in HIV infection Editor, We would like to highlight an uncommon clinical occurrence of vitiligo-like leukoderma subsequent to human immunodeficiency virus (HIV) photodermatitis. At universities in South Africa and the USA, we have had the opportunity to study nine patients of African descent with HIV infection, including both male and female subjects (Figs. 1 and 2). Patient ages ranged from 27 to 60 years, and CD4 counts ranged from 14 to 280. Five of the nine patients were on antiretroviral medications. One patient was treated for an unrelated comorbidity with a potentially photosensitizing agent, hydrochlorothiazide, which was discontinued prior to the onset of leukoderma. Six of our cases were biopsied during the initial photodermatitis stage and showed variable degrees of acanthosis, spongiosis, and superficial lymphocytic inflammation with and without eosinophils. Of note, photosensitivity occurs in approximately 5.4% of HIV-seropositive patients, and individuals of African descent are more susceptible to these cutaneous changes. This condition commonly afflicts HIV-infected people with advanced disease (CD4 counts of <50) and worsens as the disease progresses. However, the development of leukoderma is rare. In instances in which medications are not implicated, the etiology of HIV photodermatitis is not well understood. However, ultraviolet (UV) radiation is known to increase the same inflammatory cytokines that are upregulated in HIV infection. Moreover, UV radiation accelerates oxidative damage, further weakening the hampered immune system in HIV. As a result, patients with HIV who are already susceptible to inflammatory and oxidative reactions become even more vulnerable in response to sunlight. Leukoderma or vitiligo-like depigmentation following HIV photodermatitis is rarely described in the literature. Although this appears to be a secondary phenomenon, given its temporal association and distribution of lesions, it is distinct from post-inflammatory hypopigmentation. This view is supported by the presence of palmoplantar leukoderma in one of our patients, in addition to typical papulosquamous, photodistributed lesions. Furthermore, histology of the leukoderma in one biopsied case showed loss of both melanocytes and pigment, similarly to histologic findings in vitiligo; this is by contrast with findings in post-inflammatory hypopigmentation, which is characterized by normal melanocytes and superficial dermal pigment incontinence. In some of the few instances of primary, new-onset vitiligo in HIV patients, it has been speculated that HIV may Figure 2 Acral depigmentation in association with HIV photodermatitis Figure 1 Photodistributed papulosquamous eruption with transition to leukoderma in a patient with human immunodeficiency virus infection e306

Psoriasis in HIV-infected patients poses a distinct challenge to the dermatologist due to its increased severity, tendency to be refractory to common treatment modalities, and necessity for cautious use of immunosuppressive agents. Tumor necrosis factor-α inhibitors have been shown to be safe and effective for the treatment of psoriasis in the general population, but their role in the treatment of HIV-positive patients is still unclear. The use of the tumor necrosis factor-α inhibitor adalimumab for the treatment of psoriasis in HIV-positive patients has yet to be reported. We present the case of a 49-year-old HIV-positive man with severe plaque psoriasis who has been successfully treated with adalimumab for the past 30 months with no adverse events related to treatment.

Background Many HIV-2 and SIV isolates, as well as some HIV-1 strains, can use the orphan 7-transmembrane receptor GPR15 as co-receptor for efficient entry into host cells. GPR15 is expressed on central memory and effector memory CD4+ T cells in healthy individuals and a subset of these cells is susceptible to HIV-1 and SIV infection. However, it has not been determined whether GPR15 expression is altered in the context of HIV-1 infection. Results Here, we show that GPR15 expression in CD4+ T cells is markedly up-regulated in some HIV-1 infected individuals compared to the rest of the infected patients and to healthy controls. Infection of the PM1 T cell line with primary HIV-1 isolates was found to up-regulate GPR15 expression on the infected cells, indicating that viral components can induce GPR15 expression. Up-regulation of GPR15 expression on CD4+ T cells was induced by activation of Toll-like receptor 3 signalling via TIR-domain-containing adapter-inducing interferon-β (TRIF) and was more prominent on gut-homing compared to lymph node-homing CD4+ T cells. Conclusion These results suggest that infection-induced up-regulation of GPR15 expression could increase susceptibility of CD4+ T cells to HIV infection and target cell availability in the gut in some infected individuals.

