Skin Health
Case Studies: Pemphigus Vulgaris, Psoriasis with Contact Dermatitis
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Ace Skinvestigators

Think dermatologists are just Botox® and beauty? What some of them are capable of may surprise you. We shine the light on the dermatologist mystery solvers, complicated disease managers, and life savers.

All names and some details that could allude to patients’ and doctors’ identities have been changed to protect their privacy. In the collection of these case studies, no patient names were disclosed. These articles are intended for informational purposes only, to share interesting real-life dermatology cases—they should not be relied on for diagnostic accuracy or applicability to your particular skin, which requires an in-person ocular consultation with a qualified physician. For appropriate care for your skin, please consult your dermatologist.

Case 1: (Re)Search Rescue

Ann presented with violently raw and blistered skin that was peeling off in large, painful patches. Not yet diagnosed, she was quickly hospitalized and, recognizing that the primary problem was one of the skin, the admitting doctor referred Ann to a senior dermatologist and head of the hospital’s dermatopathology department.

Ann could no longer eat from the pain (she had blisters in the mouth and throat, too), developed multiple infections, and was rapidly deteriorating. A biopsy revealed that she had pemphigus vulgaris, an immunologic disease where antibiodies are formed against the cementing substance between skin cells. Imagine a wall built of bricks and mortar, where the mortar is constantly dissolving so the bricks fall from the wall. With pemphigus vulgaris, the body rejects the “cement” that holds the skin cells together. This is why Ann looked like a burn victim:her skin was coming apart.

Pemphigus is traditionally treated with steroids but by this time, Ann’s life was at stake and more aggressive treatment was needed. The doctor began frantically researching, looking up new drugs, including experimental ones, that could work quickly and broadly, and that would not suppress Ann’s immunity further. She learned that rituximab, a drug used for certain types of cancer, had been tried by some specialists for pemphigus but not often; there were just 15-20 initial reports in the world, and none in her country.

Running out of time and options, she prescribed it. And it’s a good thing she did. Despite considerable degeneration, Ann responded almost immediately and dramatically. She survived, and not only cleared up within 6 weeks, but stayed clear.

With the usual treatment of steroids, pemphigus patients battle infections, diabetes and other side effects for two years or longer. More than a year later, Ann continues to be completely healthy.

No matter the concern—be it reshaping faces, erasing acne, lightening dark spots or saving lives—a strong clinician who researches and innovates is the kind of physician who discovers breakthrough therapies, delivers the best results and pushes the science forward.

Case 2: P.S.O.R.I.A.S.I.S. Bingo!

Kim’s psoriasis was finally well controlled. In addition to bath-PUVA sessions and membership in a support group, Kim steered clear of dyes and preservatives (a patch test showed she was sensitive to them). Still, Kim had dry, scaly patches on one hand that wouldn’t go away.

Kim’s dermatologist grilled her about what she was using that could be causing the patches. Kim was adamant: nothing! Because she was so happy about her therapy’s success, Kim was exacting about avoiding dyes and preservatives. The doctor persisted, asking if Kim had begun working (she was retired) or had any other changes in her life that could be causing even accidental exposure. They finally got to new hobbies. Kim said she had recently started playing weekly bingo. Delving deeper, the dermatologist asked Kim to show him what she used when playing. Kim came back with an ink-stained marker and paper. Sure enough, where Kim’s skin came into contact with the ink and where she rested her hand on the paper (thiourea is related to dyes and preservatives and is common in paper) matched the pattern of her dry, scaly patches.

After just a few weeks of minimizing contact with the pen and paper, Kim was finally scale free from head to toe.

Case 3: Skindefatigable

Thirty-one year old Ali has had atopic dermatitis since infancy. He’d been patch tested but was no longer responsive to his preventive and therapeutic measures. He was constantly on steroids and suffering their side effects. Ali got another patch test at a second clinic but it showed nothing new. Because this clinic only had a standard patch test for 30 allergens, the doctor referred Ali to a contact dermatitis specialist who had expanded patch test trays (these expanded trays are expensive and unnecessary for most people so few clinics have them).

The 103-allergen test showed Ali was also highly allergic to clothing and red dye (and he happened to love red—many of his shirts, his cell phone cover, etc. were red). Ali needed the expanded test to get a broader picture of his sensitivities. But what was disconcerting was the discovery that even without the expanded test, Ali could have suffered much less. During his consultation, the third doctor learned that Ali was using many products with allergens he was acutely sensitive to including fragrance (a 3+ reaction, the most severe), propylene glycol, and ethylenediamine—all of which are in the standard 30-allergen patch test and were already identified as things for him to avoid in his first patch test.

If these allergens are in the standard test and Ali knew he needed to avoid them, why didn’t he? Unfortunately, Ali thought he was avoiding them. The first clinic gave him a popular “perfume-free” soap, not realizing that while it didn’t have “perfume” or “fragrance” listed in its ingredients, it contained benzyl alcohol, a preservative related to fragrance.

In addition, the clinic didn’t tell him his allergens were common in laundry soap, lotions or clothing, so Ali didn’t watch out for them. And they didn’t know that ethylenediamine is common in steroids. Ali had been using products and drugs to control his atopic dermatitis that were in fact making it worse!

After just two weeks of stopping steroids and replacing his personal care products, clothing and detergent, Ali was a full 60% better. Within another two weeks, he was 100% clear and has stayed clear for over a year now, without any steroid use at all.

Even for such a severe case of atopic and contact dermatitis, pure prevention was all the treatment that was needed. Had Ali’s doctors been better educated about ingredients, he could have been spared the worst of his reactions, including the steroid side effects.

A patient who does not improve after a standard patch test may still need to be referred to a center with an expanded tray. But because these are costly and few patients really need them, it is crucial to first ensure the accurate interpretation of standard patch test results and to have enough knowledge of ingredients to help the patient achieve proper compliance.

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