Title: 2017 ACC/AHA/HRS guidelines for patients with syncope

Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?

Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.

 

Study Design: Evidence-based guidelines.

Setting: Panel of experts.

Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.

The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.

Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.

Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.

Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.

Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.

Title: 2017 ACC/AHA/HRS guidelines for patients with syncope

Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?

Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.

 

Study Design: Evidence-based guidelines.

Setting: Panel of experts.

Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.

The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.

Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.

Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.

Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.

Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.

Title: 2017 ACC/AHA/HRS guidelines for patients with syncope

Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?

Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.

 

Study Design: Evidence-based guidelines.

Setting: Panel of experts.

Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.

The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.

Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.

Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.

Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.

Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.

Citing safety concerns, the Food and Drug Administration’s Arthritis Advisory Committee voted overwhelmingly against recommending FDA approval of the interleukin-6 inhibitor sirukumab for refractory rheumatoid arthritis.

Janssen Biotech submitted a biologics license application (BLA) for the monoclonal antibody, seeking an indication for adults with moderately to severely active rheumatoid arthritis (RA) who had an inadequate response or intolerance to one or more prior disease-modifying antirheumatic drugs, but despite agreeing unanimously that the data presented by the applicant provided substantial evidence of efficacy for this indication, the committee voted 12-1 against approval at an Aug. 2 meeting.

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Citing safety concerns, the Food and Drug Administration’s Arthritis Advisory Committee voted overwhelmingly against recommending FDA approval of the interleukin-6 inhibitor sirukumab for refractory rheumatoid arthritis.

Janssen Biotech submitted a biologics license application (BLA) for the monoclonal antibody, seeking an indication for adults with moderately to severely active rheumatoid arthritis (RA) who had an inadequate response or intolerance to one or more prior disease-modifying antirheumatic drugs, but despite agreeing unanimously that the data presented by the applicant provided substantial evidence of efficacy for this indication, the committee voted 12-1 against approval at an Aug. 2 meeting.

[email protected]

Citing safety concerns, the Food and Drug Administration’s Arthritis Advisory Committee voted overwhelmingly against recommending FDA approval of the interleukin-6 inhibitor sirukumab for refractory rheumatoid arthritis.

Janssen Biotech submitted a biologics license application (BLA) for the monoclonal antibody, seeking an indication for adults with moderately to severely active rheumatoid arthritis (RA) who had an inadequate response or intolerance to one or more prior disease-modifying antirheumatic drugs, but despite agreeing unanimously that the data presented by the applicant provided substantial evidence of efficacy for this indication, the committee voted 12-1 against approval at an Aug. 2 meeting.

[email protected]

The Food and Drug Administration has approved a monthly injectable formulation of aripiprazole, (Abilify Maintena) , for a maintenance monotherapy treatment of bipolar I disorder for adults, Otsuka and Lundbeck have announced.

Patients treated with the injectable formulation of the atypical antipsychotic must continue to take a daily oral antipsychotic for the first 14 days. After that, however, the long-acting injectable (LAI) – which must be administered by a health care professional – can replace the daily medication.

[email protected]

The Food and Drug Administration has approved a monthly injectable formulation of aripiprazole, (Abilify Maintena) , for a maintenance monotherapy treatment of bipolar I disorder for adults, Otsuka and Lundbeck have announced.

Patients treated with the injectable formulation of the atypical antipsychotic must continue to take a daily oral antipsychotic for the first 14 days. After that, however, the long-acting injectable (LAI) – which must be administered by a health care professional – can replace the daily medication.

[email protected]

The Food and Drug Administration has approved a monthly injectable formulation of aripiprazole, (Abilify Maintena) , for a maintenance monotherapy treatment of bipolar I disorder for adults, Otsuka and Lundbeck have announced.

Patients treated with the injectable formulation of the atypical antipsychotic must continue to take a daily oral antipsychotic for the first 14 days. After that, however, the long-acting injectable (LAI) – which must be administered by a health care professional – can replace the daily medication.

[email protected]

Critics have feared that California’s “Laura’s Law,” designed to prevent violence by making it easier for officials to force outpatient care upon people with mental illness who have resisted treatment, would violate the civil rights of Golden State residents.

But early statistics gathered by a Northern California psychiatrist suggest that few people have been forced involuntarily into outpatient care in large counties that have adopted the tougher approach in recent years. Instead, Californians targeted by the law appear to be choosing – under pressure – the alternative of accepting outpatient treatment.

Critics have feared that California’s “Laura’s Law,” designed to prevent violence by making it easier for officials to force outpatient care upon people with mental illness who have resisted treatment, would violate the civil rights of Golden State residents.

But early statistics gathered by a Northern California psychiatrist suggest that few people have been forced involuntarily into outpatient care in large counties that have adopted the tougher approach in recent years. Instead, Californians targeted by the law appear to be choosing – under pressure – the alternative of accepting outpatient treatment.

Critics have feared that California’s “Laura’s Law,” designed to prevent violence by making it easier for officials to force outpatient care upon people with mental illness who have resisted treatment, would violate the civil rights of Golden State residents.

But early statistics gathered by a Northern California psychiatrist suggest that few people have been forced involuntarily into outpatient care in large counties that have adopted the tougher approach in recent years. Instead, Californians targeted by the law appear to be choosing – under pressure – the alternative of accepting outpatient treatment.

CHICAGO – Late dermatologic manifestations in children who have received hematopoietic stem cell transplants may be more common than previously thought, according to results of a new study.

Johanna Song, MD, and her collaborators reported that, in their prospective pediatric study, 25% of patients had permanent alopecia and 16% had psoriasis, noting that late nonmalignant skin effects of hematopoietic stem cell transplantation (HSCT) have been studied primarily retrospectively, and in adults. Vitiligo and nail changes were also seen.

In a poster presentation at the World Congress of Dermatology, Dr. Song and her colleagues noted that these figures are higher than the previously reported pediatric rates of 1.7% for vitiligo and 15.6% for permanent alopecia. “Early recognition of these late effects can facilitate prompt and appropriate treatment, if desired,” they said.

The single-center, cross-sectional cohort study tracked pediatric patients over an 18-month period and included patients who were at least 1 year post allogeneic HSCT and had not relapsed. Patients who were not English speaking were excluded.

The median age of the 85 patients enrolled in the study was 13.8 years, and participants were a median of 3.6 years post transplant at the time of enrollment. The study’s analysis attempted to determine which patient, transplant, and disease factors might be associated with the late nonmalignant skin changes, according to Dr. Song, a resident dermatologist at Harvard University, Boston, and her colleagues.

Most – 52– of the patients (61.2%) had hematologic malignancies; 12 patients (14.1%) received their transplant for bone marrow failure, and 11 patients (12.5%) had immunodeficiency. Three patients (3.5%) received HSCT for other malignancies, and seven (8.2%) for nonmalignant diseases.

Diffuse hair thinning was seen in 13 (62%) of the 21 patients who had alopecia, while 11 (52%) of the patients with alopecia had an androgenetic hair loss pattern. Chronic graft versus host disease (GVHD), skin chronic GVHD, a HSCT regimen that included busulfan conditioning, and a family history of early male-pattern alopecia were all significantly associated with post-HSCT permanent alopecia (P less than .05 for all).

The patients with androgenetic alopecia may be experiencing an accelerated time course of a condition to which they are already genetically disposed, noted Dr. Song and her colleagues.

Psoriasis was commonly seen on the scalp, affecting 11 of the 14 patients with psoriasis (79%), and involved the face in five of the patients (36%). Just one patient had psoriasis elsewhere on the body. There was a nonsignificant trend towards human leukocyte antigen mismatch among patients who had psoriasis. Although “psoriasis may be a marker of persistent immune dysregulation,” the investigators said, they did not identify any associated risk factors that would point toward this mechanism in their analysis.

