018. This outbreak coincides with the anti-vaccination movement, which stems from religious and personal exemptions. Vaccination laws, which vary by state, often allow these exemptions; Maine, New York, West Virginia, Mississippi, and California currently allow medical exemptions only.
Mosquito-borne infectious diseases are also increasingly relevant to the dermatologist. While dengue, zika, and chikungunya are all well-known, two new viruses are becoming more common. Mayaro virus (of the Caribbean, Central America, and South America) can cause a nonspecific rash along with high fever, pain behind the eyes, arthralgia, myalgia, and more. Parechovirus (found in Japan and Australia) causes a nonspecific or “mittens and booties” rash commonly seen in children less than 5 years of age.
Approaching Abnormal, Inflamed, and Infected Nails
Boni E. Elewski, MD, shared practical tips for dermatologists looking to approach a variety of nail presentations.3
In her first tip, Dr Elewski discussed how diagnosing the solitary abnormal nail can be a relatively easy process. When the patient presents with a solitary abnormal nail, the dermatologist should take steps to determine the differential diagnosis, including biopsy, x-ray, and culture. However, if malignancy is suspected, x-ray should be used first to note of soft tissue growth. Dermoscopy can be especially useful tool for differential diagnosis.
Dermatologists should also pay attention to longitudinal erythronychia. When multiple nails present with longitudinal erythronychia, the underlying cause is an inflammatory process (eg, lichen planus, graft vs host disease, related to a medication). When longitudinal erythronychia is localized to one nail, it is commonly a sign of onychopapilloma, but it can also be glomus tumor, verrucae, warty dyskeratoma, or isolated lichen planus. Cancerous causes include basal cell carcinoma, Bowen’s disease, and amelanotic melanoma.
In short, Dr Elewski said, if only one nail is involved, the abnormal nail is likely to be caused by a tumor.
Dr Elewski’s second tip regarded inflammatory nail disorders. For example, nail psoriasis occurs in up to 78% of patients with psoriasis and is common in patients with PsA and genital psoriasis. It usually involves several nails and both hands.
When dermatologists consider the nail-joint relationship, particularly the distal and proximal interphalangeal (DIP, PIP) joints, the relationship between nail psoriasis and PsA should be no surprise. “It’s helpful, in my experience, when you have an abnormal nail to feel the DIP and PIP joints,” explained Dr Elewski, “and talk to the patient about pain, difficulty moving, morning stiffness, and so forth, to help nail the diagnosis.”
Three additional features to consider in diagnosing nail psoriasis are irregular pitting of the nail plate, salmon-colored patches or oil spots on the nail bed, and onycholysis with erythematous borders.
Lichen planus can occur in the nail bed as well. This often presents with longitudinal nail plate fissures, nail plate thinning, longitudinal erythronychia, angel wing deformity, dorsal pterygium, and anonychia. Treatment of nail lichen planus is paramount and should be considered a nail emergency. Treatment options include intralesional steroids to the nail matrix at the proximal nail fold, intramuscular or oral steroids, and topical treatments with potent corticosteroids and tazarotene. However, when the nail presents with dorsal pterygium, the nail matrix is dead, so no treatment is going to be effective. Notably, one-third of nail lichen planus presentations progress despite treatment.
The final tip shared recommendations for the treatment of various nail infections. Dr Elewski discussed three major infections:
- Onychomycosis—Trichophyton rubrum is the most common isolate. This infection is treated with terabinafine 250 mg daily for 90 days (though dermatologists should be careful regarding T rubrum’s growing resistance), itraconazole 400 mg daily for 1 week per month for 4 months or 200 mg daily for 3 months, and fluconazole 200 mg to 400 mg once weekly (such as on “Fungal Fridays” or “Toes-day”).
- Pseudomonas—A greenish nail is likely a Pseudomonas infection. An x-ray on the chronic infection or on painful nails should be done to rule out osteomyelitis. Treatment options include vinegar soaks, half white vinegar/half isopropyl alcohol drops placed under the nail, ciprofloxacin otic drops, and oral antibiotics. Most importantly, the affected area should be kept dry.
- Candida—A blackish nail, towards a lateral edge with edema and loss of cuticle, may be caused by Candida infection. Treatment includes oral fluconazole 200 mg daily for one week.
Provide Relief for Patients With Urticaria
Mark Lebwohl, MD, addressed updates in the diagnosis and treatment of chronic urticaria and shared some tips for management.4
Distinguishing physical urticaria from urticarial vasculitis can be easy when dermatologists consider the clinical signs. Chronic physical urticaria lasts less than 24 hours in any one place on the body and often itches, whereas urticarial vasculitis is often painful and can last for weeks in a single place. Notably, autoimmune diseases, such as hyperthyroidism and hypothyroidism, Celiac disease, and Sjögren syndrome, are more prevalent in patients with chronic urticaria.
Interestingly, diet plays no role in the management of urticaria. Patients often share anecdotal improvement in their urticaria when certain foods are eliminated from their diets, but the literature has not shown improvement. The only possible dietary change that may occur in the presentation of urticaria angioedema, noted Dr Lebwohl, follows the bite of a Lonestar tick, which can induce a red meat allergy through the transmission of alpha-gal antibodies.
A number of treatment options for chronic urticaria exist, but as Dr Lebwohl noted, many are relatively ineffective or unsupported in the literature, including narrowband UV-B therapy, methotrexate, tacrolimus, warfarin, eradication of Helicobacter, and sulfasalazine.
Dr Lebwohl highlighted several therapies that have found some success in the treatment of chronic urticaria. For example, systemic corticosteroids can be an option, though it carries the associated risks of systemic treatment and should be initiated with extreme caution.
Next, Dr Lebwohl mentioned antihistamine H₁ as an effective option. In one 2010 study from the Journal of Allergy and Clinical Immunology, 75% of refractory patients with urticaria responded to a higher dose of antihistamines. “My favorite, because it doesn’t make you sleepy even if you up the dose dramatically, is fexofendadine, which is Allegra over-the-counter,” continued Dr Lebwohl. He explained that fexofendadine can be used up to four times a day without side effects.