Contributions from WCD2023 Ambassadors
Collection of articles about dermatology from all over the world. Dermatology beyond borders.
Professor Neil H. Shear MD FRCPC FACP FCDA
Changing the landscape of severe drug reactions: Presentation by Prof. Shear at Society of Pediatric Dermatology 2021
In the opinion of Neil H. Shear, MD, FRCP, FACP, a stepwise approach is the best way to diagnose possible drug-induced skin disease and to determine the root cause.
“Often we need to think of more than one cause,” he said during the annual meeting of the Society for Pediatric Dermatology. “It could be drug X. It could be drug Y. It could be contrast media. We must think broadly and pay special attention to skin of color, overlapping syndromes, and the changing diagnostic assessment over time.”
His suggested diagnostic triangle includes appearance of the rash or lesion(s), systemic impact, and histology.
“The first is the appearance,” said Dr. Shear, professor emeritus of dermatology, clinical pharmacology & toxicology, and medicine at the University of Toronto. “You need to know, is it exanthem? Is it blistering? Don’t just say drug ‘rash.’ That doesn’t work. You need to know if there are systemic features, and sometimes histologic information can change your approach or diagnosis, but not as often as one might think. I think the two main factors are appearance and systemic impact.”
The presence of fever is a hallmark of systemic problems, he continued, “so if you see fever, you know you’re probably going to be dealing with a complex reaction, so we need to know the morphology. Is it simple exanthem (a mild, uncomplicated rash), or is it complex exanthem (DReSS or fever, malaise, adenopathy)?” As for other morphologies, urticarial lesions could be urticarial or SSLR, pustular lesions could be acneiform or AGEP, while blistering lesions could suggest a fixed drug response or SJS/TEN.
Dr. Shear considers SJS/TEN as a spectrum of blistering disease, “because there’s not a single diagnosis,” he said. “There’s a spectrum, if you will, depending on how advanced people are in their disease.”
In 1991 he coauthored a report on eight cases of mycoplasma and Stevens-Johnson syndrome (Clin Pediatr 1991; 30:42-9). “I was surprised at how long that stood up as about the only paper in that area,” he said. “But there’s much more happening now with a proliferation of terms. There’s MIRM, which is mycoplasma pneumonia-induced rash and mucositis. There’s RIME, which is reactive infectious mucocutaneous eruption, and Fuchs syndrome, or SJS without skin lesions (Arch Dermatol 2012;148:963-4).”
What was not appreciated in the early classification of SJS, he continued, was a “side basket” of bullous erythema multiforme (Arch Dermatol 1993;129:92-6). “We didn’t know what to call it,” he said. “At one point we called it bullous erythema multiforme. At another point we called it erythema multiforme major. We just didn’t know what it was.” The appearance and systemic effects of SJS comprise what he termed SJS Type 2—or the early stages of TEN. Taken together he refers to these two conditions as TEN Spectrum, or TENS. “One of the traps is that TENS can look like varicella, and vice versa, especially in very dark brown or black skin,” Dr. Shear said. “You have to be careful. A biopsy might be worthwhile. Acute lupus has the pathology of TENS but the patients are not as systemically ill as true TENS.”
In 2011, Japanese researchers reported on of 38 cases of Mycoplasma pneumoniae-associated SJS and 78 cases of drug-induced SJS (Allergol Int 2011;60:525-32). They found that 66% of adult patients with M. pneumonia-associated SJS developed fever/respiratory symptoms and mucocutaneous lesions on the same day, mostly shortness of breath and cough. In contrast, most of the patients under 20 years of age developed fever/respiratory symptoms before mucocutaneous involvement. “The big clinical differentiator between drug-induced SJS and mycoplasma-induced SJS was respiratory disorder,” said Dr. Shear, who was not affiliated with the study. “That means you’re probably looking at something that’s mycoplasma-related [when respiratory problems are present].