Twelve patients (14%) had vitiligo, with halo nevi seen in four of these patients. Children who were younger than age 10 years and those who received their transplant for primary immunodeficiency were significantly more likely to have vitiligo (P less than .05 for both). Specific possible mechanisms triggering vitiligo could include thymic dysfunction resulting in loss of self-tolerance, and donor alloreactivity against the patient’s host antigens, according to the authors.

Nail changes such as pterygium and nail pitting, ridging, or thickening were seen in just five patients, all of whom had chronic GVHD of the skin. “Nail changes are likely a result of persistent inflammation and immune dysregulation from chronic GVHD,” said Dr. Song.

These late effects “can significantly impact patients’ quality of life,” according to the authors, who called for larger studies that follow pediatric HSCT patients longitudinally, beginning before the transplant – and for more investigation into the pathogenesis of specific late effects.

Dr. Song reported no relevant conflicts of interest.
 

[email protected]

On Twitter @karioakes

CHICAGO – Late dermatologic manifestations in children who have received hematopoietic stem cell transplants may be more common than previously thought, according to results of a new study.

Johanna Song, MD, and her collaborators reported that, in their prospective pediatric study, 25% of patients had permanent alopecia and 16% had psoriasis, noting that late nonmalignant skin effects of hematopoietic stem cell transplantation (HSCT) have been studied primarily retrospectively, and in adults. Vitiligo and nail changes were also seen.

In a poster presentation at the World Congress of Dermatology, Dr. Song and her colleagues noted that these figures are higher than the previously reported pediatric rates of 1.7% for vitiligo and 15.6% for permanent alopecia. “Early recognition of these late effects can facilitate prompt and appropriate treatment, if desired,” they said.

The single-center, cross-sectional cohort study tracked pediatric patients over an 18-month period and included patients who were at least 1 year post allogeneic HSCT and had not relapsed. Patients who were not English speaking were excluded.

The median age of the 85 patients enrolled in the study was 13.8 years, and participants were a median of 3.6 years post transplant at the time of enrollment. The study’s analysis attempted to determine which patient, transplant, and disease factors might be associated with the late nonmalignant skin changes, according to Dr. Song, a resident dermatologist at Harvard University, Boston, and her colleagues.

Most – 52– of the patients (61.2%) had hematologic malignancies; 12 patients (14.1%) received their transplant for bone marrow failure, and 11 patients (12.5%) had immunodeficiency. Three patients (3.5%) received HSCT for other malignancies, and seven (8.2%) for nonmalignant diseases.

Diffuse hair thinning was seen in 13 (62%) of the 21 patients who had alopecia, while 11 (52%) of the patients with alopecia had an androgenetic hair loss pattern. Chronic graft versus host disease (GVHD), skin chronic GVHD, a HSCT regimen that included busulfan conditioning, and a family history of early male-pattern alopecia were all significantly associated with post-HSCT permanent alopecia (P less than .05 for all).

The patients with androgenetic alopecia may be experiencing an accelerated time course of a condition to which they are already genetically disposed, noted Dr. Song and her colleagues.

Psoriasis was commonly seen on the scalp, affecting 11 of the 14 patients with psoriasis (79%), and involved the face in five of the patients (36%). Just one patient had psoriasis elsewhere on the body. There was a nonsignificant trend towards human leukocyte antigen mismatch among patients who had psoriasis. Although “psoriasis may be a marker of persistent immune dysregulation,” the investigators said, they did not identify any associated risk factors that would point toward this mechanism in their analysis.

Twelve patients (14%) had vitiligo, with halo nevi seen in four of these patients. Children who were younger than age 10 years and those who received their transplant for primary immunodeficiency were significantly more likely to have vitiligo (P less than .05 for both). Specific possible mechanisms triggering vitiligo could include thymic dysfunction resulting in loss of self-tolerance, and donor alloreactivity against the patient’s host antigens, according to the authors.

Nail changes such as pterygium and nail pitting, ridging, or thickening were seen in just five patients, all of whom had chronic GVHD of the skin. “Nail changes are likely a result of persistent inflammation and immune dysregulation from chronic GVHD,” said Dr. Song.

These late effects “can significantly impact patients’ quality of life,” according to the authors, who called for larger studies that follow pediatric HSCT patients longitudinally, beginning before the transplant – and for more investigation into the pathogenesis of specific late effects.

Dr. Song reported no relevant conflicts of interest.
 

[email protected]

On Twitter @karioakes

CHICAGO – Late dermatologic manifestations in children who have received hematopoietic stem cell transplants may be more common than previously thought, according to results of a new study.

Johanna Song, MD, and her collaborators reported that, in their prospective pediatric study, 25% of patients had permanent alopecia and 16% had psoriasis, noting that late nonmalignant skin effects of hematopoietic stem cell transplantation (HSCT) have been studied primarily retrospectively, and in adults. Vitiligo and nail changes were also seen.

In a poster presentation at the World Congress of Dermatology, Dr. Song and her colleagues noted that these figures are higher than the previously reported pediatric rates of 1.7% for vitiligo and 15.6% for permanent alopecia. “Early recognition of these late effects can facilitate prompt and appropriate treatment, if desired,” they said.

The single-center, cross-sectional cohort study tracked pediatric patients over an 18-month period and included patients who were at least 1 year post allogeneic HSCT and had not relapsed. Patients who were not English speaking were excluded.

The median age of the 85 patients enrolled in the study was 13.8 years, and participants were a median of 3.6 years post transplant at the time of enrollment. The study’s analysis attempted to determine which patient, transplant, and disease factors might be associated with the late nonmalignant skin changes, according to Dr. Song, a resident dermatologist at Harvard University, Boston, and her colleagues.

Most – 52– of the patients (61.2%) had hematologic malignancies; 12 patients (14.1%) received their transplant for bone marrow failure, and 11 patients (12.5%) had immunodeficiency. Three patients (3.5%) received HSCT for other malignancies, and seven (8.2%) for nonmalignant diseases.

Diffuse hair thinning was seen in 13 (62%) of the 21 patients who had alopecia, while 11 (52%) of the patients with alopecia had an androgenetic hair loss pattern. Chronic graft versus host disease (GVHD), skin chronic GVHD, a HSCT regimen that included busulfan conditioning, and a family history of early male-pattern alopecia were all significantly associated with post-HSCT permanent alopecia (P less than .05 for all).

The patients with androgenetic alopecia may be experiencing an accelerated time course of a condition to which they are already genetically disposed, noted Dr. Song and her colleagues.

Psoriasis was commonly seen on the scalp, affecting 11 of the 14 patients with psoriasis (79%), and involved the face in five of the patients (36%). Just one patient had psoriasis elsewhere on the body. There was a nonsignificant trend towards human leukocyte antigen mismatch among patients who had psoriasis. Although “psoriasis may be a marker of persistent immune dysregulation,” the investigators said, they did not identify any associated risk factors that would point toward this mechanism in their analysis.

Twelve patients (14%) had vitiligo, with halo nevi seen in four of these patients. Children who were younger than age 10 years and those who received their transplant for primary immunodeficiency were significantly more likely to have vitiligo (P less than .05 for both). Specific possible mechanisms triggering vitiligo could include thymic dysfunction resulting in loss of self-tolerance, and donor alloreactivity against the patient’s host antigens, according to the authors.