Patients with delusional infestations ( DI ), previously named delusions of parasitosis, have a fixed, false belief that they are infested with living or non‐living pathogens. Patients have abnormal cutaneous symptoms such as itching, biting, or crawling sensations. They often demonstrate self‐destructive behavior in an effort to rid the pathogens from under their skin, leading to excoriations, ulcerations, and serious secondary infections. This review article aims to provide an overview of DI including its clinical presentation, diagnosis, and treatment. Strategies on how to establish a strong therapeutic alliance with DI patients are discussed. In addition, antipsychotic medications used in the treatment of DI are described.

The ideal repair mechanism for overcoming barrier disruption in atopic dermatitis (AD) needs to completely eliminate microbe and allergen penetration as well as transepidermal water loss. We propose the hydrogel patch as an innovative approach to complete barrier repair. It is composed of an adhesive, thin, flexible, hydrogel layer on an impermeable urethane surface. We conducted a 6-week pilot study with 15 AD patients, who applied the hydrogel patch over one lesion for 6-8 h daily and triamcinolone (TAC) 0.1% cream twice daily to another lesion. Results after 2-week no treatment follow-up showed hydrogel patch had notable efficacy, and comparable to TAC 0.1% cream. Larger studies are needed to validate these results.

When treating psoriasis, various topical emollients exist that can affect the penetration of ultraviolet radiation in phototherapy. Compared with normal-appearing skin with a reflectance of 4% to 5%, psoriatic skin has higher reflectance as a result of its increased air-to-corneocyte interfaces. Studies have tested the effect of emollients on light penetration by assessing psoriatic plaque clearance, differences in minimal erythema dose, and physical properties of the emollient (eg, monochromatic protection factor and absorbance). Psoriatic plaque clearance was found to improve with serous (thin liquid)-based emollients (eg, Vaseline oil [Unilever, Blackfriars, London, UK], mineral oil, and glycerol), whereas clearance decreased with salicylic acid and viscous-based emollients (eg, petrolatum). Emollients with high ultraviolet absorbance properties increased minimal erythema dose, and those with low absorbance properties decreased minimal erythema dose. Interestingly, when a liquid emollient with a refractive index close to that of normal-appearing skin was applied, there was a net increase in light absorption, or a reduction in reflection that exceeded the emollient's innate ability to absorb light.

The availability of new biologic agents for the treatment of psoriasis provides hope for improved quality of life outcomes. However, the way patients come to use biologics, the potential barriers they encounter, and their attitudes towards using these medications are still not well studied. Here, we conducted a survey of 106 psoriasis patients at an academic medical center to discern patient attitudes towards biologics. We found that most patients learn of biologics through their physician and perform follow-up research using the Internet. Most patients did not find it difficult to make the decision to start a biologic. Difficulty in obtaining biologics was associated with age less than 55 (p = 0.01), lower income level (p = 0.007), and lack of insurance (p = 0.04). Patients were found to have high satisfaction and compliance rates on biologics. Of patients who missed a dose of their biologic, this was mainly due to logistical reasons such as not having the medication or forgetting to take it, rather than being depressed or overwhelmed. Patients with lower income levels had increased cut backs in personal expenses due to co-payments (p = 0.001). Among respondents, the mean annual out-of-pocket expense for a biologic was $557.12 per year, with a range of $0-7000.

Vitamin D as a topical treatment has become one of the mainstays for treatment of psoriasis vulgaris. Oral vitamin D on the other hand has for the most part become a forgotten option. But a review of the literature on oral vitamin D as a treatment for psoriasis reveals that this treatment is efficacious. The main side effect of this therapy is hypercalcemia, which appears to be easily monitored and avoidable with proper dosing and monitoring. The literature also suggests a correlation between low levels of serum vitamin D in this patient population associated with increased severity of disease involvement. In addition, oral vitamin D improves psoriatic arthropathy. Moreover, vitamin D has been proven to have many health benefits such as prevention of cancer, improved cardiovascular health among many others. Psoriatic patients as a population are at increased risk of developing adverse health complications such as cardiovascular disease, and oral vitamin D may prove to be of benefit in this population. Oral vitamin D is inexpensive and easily available. It is still a viable option and should not be forgotten as a possible treatment for psoriasis.