Even if you can’t prove it’s mycoplasma-related, that probably needs to be the target of your therapy. The idea of that is to make sure it’s clear at the end. One, so they get better, and two, so that we’re not giving drugs needlessly when it was really mycoplasma.”
HLA-B∗15:02 is a marker for carbamazepine-induced SJS and TEN. “A positive HLA test can support the diagnosis, confirm the suspected offending drug, and is valuable for familial genetic counseling,” he said.
As for treatment of SJS, TEN, and other cytotoxic T lymphocyte-mediated severe cutaneous adverse reactions, a large Japanese clinical trial of prednisolone 1-1.5 mg/kg/day IV versus etanercept 25-50 mg subcutaneously twice per week found that etanercept decreased the mortality rate by 8.3% (J Clin Invest 2018;128:985-96). Compared with prednisolone, etanercept reduced skin healing time (a mean of 14 vs. 19 days, respectively; P=0.010) and resulted in a lower incidence of GI hemorrhage (2.6% vs. 18.2%; P=0.03).
Dr. Shear said that he would like to see better therapeutics for severe complex patients. “After leaving the hospital, people with SJS or people with TEN need to have ongoing care, consultation, and explanation so they and their families know what drugs are safe in the future,” he said. Dr. Shear disclosed that he has been a consultant to AbbVie, Amgen, Bausch Medicine, Novartis, Sanofi-Genzyme, UCB, LEO Pharma, Otsuka, Janssen, Alpha Laboratories, Lilly, ChemoCentryx, Vivoryon, Galderma, Innovaderm, ChromoCell, and Kyowa Kirin.
Dr. Rataporn Ungpakorn
Dermatological Society of Thailand
Impact of COVID-19 on Dermatology Training and Congresses
Dermatology training is all about visual and tactile sensation. Dermatologists were trained to master the art of seeing and palpating skin changes from the very surface deep down to underlying bony structures. Minute details of skin appearances are crucial for differential diagnoses of skin conditions. It is fortunate that more than half of skin diseases can be accurately diagnosed by fundamental skin examination. Aesthetic procedures follow the same paths whether through gliding filler canula, laser or tightening devices gracefully performed by expert hands.
COVID-19 pandemic has elevated universal precautions to a higher standard. Social distancing norm, PPE, gloves, masks and face shields are among the necessities for safe dermatological practice. Preventative measures evolved from bulky, awkward acrylic boxes to protect both doctor-patient during head and neck procedures but immediately became impractically obsolete. Fully vaccination protocol and COVID-19 screening procedures have resumed dermatological practices to the present norm. Initially, people were so excited about virtual technology that compensated physical activities. Pros and Cons are that a variety of social and business functions were replaceable by development of new virtual platforms. We were able to lean and discard a lot of formalities as well as revolutionized many protocols to match with social distancing scheme. Time zone is no longer a limitation to working hours when scheduling for business discussions except for the adaptability to wake up at beck and call to appointments. Major disadvantage of virtual application is screen size and resolution that limit clarity required for refined clinical images and real-time presentations.
Modern technology still cannot replace actual tactile experience required for dermatological and aesthetic training. Full exposure of oneself to a camera for total skin examination despite being in own private home is still more embarrassing than in a normal private hospital ambiance. Technology still cannot replace human touch.
One of the most enjoyable professional dimensions for dermatologists and aesthetics are attendance to domestic and international congresses. Educational aspects are highlighted by exhibitions, hands-on sessions and vibes of social connectivity. Industrial exhibitors take pride to elaborate their spaces with interactive activities, launching new pharma-cosmeceutical products and state-of-the-art medical devices. It is also a high time opportunity for distributors to hunt for companies, and doctors for advanced medical tools. But most importantly, it is always a great opportunity to connect with colleagues, mentors and friends in an enjoyable blend of academic and sociable environment. Something that COVID-19 has been depriving us from. It would have been unimaginably disappointing to attend a virtual 25th World Congress of Dermatology in Singapore, or anywhere. Let us physically make this a memorable event to celebrate that “Dermatology Goes On as Usual”.