Nail changes such as pterygium and nail pitting, ridging, or thickening were seen in just five patients, all of whom had chronic GVHD of the skin. “Nail changes are likely a result of persistent inflammation and immune dysregulation from chronic GVHD,” said Dr. Song.

These late effects “can significantly impact patients’ quality of life,” according to the authors, who called for larger studies that follow pediatric HSCT patients longitudinally, beginning before the transplant – and for more investigation into the pathogenesis of specific late effects.

Dr. Song reported no relevant conflicts of interest.
 

[email protected]

On Twitter @karioakes

Discontinuing statin therapy 3-6 months after a stroke may increase the risk of recurrent stroke within a year, according to findings from a large retrospective Taiwanese cohort study.

And being older or male in the Stroke Belt increases the likelihood that statins won’t be prescribed at all at the time of hospital discharge after a stroke, a separate cohort study from the United States suggests.

Both studies were reported online in the Journal of the American Heart Association.

Of 45,151 ischemic stroke patients from the Taiwan National Health Insurance Research Database who were on a moderate- or high-intensity statin within 90 days of discharge after an ischemic stroke between 2001 and 2012, 3,175 (7%) were on a reduced dosage by the 90- to 180-day period, and 8,353 (18.5%) were not on any statin by that period. After adjustment for numerous factors including age, sex, several comorbid conditions, and stroke severity index, discontinuation of statins was associated with an increased hazard of recurrent ischemic or hemorrhagic stroke (6.2% vs. 4.4%; adjusted hazard ratio [HR], 1.42), Meng Lee, MD, of Chang Gung Memorial Hospital, Chiayi Branch, Puzy, Taiwan and colleagues reported.

stockce/Thinkstock

[email protected]

Discontinuing statin therapy 3-6 months after a stroke may increase the risk of recurrent stroke within a year, according to findings from a large retrospective Taiwanese cohort study.

And being older or male in the Stroke Belt increases the likelihood that statins won’t be prescribed at all at the time of hospital discharge after a stroke, a separate cohort study from the United States suggests.

Both studies were reported online in the Journal of the American Heart Association.

Of 45,151 ischemic stroke patients from the Taiwan National Health Insurance Research Database who were on a moderate- or high-intensity statin within 90 days of discharge after an ischemic stroke between 2001 and 2012, 3,175 (7%) were on a reduced dosage by the 90- to 180-day period, and 8,353 (18.5%) were not on any statin by that period. After adjustment for numerous factors including age, sex, several comorbid conditions, and stroke severity index, discontinuation of statins was associated with an increased hazard of recurrent ischemic or hemorrhagic stroke (6.2% vs. 4.4%; adjusted hazard ratio [HR], 1.42), Meng Lee, MD, of Chang Gung Memorial Hospital, Chiayi Branch, Puzy, Taiwan and colleagues reported.

stockce/Thinkstock

[email protected]

Discontinuing statin therapy 3-6 months after a stroke may increase the risk of recurrent stroke within a year, according to findings from a large retrospective Taiwanese cohort study.

And being older or male in the Stroke Belt increases the likelihood that statins won’t be prescribed at all at the time of hospital discharge after a stroke, a separate cohort study from the United States suggests.

Both studies were reported online in the Journal of the American Heart Association.

Of 45,151 ischemic stroke patients from the Taiwan National Health Insurance Research Database who were on a moderate- or high-intensity statin within 90 days of discharge after an ischemic stroke between 2001 and 2012, 3,175 (7%) were on a reduced dosage by the 90- to 180-day period, and 8,353 (18.5%) were not on any statin by that period. After adjustment for numerous factors including age, sex, several comorbid conditions, and stroke severity index, discontinuation of statins was associated with an increased hazard of recurrent ischemic or hemorrhagic stroke (6.2% vs. 4.4%; adjusted hazard ratio [HR], 1.42), Meng Lee, MD, of Chang Gung Memorial Hospital, Chiayi Branch, Puzy, Taiwan and colleagues reported.

stockce/Thinkstock

[email protected]

A novel vaginal inserter currently in development at Duke University for use with a miniature colposcope proved feasible for comfortable, speculum-free cervical image capture in a recent study.

Along with allowing for more comfortable – and possibly self-facilitated – cervical cancer screening, the device could have important implications for providing care and improving screening rates in underserved, low-resource communities in the United States and around the world, according to Mercy N. Asiedu, a graduate student research assistant in the Duke University department of biomedical engineering.

Ms. Asiedu is part of a team that has been working to develop effective, low-cost methods for diagnosing cervical and breast cancer, particularly in low-resource regions.

A device such as the integrated inserter and colposcope could potentially be purchased over the counter at a local pharmacy and used for “self checkups,” or used in clinics to facilitate a more comfortable, patient-friendly approach to exams here in the United States, she said in an interview.

“But in other countries, one of the bigger benefits [relates to] cultural factors that deter women from going in for gynecological exams,” Ms. Asiedu said.

Overcoming screening barriers

Invasive cervical cancer ranks as the second most common female cancer in low and middle-income countries and the seventh most common in high-income countries, she and her colleagues wrote in a study published in PLoS ONE (12[5]:e0177782. doi: 10.1371/journal.pone.0177782).

The discrepancies between high- and low-resource areas largely result from the fact that visualization of the cervix via colposcopy using a standard approach requires a highly-trained professional and expensive equipment that is not easily accessible in underserved regions.

But even in the United states, the use of a standard speculum to expand the vaginal canal has been identified as a factor in the resistance of some women to undergo screening. Embarrassment and fear of pain have also been reported as potential barriers to screening.

Courtesy Duke University

A speculum alternative

The inserter is a tampon-sized tubular device designed as an alternative to a standard speculum, and is used with the Pocket Colposcope, a miniature pen-sized colposcope also developed by Duke University researchers and validated by physicians worldwide as providing image quality comparable to high-end, state-of-the-art digital colposcopes.

The current rendition of the inserter device has a funnel-like, curved tip measuring approximately 2.6 cm in diameter, a channel for insertion of a 2-megapixel mini-USB camera with LED illumination for the cervical image capture (as opposed to the 5-megapixel camera typically used with the Pocket Colposcope in the setting of standard speculum use), and can connect to a number of devices such as smartphones and laptop computers for image display.

“The curved tip enables easy manipulation of the cervix, especially in cases where the patient has a tilted uterus,” Ms Asiedu and her colleagues wrote in PLoS. “Our design also enables manipulation of the cervix for cervical imaging of women with tilted uteri, a condition that affects about 20% of women and is difficult and painful when using the standard speculum for manipulation.”

Using a custom-made vaginal phantom, the researchers tested various designs and demonstrated that it was able to withstand a range of supine vaginal pressures. In addition, 12 of 15 healthy volunteers achieved adequate cervical image capture after self-insertion of the device, and 14 of the 15 women expressed an overall preference for the inserter over the speculum (based on past experience). All of the volunteers said the inserter was slightly more, or much more, comfortable than a standard speculum, and noted that comfort was a particular benefit.

Prior to self-insertion, the volunteers typically received about 5 minutes of instruction using a pelvic mannequin. Images were captured and displayed on a mobile device once the cervix was in view.

From a patient perspective, the volunteer study “was almost universally positive,” John W. Schmitt, MD, professor of obstetrics and gynecology, as well as global health, at Duke, said in an interview. He conducted the clinical portion of the research.

Future directions

Efforts are underway to further improve the design for better visualization, ease of use, and comfort. The next phase of study will involve comparing visualization between the device and a standard speculum for routine exams and more advanced cancer screening exams. Ms. Asiedu said the researchers are also seeking to modify the inserter to accommodate the original Pocket Colposcope with a 5-megapixel camera for better image quality.