The treatment options for psoriasis in HIV-infected individuals are limited due to the immunosuppressive nature of the therapeutic modalities and the patient's immunocompromised state. Etanercept has been shown to be safe and effective in the non-HIV psoriasis population with nearly 20 years of experience. However, there is limited data on the safety of etanercept use in the HIV patient population. The authors report a case of an HIV-infected patient with psoriasis who has remained mostly clear on continuous, uninterrupted etanercept use for over six years.

The negative impact of psoriasis on a patient's quality of life (QoL) is well documented in the literature. Patients often suffer poor self-esteem, difficulties in social interactions, and significant psychological distress. It is, therefore, critically important that a clinician evaluate the extent to which the disease impacts a patient's QoL. This chapter reviews several validated and reliable generic, dermatology-specific, and disease-specific QoL instruments useful in measuring the impact of psoriasis on patient's QoL. These QoL instruments can be especially helpful in identifying those patients who would most benefit from systemic or biologic therapy.

Treatment of psoriasis in the elderly population can present many challenges to the physician. Herein we propose a treatment algorithm for psoriasis in this age group. When choosing a therapy for generalized psoriasis in elderly patients, ultraviolet treatments should be attempted first because of their efficacy and safety. Of the external treatment approaches, Goeckerman, although one of the safest and most effective therapies, should be a later treatment option, reserved for the most severe, recalcitrant cases. Acitretin is the next best approach because of its nonclinically immunosuppressive nature. If combination therapy of acitretin with phototherapy proves inadequate, etanercept, adalimumab, alefacept, ustekinumab, and infliximab should then be considered, in successive order. The penultimate treatment options to consider should be the oral agents, cyclosporine and methotrexate, because of their greater risk of major organ toxicity. The last option involves combination therapy with systemic immunosuppressant agents.

As early as 1925, patients suffering from psoriasis have been effectively treated with combination crude coal tar and ultraviolet B radiation, commonly known as Goeckerman therapy. Even though the efficacy of Goeckerman therapy is as good as, if not better than, other more recently available treatment options, its use virtually disappeared after extended inpatient therapies became no longer feasible in the USA. Our clinic at the University of California San Francisco is one of the few outpatient dermatologic clinics that still offer Goeckerman therapy. We present a case report of a patient with severe generalized plaque-type psoriasis, who demonstrated dramatic improvement within 28 days of Goeckerman therapy. It is our hope that this case report serves to remind physicians that Goeckerman therapy is viable treatment option for patients with severe psoriasis, especially those with treatment-resistant psoriasis.

Recent studies have suggested that inflammatory responses may play an important role in the pathophysiology of depression. In fact, depressed individuals have been found to have higher levels of pro-inflammatory cytokines, especially tumor necrosis factor-alpha (TNF-α) and interleukin-6. This appears to be independent of any pre-existing chronic inflammatory disorders. In this article, various studies correlating increased levels of cytokines to depression are reviewed. As much as 60% of individuals with psoriasis also suffer from clinical depression. TNF-α antagonists, frequently used in the treatment of psoriasis, may be helpful in directly reducing depressive symptoms for patients with psoriasis and other chronic inflammatory conditions.

Phototherapy is one of the oldest therapeutic modalities for the treatment of generalized psoriasis. Optimal efficacy for phototherapy is based on achieving the minimal erythema dose (MED) as quickly as possible. MED testing on every patient would be ideal to determine each individual's most effective dose. Previous methods of determining MED are cumbersome; however, the excimer laser has made MED determination easy. The excimer laser is not only a treatment modality in itself, but it can also be used to provide the clinician with a quick and easy way of determining each individual patient's MED. In this way, the laser can also significantly enhance efficacy for patients undergoing traditional narrowband ultraviolet B phototherapy.