May 8


IN THIS ISSUE / May 8, 2019

Skin scratching and intestinal changes: What’s the link?

Patients with atopic dermatitis (AD) who scratch their skin may have more severe food allergies, according to a recent study published online in Immunity. The study authors connected skin scratching to intestinal changes that make it easier for allergens to enter tissues. To investigate this link, the researchers applied and removed tape to the skin of mice — replicating the scraping away of skin cells from scratching. In the mice models, this led to increased food-related anaphylaxis.

The researchers found that scratching signals interleukin 33 (IL-33), which then enters the patient’s bloodstream and makes its way to the intestines, where it interacts with IL-25. IL-33 and IL-25 interact and activate type 2 innate lymphoid cells, which in turn produce the proteins IL-13 and IL-4. Lastly, IL-13 and IL-4 cause mast cells to expand in the gut, leading to increased food allergen sensitivity.

The investigators conducted intestinal biopsies in eight children — four with atopic dermatitis and four without — to see whether there was a similar effect in humans. As expected, the intestines of the four children with AD contained more mast cells than the intestines of children without AD.

Can the elimination diet hurt pediatric atopic dermatitis patients? Find out in DW Weekly.

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DW Insights and Inquiries: Progress for progressive multifocal leukoencephalopathy

heymann-warren-95px.jpgProgressive multifocal leukoencephalopathy (PML) is a nightmare. For any dermatologist seeing patients with autoimmune diseases, HIV, lymphoproliferative disorders, or who are on immunosuppressive medications (azathioprine, chlorambucil, cyclophosphamide, glucocorticoids methotrexate, TNF inhibitors, and rituximab), PML is a “sword of Damocles,” despite its rarity when such medications are utilized for dermatologic disorders. 

PML is caused by a lytic infection with the John Cunningham (JC) virus leading to progressive damage of oligodendrocytes in the central nervous system (CNS). PML is due to reactivation of a dormant systemic JC virus infection, usually in the setting of systemic immunosuppression. PML presents with progressive cortical symptoms such as paresis, cognitive deficits, sensory deficits, gait disturbances, difficulties with coordination, hemianopia, or aphasia. The diagnosis of PML is confirmed with a combination of clinical, radiographic, and laboratory data. For a definite diagnosis, a positive CSF PCR for JC virus in addition to compatible clinical and imaging findings is mandatory. The prognosis of PML depends on the underlying cause of immunodeficiency and the ability to restore the host’s immune response. The mortality rate for PML is as high as 56.2% for autoimmune diseases, 68.4% for post-transplantation patients, and 83.3% for those with neoplasms. Keep reading!

Sunscreen study supports FDA call for additional data 

According to results of a preliminary study published in JAMA, the application of four commercially available sunscreens under maximal use conditions resulted in plasma concentrations that exceeded the threshold established by the FDA for products to avoid requirements for additional safety data. The threshold is not for whether the sunscreens are safe, but rather for whether nonclinical toxicology studies are subsequently needed. In this pilot study, 24 participants received two milligrams of spray, lotion, or cream sunscreen per 1 cm², applied to 75% of body surface area four times per day for four days. Thirty blood samples were collected over seven days from each participant to determine maximum plasma concentration of avobenzone as well as oxybenzone, octocrylene, and ecamsule. Systemic concentrations greater than 0.5 ng/mL were reached for all four products after four applications on the first day.

The study authors noted, that “The systemic absorption of sunscreen ingredients supports the need for further studies to determine the clinical significance of these findings.” However, they went on to say, “These results do not indicate that individuals should refrain from the use of sunscreen.” In an official statement, Academy President George Hruza, MD, MBA, said “These sunscreen ingredients have been used for several decades without any reported internal side effects in humans. Importantly, the study authors conclude that individuals should not refrain from the use of sunscreen, which the AAD encourages as one component of a comprehensive sun protection plan as sunscreen use has been shown to reduce the risk of skin cancer in a number of scientific studies.” Read more from the Academy statement

For talking points on the JAMA study, visit the AADA Practice Management Center.

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New maximum penalties for HIPAA violations

The Department of Health and Human Services (HHS) has published a new legal interpretation that updates the maximum penalty for HIPAA violations. Up until this point, HIPAA fines have been $1.5 million annually for each category — regardless of the severity of the violation.

The new interpretation sets annual limits for the fines based on the organization’s “level of culpability” associated with the HIPAA violation, according to the HHS’s notice of enforcement discretion. Organizations that have taken measures to meet HIPAA’s requirements will face a much smaller maximum penalty than those who are found neglectful. 

The four tiers with possible penalties are:

  • Tier 1: $100-$50,000 per violation, capped at $25,000 per year the issue persisted
  • Tier 2: $1,000-$50,000 per violation, capped at $100,000 per year the issue persisted
  • Tier 3: $10,000-$50,000 per violation, capped at $250,000 per year the issue persisted
  • Tier 4: $50,000 per violation, capped at $1.5 million per year the issue persisted

 Access Academy tools and resources in the HIPAA Resource Center to make sure your practice is compliant.

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Adopt-a-Shade: Working together 

john-stephens-95px.jpgAt the Indiana Academy of Dermatology (IAD), we do everything we can to make a difference in our communities, to raise awareness of skin health issues, and to protect our patients. So when our executive council recently found itself with a little leftover funding, it was a no-brainer that we should use it to donate a shade structure through the American Academy of Dermatology’s Adopt-a-Shade program

We reached out to the AAD, and they provided us with a list of deserving organizations that had applied for shade structure grants. In the end, we settled on Boone Meadow Elementary School in Whitestown, Indiana. Their application was a few years old, and it had been submitted by the mother of a student who suffered migraines worsened by sun exposure. Keep reading!

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Teledermatology templates decrease face-to-face referrals

Implementing standardized templates with teledermatology referrals decreased the need for face-to-face consultation, according to a study published in the International Journal of Dermatology. Researchers evaluated 42 store-and-forward teledermatology consultations from family medicine providers at the Mayo Clinic. The data were then compared to previous teledermatology referrals that did not use the standardized templates.

Implementation of the standardized templates decreased face-to-face referrals by 28%. The teledermatology consultation increased the concordance of diagnosis and management plan between the family medicine practitioners and the dermatologist by 26% and 33%, respectively. The study authors conclude that teledermatology improves primary care-based dermatologic care and reduces theoretical referral rates.

How are practices making teledermatology work? Find out in Dermatology World.

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