Should the inserter and colposcope be validated in further studies, the potential benefits are numerous, she said, explaining that the device’s potential for expanding access to screening are driven by its portability and low cost; the 2-megapixel camera currently used with the device costs about $54, compared with $20,000 for a standard-of-care digital colposcope. The estimated cost of the inserter under mass production would be less than $1.

It may be possible to produce the inserter in varying sizes to match cervix size. There are other potential uses for the device, including at-home viewing of the cervical os to gauge cervical dilation during labor and to detect false labor, she and her colleagues noted.

One limitation, which is also a problem with current methods of visual inspection of the cervix, is lack of ability to see the squamocolumnar junction.

“It is therefore not a replacement for gold standard pathology, where cells from the squamocolumnar junction are removed for pathology. However, our device can aid in guiding biopsies and has merit for places that lack gold standard biopsy,” they wrote, noting that future studies will compare cervix samples collected via the inserter versus a standard speculum to explore the possibility of self-sampling.

Efforts also are underway to develop an algorithm for making a diagnosis based on such samples, Ms. Asiedu said.

Given that 11 of the 15 volunteers in the study said that self-screening with the device was more difficult than having a physician perform the exam, another longitudinal study will look at whether ease of use improves over time, she said.

“There’s a lot of work to be done to get it where it could be routinely used,” Dr. Schmitt said. “Even for someone like me who does have this healthy skepticism, this might really be a profound change in the way we do pelvic exams.”

A word of caution

But Michael R. Caudle, MD, an ob.gyn. with Cherokee Health Systems in Knoxville, Tenn., urged caution, at least among rural U.S. health centers, with any approach that involves only visualizing the cervix. His concern is that this type of device could give women “false reassurances.”

“The promulgation of Pap smears and HPV testing would be the direction rural sites should go,” he said. “Colposcopy requires biopsies to rule out serious disease.”

He noted that the American Society for Colposcopy and Cervical Pathology (ASCCP) provides training for mid-level providers to do these evaluations.

“I think this is better than looking only. We see tragedies from women not getting adequate follow-up for abnormal paps, so making this even more removed from proper oversight is a concern. There have been attempts in the past to send photos of the cervix for evaluation and one problem again was the lack of biopsies.

“Rural health departments do a good job at triaging abnormal paps, and expansion of this, in my opinion, is a better idea,” he said.

The Duke University study was supported by the National Institutes of Health. Ms. Asiedu reported having no disclosures, but two of her coauthors founded companies and developed technologies related to this work where the investigators or Duke may benefit financially if the system is sold commercially. Ms. Asiedu and her coauthors have filed a provisional patent application for the concept of the system.

[email protected]

A novel vaginal inserter currently in development at Duke University for use with a miniature colposcope proved feasible for comfortable, speculum-free cervical image capture in a recent study.

Along with allowing for more comfortable – and possibly self-facilitated – cervical cancer screening, the device could have important implications for providing care and improving screening rates in underserved, low-resource communities in the United States and around the world, according to Mercy N. Asiedu, a graduate student research assistant in the Duke University department of biomedical engineering.

Ms. Asiedu is part of a team that has been working to develop effective, low-cost methods for diagnosing cervical and breast cancer, particularly in low-resource regions.

A device such as the integrated inserter and colposcope could potentially be purchased over the counter at a local pharmacy and used for “self checkups,” or used in clinics to facilitate a more comfortable, patient-friendly approach to exams here in the United States, she said in an interview.

“But in other countries, one of the bigger benefits [relates to] cultural factors that deter women from going in for gynecological exams,” Ms. Asiedu said.

Overcoming screening barriers

Invasive cervical cancer ranks as the second most common female cancer in low and middle-income countries and the seventh most common in high-income countries, she and her colleagues wrote in a study published in PLoS ONE (12[5]:e0177782. doi: 10.1371/journal.pone.0177782).

The discrepancies between high- and low-resource areas largely result from the fact that visualization of the cervix via colposcopy using a standard approach requires a highly-trained professional and expensive equipment that is not easily accessible in underserved regions.

But even in the United states, the use of a standard speculum to expand the vaginal canal has been identified as a factor in the resistance of some women to undergo screening. Embarrassment and fear of pain have also been reported as potential barriers to screening.

Courtesy Duke University

A speculum alternative

The inserter is a tampon-sized tubular device designed as an alternative to a standard speculum, and is used with the Pocket Colposcope, a miniature pen-sized colposcope also developed by Duke University researchers and validated by physicians worldwide as providing image quality comparable to high-end, state-of-the-art digital colposcopes.

The current rendition of the inserter device has a funnel-like, curved tip measuring approximately 2.6 cm in diameter, a channel for insertion of a 2-megapixel mini-USB camera with LED illumination for the cervical image capture (as opposed to the 5-megapixel camera typically used with the Pocket Colposcope in the setting of standard speculum use), and can connect to a number of devices such as smartphones and laptop computers for image display.

“The curved tip enables easy manipulation of the cervix, especially in cases where the patient has a tilted uterus,” Ms Asiedu and her colleagues wrote in PLoS. “Our design also enables manipulation of the cervix for cervical imaging of women with tilted uteri, a condition that affects about 20% of women and is difficult and painful when using the standard speculum for manipulation.”

Using a custom-made vaginal phantom, the researchers tested various designs and demonstrated that it was able to withstand a range of supine vaginal pressures. In addition, 12 of 15 healthy volunteers achieved adequate cervical image capture after self-insertion of the device, and 14 of the 15 women expressed an overall preference for the inserter over the speculum (based on past experience). All of the volunteers said the inserter was slightly more, or much more, comfortable than a standard speculum, and noted that comfort was a particular benefit.

Prior to self-insertion, the volunteers typically received about 5 minutes of instruction using a pelvic mannequin. Images were captured and displayed on a mobile device once the cervix was in view.

From a patient perspective, the volunteer study “was almost universally positive,” John W. Schmitt, MD, professor of obstetrics and gynecology, as well as global health, at Duke, said in an interview. He conducted the clinical portion of the research.

Future directions

Efforts are underway to further improve the design for better visualization, ease of use, and comfort. The next phase of study will involve comparing visualization between the device and a standard speculum for routine exams and more advanced cancer screening exams. Ms. Asiedu said the researchers are also seeking to modify the inserter to accommodate the original Pocket Colposcope with a 5-megapixel camera for better image quality.

Should the inserter and colposcope be validated in further studies, the potential benefits are numerous, she said, explaining that the device’s potential for expanding access to screening are driven by its portability and low cost; the 2-megapixel camera currently used with the device costs about $54, compared with $20,000 for a standard-of-care digital colposcope. The estimated cost of the inserter under mass production would be less than $1.

It may be possible to produce the inserter in varying sizes to match cervix size. There are other potential uses for the device, including at-home viewing of the cervical os to gauge cervical dilation during labor and to detect false labor, she and her colleagues noted.

One limitation, which is also a problem with current methods of visual inspection of the cervix, is lack of ability to see the squamocolumnar junction.

“It is therefore not a replacement for gold standard pathology, where cells from the squamocolumnar junction are removed for pathology. However, our device can aid in guiding biopsies and has merit for places that lack gold standard biopsy,” they wrote, noting that future studies will compare cervix samples collected via the inserter versus a standard speculum to explore the possibility of self-sampling.

Efforts also are underway to develop an algorithm for making a diagnosis based on such samples, Ms. Asiedu said.

Given that 11 of the 15 volunteers in the study said that self-screening with the device was more difficult than having a physician perform the exam, another longitudinal study will look at whether ease of use improves over time, she said.

