UPDATES IN MEDICAL DERMATOLOGY
Introduction
Iam pleased to present you with this issue of Seminars in
Cutaneous Medicine and Surgery on the topic of Updates in
Medical Dermatology. Over the past decade or so, a great
emphasis has been placed on procedural and cosmetic dermatology,
causing many experts in our field to be concerned
that the scope of dermatology is narrowing. The management
of psoriasis, atopic dermatitis, cutaneous T-cell lymphoma
(CTCL), melanoma, and wound healing is often now done by
nondermatology providers—rheumatologists, allergists, oncologists,
and others. With the many advances in the understanding
of these cutaneous disease processes— having implications
for diagnosis, prognosis, and treatment—there is a
broad scope where we as a profession can have an impact.
This issue will update the reader on important medical dermatology
topics, such as atopic dermatitis, CTCL, melanoma,
and wound healing. It will also provide the reader with a
thorough review of two of the most controversial vitamins—
vitamin A and vitamin D.
This issue begins with a comprehensive and clinically useful
update on the “sunshine vitamin.” Dr Gilchrest has published
extensively on this topic and dispels myths propagated
by the media and supplement industry. The next article by Dr
Chapman highlights the other important and controversial
vitamin, vitamin A, offering the reader insight into the controversy
and confusion that surrounds isotretinoin therapy.
Moving away from the vitamins and to other hot medical
dermatology issues, Dr Armstrong’s group highlights advances
in the treatment of atopic dermatitis since it was last
reviewed in Seminars in Cutaneous Medicine and Surgery in
June 2008. Dr Peter Heald, a world’s expert in CTCL, presents
his “menus for the management” of CTCL. An update on
wound healing by Dr Tania Phillips both reviews important
wound management issues and highlights new advances in
this field. The final two articles are dedicated to melanoma, a
disease which in its advanced stages has remained incurable
and a focus of much research. Dr Kim’s group summarizes
imaging technologies for pigmented lesions, highlighting
those advances since the September 2009 issue of Seminars in
Cutaneous Medicine and Surgery. With recent advances in the
understanding of the molecular and immunologic mechanisms
of melanoma, Dr Krathen updates the reader on the
ever-changing areas of diagnosis, prognosis, and treatment of
melanoma.
It has been my pleasure to work with this group of esteemed
dermatologists. Their thoughtful contributions make
this update in medical dermatology fascinating, and I hope
will remind the reader of the breadth of our wonderful field.
What You and Your Patients Need to Know About Vitamin D
“Vitamin D” is the term commonly used to denote the lipid-soluble hormone critical for
calcium homeostasis and skeletal maintenance. A precursor to the active compound is
found in many plants and animal tissues and can be absorbed from the gut; it can also be
derived from cell membranes in the epidermis during ultraviolet B irradiation. This compound
is then hydroxylated sequentially in the liver and kidney to produce the active
hormone 1,25(OH)2D that binds its nuclear receptor to modulate gene expression. Recently,
vitamin D hydroxylases and the nuclear receptor have been identified in many
tissues, suggesting previously unrecognized roles for vitamin D. Some epidemiologic
studies have also correlated low levels of the inactive storage form 25(OH)D with an
increased incidence or prevalence of a variety of diseases, suggesting that large oral
supplements and/or increased ultraviolet (UV) exposure might therefore improve individual
health. However, randomized, prospective controlled trials comparing vitamin D supplements
with placebo have not supported this belief. Moreover, current evidence supports
the conclusion that protection from UV radiation does not compromise vitamin D status or
lead to iatrogenic disease. In contrast, high vitamin D levels appear to incur a risk of kidney
stones and other adverse effects. In the case of true vitamin D deficiency, supplements are
a more reliable and quantifiable source of the vitamin than UV exposure.
Semin Cutan Med Surg 31:2-10 © 2012 Elsevier Inc. All rights reserved.
Vitamin A: History, Current Uses, and Controversies
Vitamin A is required for the proper functioning of many important metabolic and physiologic
activities, including vision, gene transcription, the immune system and skin cell
differentiation. Both excessive and deficient levels of vitamin A lead to poor functioning of
many human systems. The biologically active form, retinoic acid, binds to nuclear receptors
that facilitate transcription that ultimately leads to it’s physiological effects. Retinoids are
derivatives of vitamin A that are medications used to treat acne vulgaris, psoriasis,
ichthyosis (and other disorders of keratinization), skin cancer prevention as well as several
bone marrow derived neoplasias. Systemic retinoids are teratogenic and have to be
prescribed with caution and close oversight. Other potential adverse events are controversial.
These include the relationship of retinoid derivatives in sunscreens, their effects on
bone mineral density, depression and suicidal ideation and inflammatory bowel disease.
These controversies will be discussed in detail.
Semin Cutan Med Surg 31:11-16 © 2012 Published by Elsevier Inc.
Advances in Management of Atopic Dermatitis: New Therapies and Novel Uses of Existing Treatments
Atopic dermatitis (AD) is a chronic inflammatory skin condition marked by intensely
pruritic, eczematous changes. First-line therapy includes topical corticosteroids during an
exacerbation and long-term emollient use, followed by topical calcineurin inhibitors, phototherapy,
and systemic therapy in more difficult cases. The need for more effective AD
therapies with safer side effect profiles has pushed researchers to devise new therapies
and to recycle traditional treatments for use in a novel manner. Innovative therapies include
barrier therapy, novel antistaphylococcal treatments, new immunomodulatory agents, unconventional
antipruritic agents, exclusionary diets, and probiotics. Advancements in these
options have paved the way for a targeted approach to AD therapy. We will review the latest
clinical research exploring these cutting-edge AD treatment modalities and discuss forward-
thinking therapy strategies that use conventional AD medications in a novel manner.
Semin Cutan Med Surg 31:17-24 © 2012 Elsevier Inc. All rights reserved.
Menus for Managing Patients With Cutaneous T-Cell Lymphoma
In the management of patients with cutaneous T-cell lymphoma (CTCL), there are numerous
distinct therapy options. Each of these therapies is discussed in terms of when to use
it, what factors limit the success of the treatment, and what to expect. A menu is defined
as a list of items from which to choose. The treatments for CTCL are presented in various
menus where they are options for a particular goal in a particular setting of CTCL. The best
recognized clinical scenarios of CTCL are those recognized by the staging system: limited
patch plaque (T1), disseminated patch plaque (T2), erythroderma (T4), and tumor (T3). Each
phase of the disease will have the menu of therapy options presented for a given goal of
management.
Semin Cutan Med Surg 31:25-32 © 2012 Published by Elsevier Inc.
Wound Healing Update
The management of acute and chronic wounds has drastically changed within the past 20
years. This update focuses on the most recent recommendations for acute wound care as
well as new technologies that are available for chronic wounds.
Semin Cutan Med Surg 31:33-37 © 2012 Elsevier Inc. All rights reserved.