“There’s a lot of work to be done to get it where it could be routinely used,” Dr. Schmitt said. “Even for someone like me who does have this healthy skepticism, this might really be a profound change in the way we do pelvic exams.”

A word of caution

But Michael R. Caudle, MD, an ob.gyn. with Cherokee Health Systems in Knoxville, Tenn., urged caution, at least among rural U.S. health centers, with any approach that involves only visualizing the cervix. His concern is that this type of device could give women “false reassurances.”

“The promulgation of Pap smears and HPV testing would be the direction rural sites should go,” he said. “Colposcopy requires biopsies to rule out serious disease.”

He noted that the American Society for Colposcopy and Cervical Pathology (ASCCP) provides training for mid-level providers to do these evaluations.

“I think this is better than looking only. We see tragedies from women not getting adequate follow-up for abnormal paps, so making this even more removed from proper oversight is a concern. There have been attempts in the past to send photos of the cervix for evaluation and one problem again was the lack of biopsies.

“Rural health departments do a good job at triaging abnormal paps, and expansion of this, in my opinion, is a better idea,” he said.

The Duke University study was supported by the National Institutes of Health. Ms. Asiedu reported having no disclosures, but two of her coauthors founded companies and developed technologies related to this work where the investigators or Duke may benefit financially if the system is sold commercially. Ms. Asiedu and her coauthors have filed a provisional patent application for the concept of the system.

[email protected]

A novel vaginal inserter currently in development at Duke University for use with a miniature colposcope proved feasible for comfortable, speculum-free cervical image capture in a recent study.

Along with allowing for more comfortable – and possibly self-facilitated – cervical cancer screening, the device could have important implications for providing care and improving screening rates in underserved, low-resource communities in the United States and around the world, according to Mercy N. Asiedu, a graduate student research assistant in the Duke University department of biomedical engineering.

Ms. Asiedu is part of a team that has been working to develop effective, low-cost methods for diagnosing cervical and breast cancer, particularly in low-resource regions.

A device such as the integrated inserter and colposcope could potentially be purchased over the counter at a local pharmacy and used for “self checkups,” or used in clinics to facilitate a more comfortable, patient-friendly approach to exams here in the United States, she said in an interview.

“But in other countries, one of the bigger benefits [relates to] cultural factors that deter women from going in for gynecological exams,” Ms. Asiedu said.

Overcoming screening barriers

Invasive cervical cancer ranks as the second most common female cancer in low and middle-income countries and the seventh most common in high-income countries, she and her colleagues wrote in a study published in PLoS ONE (12[5]:e0177782. doi: 10.1371/journal.pone.0177782).

The discrepancies between high- and low-resource areas largely result from the fact that visualization of the cervix via colposcopy using a standard approach requires a highly-trained professional and expensive equipment that is not easily accessible in underserved regions.

But even in the United states, the use of a standard speculum to expand the vaginal canal has been identified as a factor in the resistance of some women to undergo screening. Embarrassment and fear of pain have also been reported as potential barriers to screening.

Courtesy Duke University

A speculum alternative

The inserter is a tampon-sized tubular device designed as an alternative to a standard speculum, and is used with the Pocket Colposcope, a miniature pen-sized colposcope also developed by Duke University researchers and validated by physicians worldwide as providing image quality comparable to high-end, state-of-the-art digital colposcopes.

The current rendition of the inserter device has a funnel-like, curved tip measuring approximately 2.6 cm in diameter, a channel for insertion of a 2-megapixel mini-USB camera with LED illumination for the cervical image capture (as opposed to the 5-megapixel camera typically used with the Pocket Colposcope in the setting of standard speculum use), and can connect to a number of devices such as smartphones and laptop computers for image display.

“The curved tip enables easy manipulation of the cervix, especially in cases where the patient has a tilted uterus,” Ms Asiedu and her colleagues wrote in PLoS. “Our design also enables manipulation of the cervix for cervical imaging of women with tilted uteri, a condition that affects about 20% of women and is difficult and painful when using the standard speculum for manipulation.”

Using a custom-made vaginal phantom, the researchers tested various designs and demonstrated that it was able to withstand a range of supine vaginal pressures. In addition, 12 of 15 healthy volunteers achieved adequate cervical image capture after self-insertion of the device, and 14 of the 15 women expressed an overall preference for the inserter over the speculum (based on past experience). All of the volunteers said the inserter was slightly more, or much more, comfortable than a standard speculum, and noted that comfort was a particular benefit.

Prior to self-insertion, the volunteers typically received about 5 minutes of instruction using a pelvic mannequin. Images were captured and displayed on a mobile device once the cervix was in view.

From a patient perspective, the volunteer study “was almost universally positive,” John W. Schmitt, MD, professor of obstetrics and gynecology, as well as global health, at Duke, said in an interview. He conducted the clinical portion of the research.

Future directions

Efforts are underway to further improve the design for better visualization, ease of use, and comfort. The next phase of study will involve comparing visualization between the device and a standard speculum for routine exams and more advanced cancer screening exams. Ms. Asiedu said the researchers are also seeking to modify the inserter to accommodate the original Pocket Colposcope with a 5-megapixel camera for better image quality.

Should the inserter and colposcope be validated in further studies, the potential benefits are numerous, she said, explaining that the device’s potential for expanding access to screening are driven by its portability and low cost; the 2-megapixel camera currently used with the device costs about $54, compared with $20,000 for a standard-of-care digital colposcope. The estimated cost of the inserter under mass production would be less than $1.

It may be possible to produce the inserter in varying sizes to match cervix size. There are other potential uses for the device, including at-home viewing of the cervical os to gauge cervical dilation during labor and to detect false labor, she and her colleagues noted.

One limitation, which is also a problem with current methods of visual inspection of the cervix, is lack of ability to see the squamocolumnar junction.

“It is therefore not a replacement for gold standard pathology, where cells from the squamocolumnar junction are removed for pathology. However, our device can aid in guiding biopsies and has merit for places that lack gold standard biopsy,” they wrote, noting that future studies will compare cervix samples collected via the inserter versus a standard speculum to explore the possibility of self-sampling.

Efforts also are underway to develop an algorithm for making a diagnosis based on such samples, Ms. Asiedu said.

Given that 11 of the 15 volunteers in the study said that self-screening with the device was more difficult than having a physician perform the exam, another longitudinal study will look at whether ease of use improves over time, she said.

“There’s a lot of work to be done to get it where it could be routinely used,” Dr. Schmitt said. “Even for someone like me who does have this healthy skepticism, this might really be a profound change in the way we do pelvic exams.”

A word of caution

But Michael R. Caudle, MD, an ob.gyn. with Cherokee Health Systems in Knoxville, Tenn., urged caution, at least among rural U.S. health centers, with any approach that involves only visualizing the cervix. His concern is that this type of device could give women “false reassurances.”

“The promulgation of Pap smears and HPV testing would be the direction rural sites should go,” he said. “Colposcopy requires biopsies to rule out serious disease.”

He noted that the American Society for Colposcopy and Cervical Pathology (ASCCP) provides training for mid-level providers to do these evaluations.

“I think this is better than looking only. We see tragedies from women not getting adequate follow-up for abnormal paps, so making this even more removed from proper oversight is a concern. There have been attempts in the past to send photos of the cervix for evaluation and one problem again was the lack of biopsies.

“Rural health departments do a good job at triaging abnormal paps, and expansion of this, in my opinion, is a better idea,” he said.

The Duke University study was supported by the National Institutes of Health. Ms. Asiedu reported having no disclosures, but two of her coauthors founded companies and developed technologies related to this work where the investigators or Duke may benefit financially if the system is sold commercially. Ms. Asiedu and her coauthors have filed a provisional patent application for the concept of the system.

[email protected]

The Food and Drug Administration has granted accelerated approval to checkpoint inhibitor nivolumab for the treatment of patients with mismatch repair deficient (dMMR) and microsatellite instability high (MSI-H) metastatic colorectal cancer (CRC) that has progressed following treatment with fluoropyrimidine, oxaliplatin, and irinotecan.

The indication covers patients aged 12 years and older. Efficacy for adolescent patients with MSI-H or dMMR metastatic CRC is extrapolated from the results in the respective adult population, the FDA said in a statement.

Approval of nivolumab in the adult population was based on an objective response rate of 28% in CHECKMATE 142, an open-label, single-arm study of 53 patients with locally determined dMMR or MSI-H metastatic CRC who had disease progression during, after, or were intolerant to prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

[email protected]
 

The Food and Drug Administration has granted accelerated approval to checkpoint inhibitor nivolumab for the treatment of patients with mismatch repair deficient (dMMR) and microsatellite instability high (MSI-H) metastatic colorectal cancer (CRC) that has progressed following treatment with fluoropyrimidine, oxaliplatin, and irinotecan.

The indication covers patients aged 12 years and older. Efficacy for adolescent patients with MSI-H or dMMR metastatic CRC is extrapolated from the results in the respective adult population, the FDA said in a statement.

Approval of nivolumab in the adult population was based on an objective response rate of 28% in CHECKMATE 142, an open-label, single-arm study of 53 patients with locally determined dMMR or MSI-H metastatic CRC who had disease progression during, after, or were intolerant to prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

[email protected]
 

The Food and Drug Administration has granted accelerated approval to checkpoint inhibitor nivolumab for the treatment of patients with mismatch repair deficient (dMMR) and microsatellite instability high (MSI-H) metastatic colorectal cancer (CRC) that has progressed following treatment with fluoropyrimidine, oxaliplatin, and irinotecan.

The indication covers patients aged 12 years and older. Efficacy for adolescent patients with MSI-H or dMMR metastatic CRC is extrapolated from the results in the respective adult population, the FDA said in a statement.

Approval of nivolumab in the adult population was based on an objective response rate of 28% in CHECKMATE 142, an open-label, single-arm study of 53 patients with locally determined dMMR or MSI-H metastatic CRC who had disease progression during, after, or were intolerant to prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

[email protected]
 

Annular atrophic lichen planus (AALP) is a rare variant of lichen planus that was first described by Friedman and Hashimoto¹ in 1991. Clinically, it combines the configuration and morphological features of both annular and atrophic lichen planus. It is a rare entity. We report a case of AALP in a 69-year-old black man. The clinical and histopathological presentation depicted the defining features of this entity with a characteristic loss of elastic fibers corresponding to central atrophy of active lesions.

Case Report

A 69-year-old black man with a history of hepatitis C virus infection and hypothyroidism presented to the dermatology clinic with a pruritic rash on the trunk, extremities, groin, and scalp of 4 months' duration. He denied any new medications, recent illnesses, or sick contacts. Physical examination demonstrated well-demarcated violaceous papules and plaques on the trunk, extensor aspect of the forearms, and thighs involving 10% of the body surface area (Figure 1A). The lesions were annular with raised borders and central depigmented atrophic scarring (Figure 1B). The examination also revealed several large hypopigmented atrophic patches and plaques in the right inguinal region and on the dorsal aspect of the penile shaft and buttocks as well as a single atrophic plaque on the scalp. No oral lesions were seen. An initial punch biopsy was consistent with a nonspecific lichenoid dermatitis (Figure 2), and the patient was prescribed triamcinolone ointment 0.1% for the trunk and extremities and tacrolimus ointment 0.1% for the groin and genital region.

The patient continued to develop new annular atrophic skin lesions over the next several months. Repeat punch biopsies of lesional and uninvolved perilesional skin from the trunk were obtained for histopathologic confirmation and special staining. Lichenoid dermatitis again was noted on the lesional biopsy, and no notable histopathologic changes were observed on the perilesional biopsy. Verhoeff-van Gieson staining for elastic fibers was performed on both biopsies, which revealed destruction of elastic fibers in the central papillary dermis and upper reticular dermis of the lesional biopsy (Figure 3A). The elastic fibers on the perilesional biopsy were preserved (Figure 3B).

The clinical presentation and histopathological findings confirmed a diagnosis of AALP. The patient was prescribed a short taper of oral prednisone, which halted further disease progression. The patient was then started on pentoxifylline and continued on tacrolimus ointment 0.1% with minimal improvement in existing lesions. These medications were discontinued after 3 months. Hydroxychloroquine 400 mg once daily was administered, which initially resulted in some thinning of the plaques on the trunk; however, further progression of the disease was noted after 3 months. Acitretin 25 mg once daily was added to his treatment regimen. Marked thinning of active lesions, hyperpigmentation, and residual scarring was noted after 2 months of combined therapy with acitretin and hydroxychloroquine (Figure 4), with continued improvement appreciable several months later.

Comment

Lichen planus is a common pruritic inflammatory disease of the skin, mucous membranes, hair follicles, and nails with a highly variable clinical pattern and disease course that typically affects the adult population.² There are many clinical variants of lichen planus, which all demonstrate lichenoid dermatitis on histology. Annular lichen planus is an uncommon variant most commonly seen in men with asymptomatic lesions involving the axillae and groin.² Atrophic lichen planus is another variant demonstrating atrophic papules and plaques on the trunk and extremities.3 Annular atrophic lichen planus is the rarest variant of lichen planus, incorporating features of both annular and atrophic lichen planus.

The first case of AALP involved a 56-year-old black man with a 25-year history of annular atrophic papules and plaques on the trunk and extremities.¹ The second case reported by Requena et al⁴ in 1994 described a 65-year-old woman with characteristic lesions on the right elbow and left knee. Lipsker et al⁵ reported a third case in a 41-year-old man with a history of Sneddon syndrome who had lesions typical for AALP for 20 years. In all of these cases, histopathologic examination revealed a lichenoid infiltrate with thinning of the epidermis and loss of elastic fibers in the center of the active lesions.

In more recent cases of AALP, the characteristic findings primarily occurred on the trunk and extremities.^6-10 Treatment with topical corticosteroids failed in most cases and some patients noted moderate improvement with tacrolimus ointment 0.1%. Sugashima and Yamamoto¹¹ reported a unique case in 2012 of a 32-year-old woman with AALP on the lower lip. She had notable improvement with tacrolimus ointment 0.1% after 6 months.¹¹

All of the known cases of AALP to date have occurred in adults, both male and female, presenting with a limited number of annular plaques with slightly elevated borders and depressed atrophic centers.^1,3-11 Disease duration of AALP has ranged from 2 months to 25 years.¹¹ Histopathologic findings characteristically demonstrate a lichenoid dermatitis of the raised lesional border with a flattened epidermis, loss of rete ridges, and fibrosis of dermal papillae in the lesion center.⁷ The elastic fibers are destroyed in the papillary dermis of the lesion center, presumably due to elastolytic activity of inflammatory cells.¹ Macrophages present in the lichenoid infiltrate of acute lesions release elastases contributing to this destruction.⁷ Furthermore, elastic fibers appear fragmented on electron microscopy.¹

The clinical course of AALP has proven to be chronic in most cases and frequently is resistant to treatment with topical corticosteroids, retinoids, phototherapy, and immunosuppressive agents.³ Treatment administered early in the disease course may provide a more favorable outcome.¹¹ Lesions characteristically heal with scarring and hyperpigmentation. Our case displayed more extensive involvement than has previously been reported. Our patient showed minimal improvement with topical therapy; however, he demonstrated thinning and regression of active lesions after 2 months of combined treatment with hydroxychloroquine and acitretin. Our use of oral pentoxifylline, hydroxychloroquine, and acitretin has not been previously reported in the other cases of AALP we reviewed. Acitretin is the only systemic agent for lichen planus that has achieved level A evidence, as it previously was shown to be highly effective in a placebo-controlled, double-blind study of 65 patients.¹²

Conclusion

Annular atrophic lichen planus is a known variant of lichen planus characterized by a loss of elastic fibers in the papillary dermis in the center of active lesions. Treatment with topical corticosteroids and phototherapy frequently is ineffective. To our knowledge, there are no studies to date regarding the efficacy of systemic therapy in treatment of AALP. Hydroxychloroquine and acitretin may prove to be beneficial treatment options for resistant AALP. Additional alternative treatments continue to be explored. We encourage reporting additional cases of AALP to further characterize its clinical presentation and response to treatments.

Annular atrophic lichen planus (AALP) is a rare variant of lichen planus that was first described by Friedman and Hashimoto¹ in 1991. Clinically, it combines the configuration and morphological features of both annular and atrophic lichen planus. It is a rare entity. We report a case of AALP in a 69-year-old black man. The clinical and histopathological presentation depicted the defining features of this entity with a characteristic loss of elastic fibers corresponding to central atrophy of active lesions.

Case Report

A 69-year-old black man with a history of hepatitis C virus infection and hypothyroidism presented to the dermatology clinic with a pruritic rash on the trunk, extremities, groin, and scalp of 4 months' duration. He denied any new medications, recent illnesses, or sick contacts. Physical examination demonstrated well-demarcated violaceous papules and plaques on the trunk, extensor aspect of the forearms, and thighs involving 10% of the body surface area (Figure 1A). The lesions were annular with raised borders and central depigmented atrophic scarring (Figure 1B). The examination also revealed several large hypopigmented atrophic patches and plaques in the right inguinal region and on the dorsal aspect of the penile shaft and buttocks as well as a single atrophic plaque on the scalp. No oral lesions were seen. An initial punch biopsy was consistent with a nonspecific lichenoid dermatitis (Figure 2), and the patient was prescribed triamcinolone ointment 0.1% for the trunk and extremities and tacrolimus ointment 0.1% for the groin and genital region.

The patient continued to develop new annular atrophic skin lesions over the next several months. Repeat punch biopsies of lesional and uninvolved perilesional skin from the trunk were obtained for histopathologic confirmation and special staining. Lichenoid dermatitis again was noted on the lesional biopsy, and no notable histopathologic changes were observed on the perilesional biopsy. Verhoeff-van Gieson staining for elastic fibers was performed on both biopsies, which revealed destruction of elastic fibers in the central papillary dermis and upper reticular dermis of the lesional biopsy (Figure 3A). The elastic fibers on the perilesional biopsy were preserved (Figure 3B).

The clinical presentation and histopathological findings confirmed a diagnosis of AALP. The patient was prescribed a short taper of oral prednisone, which halted further disease progression. The patient was then started on pentoxifylline and continued on tacrolimus ointment 0.1% with minimal improvement in existing lesions. These medications were discontinued after 3 months. Hydroxychloroquine 400 mg once daily was administered, which initially resulted in some thinning of the plaques on the trunk; however, further progression of the disease was noted after 3 months. Acitretin 25 mg once daily was added to his treatment regimen. Marked thinning of active lesions, hyperpigmentation, and residual scarring was noted after 2 months of combined therapy with acitretin and hydroxychloroquine (Figure 4), with continued improvement appreciable several months later.

Comment

Lichen planus is a common pruritic inflammatory disease of the skin, mucous membranes, hair follicles, and nails with a highly variable clinical pattern and disease course that typically affects the adult population.² There are many clinical variants of lichen planus, which all demonstrate lichenoid dermatitis on histology. Annular lichen planus is an uncommon variant most commonly seen in men with asymptomatic lesions involving the axillae and groin.² Atrophic lichen planus is another variant demonstrating atrophic papules and plaques on the trunk and extremities.3 Annular atrophic lichen planus is the rarest variant of lichen planus, incorporating features of both annular and atrophic lichen planus.

The first case of AALP involved a 56-year-old black man with a 25-year history of annular atrophic papules and plaques on the trunk and extremities.¹ The second case reported by Requena et al⁴ in 1994 described a 65-year-old woman with characteristic lesions on the right elbow and left knee. Lipsker et al⁵ reported a third case in a 41-year-old man with a history of Sneddon syndrome who had lesions typical for AALP for 20 years. In all of these cases, histopathologic examination revealed a lichenoid infiltrate with thinning of the epidermis and loss of elastic fibers in the center of the active lesions.

In more recent cases of AALP, the characteristic findings primarily occurred on the trunk and extremities.^6-10 Treatment with topical corticosteroids failed in most cases and some patients noted moderate improvement with tacrolimus ointment 0.1%. Sugashima and Yamamoto¹¹ reported a unique case in 2012 of a 32-year-old woman with AALP on the lower lip. She had notable improvement with tacrolimus ointment 0.1% after 6 months.¹¹

All of the known cases of AALP to date have occurred in adults, both male and female, presenting with a limited number of annular plaques with slightly elevated borders and depressed atrophic centers.^1,3-11 Disease duration of AALP has ranged from 2 months to 25 years.¹¹ Histopathologic findings characteristically demonstrate a lichenoid dermatitis of the raised lesional border with a flattened epidermis, loss of rete ridges, and fibrosis of dermal papillae in the lesion center.⁷ The elastic fibers are destroyed in the papillary dermis of the lesion center, presumably due to elastolytic activity of inflammatory cells.¹ Macrophages present in the lichenoid infiltrate of acute lesions release elastases contributing to this destruction.⁷ Furthermore, elastic fibers appear fragmented on electron microscopy.¹

The clinical course of AALP has proven to be chronic in most cases and frequently is resistant to treatment with topical corticosteroids, retinoids, phototherapy, and immunosuppressive agents.³ Treatment administered early in the disease course may provide a more favorable outcome.¹¹ Lesions characteristically heal with scarring and hyperpigmentation. Our case displayed more extensive involvement than has previously been reported. Our patient showed minimal improvement with topical therapy; however, he demonstrated thinning and regression of active lesions after 2 months of combined treatment with hydroxychloroquine and acitretin. Our use of oral pentoxifylline, hydroxychloroquine, and acitretin has not been previously reported in the other cases of AALP we reviewed. Acitretin is the only systemic agent for lichen planus that has achieved level A evidence, as it previously was shown to be highly effective in a placebo-controlled, double-blind study of 65 patients.¹²

Conclusion

Annular atrophic lichen planus is a known variant of lichen planus characterized by a loss of elastic fibers in the papillary dermis in the center of active lesions. Treatment with topical corticosteroids and phototherapy frequently is ineffective. To our knowledge, there are no studies to date regarding the efficacy of systemic therapy in treatment of AALP. Hydroxychloroquine and acitretin may prove to be beneficial treatment options for resistant AALP. Additional alternative treatments continue to be explored. We encourage reporting additional cases of AALP to further characterize its clinical presentation and response to treatments.

Annular atrophic lichen planus (AALP) is a rare variant of lichen planus that was first described by Friedman and Hashimoto¹ in 1991. Clinically, it combines the configuration and morphological features of both annular and atrophic lichen planus. It is a rare entity. We report a case of AALP in a 69-year-old black man. The clinical and histopathological presentation depicted the defining features of this entity with a characteristic loss of elastic fibers corresponding to central atrophy of active lesions.

Case Report

A 69-year-old black man with a history of hepatitis C virus infection and hypothyroidism presented to the dermatology clinic with a pruritic rash on the trunk, extremities, groin, and scalp of 4 months' duration. He denied any new medications, recent illnesses, or sick contacts. Physical examination demonstrated well-demarcated violaceous papules and plaques on the trunk, extensor aspect of the forearms, and thighs involving 10% of the body surface area (Figure 1A). The lesions were annular with raised borders and central depigmented atrophic scarring (Figure 1B). The examination also revealed several large hypopigmented atrophic patches and plaques in the right inguinal region and on the dorsal aspect of the penile shaft and buttocks as well as a single atrophic plaque on the scalp. No oral lesions were seen. An initial punch biopsy was consistent with a nonspecific lichenoid dermatitis (Figure 2), and the patient was prescribed triamcinolone ointment 0.1% for the trunk and extremities and tacrolimus ointment 0.1% for the groin and genital region.

The patient continued to develop new annular atrophic skin lesions over the next several months. Repeat punch biopsies of lesional and uninvolved perilesional skin from the trunk were obtained for histopathologic confirmation and special staining. Lichenoid dermatitis again was noted on the lesional biopsy, and no notable histopathologic changes were observed on the perilesional biopsy. Verhoeff-van Gieson staining for elastic fibers was performed on both biopsies, which revealed destruction of elastic fibers in the central papillary dermis and upper reticular dermis of the lesional biopsy (Figure 3A). The elastic fibers on the perilesional biopsy were preserved (Figure 3B).

The clinical presentation and histopathological findings confirmed a diagnosis of AALP. The patient was prescribed a short taper of oral prednisone, which halted further disease progression. The patient was then started on pentoxifylline and continued on tacrolimus ointment 0.1% with minimal improvement in existing lesions. These medications were discontinued after 3 months. Hydroxychloroquine 400 mg once daily was administered, which initially resulted in some thinning of the plaques on the trunk; however, further progression of the disease was noted after 3 months. Acitretin 25 mg once daily was added to his treatment regimen. Marked thinning of active lesions, hyperpigmentation, and residual scarring was noted after 2 months of combined therapy with acitretin and hydroxychloroquine (Figure 4), with continued improvement appreciable several months later.

Comment

Lichen planus is a common pruritic inflammatory disease of the skin, mucous membranes, hair follicles, and nails with a highly variable clinical pattern and disease course that typically affects the adult population.² There are many clinical variants of lichen planus, which all demonstrate lichenoid dermatitis on histology. Annular lichen planus is an uncommon variant most commonly seen in men with asymptomatic lesions involving the axillae and groin.² Atrophic lichen planus is another variant demonstrating atrophic papules and plaques on the trunk and extremities.3 Annular atrophic lichen planus is the rarest variant of lichen planus, incorporating features of both annular and atrophic lichen planus.

The first case of AALP involved a 56-year-old black man with a 25-year history of annular atrophic papules and plaques on the trunk and extremities.¹ The second case reported by Requena et al⁴ in 1994 described a 65-year-old woman with characteristic lesions on the right elbow and left knee. Lipsker et al⁵ reported a third case in a 41-year-old man with a history of Sneddon syndrome who had lesions typical for AALP for 20 years. In all of these cases, histopathologic examination revealed a lichenoid infiltrate with thinning of the epidermis and loss of elastic fibers in the center of the active lesions.

In more recent cases of AALP, the characteristic findings primarily occurred on the trunk and extremities.^6-10 Treatment with topical corticosteroids failed in most cases and some patients noted moderate improvement with tacrolimus ointment 0.1%. Sugashima and Yamamoto¹¹ reported a unique case in 2012 of a 32-year-old woman with AALP on the lower lip. She had notable improvement with tacrolimus ointment 0.1% after 6 months.¹¹

All of the known cases of AALP to date have occurred in adults, both male and female, presenting with a limited number of annular plaques with slightly elevated borders and depressed atrophic centers.^1,3-11 Disease duration of AALP has ranged from 2 months to 25 years.¹¹ Histopathologic findings characteristically demonstrate a lichenoid dermatitis of the raised lesional border with a flattened epidermis, loss of rete ridges, and fibrosis of dermal papillae in the lesion center.⁷ The elastic fibers are destroyed in the papillary dermis of the lesion center, presumably due to elastolytic activity of inflammatory cells.¹ Macrophages present in the lichenoid infiltrate of acute lesions release elastases contributing to this destruction.⁷ Furthermore, elastic fibers appear fragmented on electron microscopy.¹

The clinical course of AALP has proven to be chronic in most cases and frequently is resistant to treatment with topical corticosteroids, retinoids, phototherapy, and immunosuppressive agents.³ Treatment administered early in the disease course may provide a more favorable outcome.¹¹ Lesions characteristically heal with scarring and hyperpigmentation. Our case displayed more extensive involvement than has previously been reported. Our patient showed minimal improvement with topical therapy; however, he demonstrated thinning and regression of active lesions after 2 months of combined treatment with hydroxychloroquine and acitretin. Our use of oral pentoxifylline, hydroxychloroquine, and acitretin has not been previously reported in the other cases of AALP we reviewed. Acitretin is the only systemic agent for lichen planus that has achieved level A evidence, as it previously was shown to be highly effective in a placebo-controlled, double-blind study of 65 patients.¹²

Conclusion

Annular atrophic lichen planus is a known variant of lichen planus characterized by a loss of elastic fibers in the papillary dermis in the center of active lesions. Treatment with topical corticosteroids and phototherapy frequently is ineffective. To our knowledge, there are no studies to date regarding the efficacy of systemic therapy in treatment of AALP. Hydroxychloroquine and acitretin may prove to be beneficial treatment options for resistant AALP. Additional alternative treatments continue to be explored. We encourage reporting additional cases of AALP to further characterize its clinical presentation and response to treatments.

The Food and Drug Administration has granted a priority review for acalabrutinib, a Bruton tyrosine kinase inhibitor, for the treatment of patients with mantle cell lymphoma (MCL) who have received at least one prior therapy.

The new drug application is based on results from the phase 2 ACE-LY-004 trial, which evaluated the safety and efficacy of acalabrutinib in patients with relapsed/refractory MCL who had received at least one prior therapy.

[email protected]

On Twitter @NikolaidesLaura

The Food and Drug Administration has granted a priority review for acalabrutinib, a Bruton tyrosine kinase inhibitor, for the treatment of patients with mantle cell lymphoma (MCL) who have received at least one prior therapy.

The new drug application is based on results from the phase 2 ACE-LY-004 trial, which evaluated the safety and efficacy of acalabrutinib in patients with relapsed/refractory MCL who had received at least one prior therapy.

[email protected]

On Twitter @NikolaidesLaura

The Food and Drug Administration has granted a priority review for acalabrutinib, a Bruton tyrosine kinase inhibitor, for the treatment of patients with mantle cell lymphoma (MCL) who have received at least one prior therapy.

The new drug application is based on results from the phase 2 ACE-LY-004 trial, which evaluated the safety and efficacy of acalabrutinib in patients with relapsed/refractory MCL who had received at least one prior therapy.

[email protected]

On Twitter @NikolaidesLaura