OCTOBER 1, 2009 • WWW.FAMILYPRACTICENEWS.COM SKIN DISORDERS 25 Cardiovascular Disease, Psoriasis Link Questioned

BY BRUCE JANCIN The same held true when the py, compared with controls of IHD hospitalization during 6 ischemic attack in patients with analysis was narrowed to hos- (19.4% vs. 16.4%, respectively), years of follow-up was 5% high- recently diagnosed psoriasis, al- B UDAPEST — The last word pitalization for acute myocar- lipid-lowering drugs (7.0% vs. er in psoriasis patients, and the though there was a suggestion on the relationship between dial infarction. The psoriasis pa- 6.2%, respectively), and antidia- MI hospitalization risk was 6% of a possible small absolute in- psoriasis and cardiovascular dis- tients, even those with more betic medications (4.4% vs. lower than in controls. These crease in MI risk in patients ease may not be in, according to severe skin disease, did not have 3.6%, respectively). This was differences were far from statis- younger than age 60 with severe the results of a new study. a greater rate of MI tical significance, she said. psoriasis (Br. J. Dermatol. Contrary to earlier studies, than controls, she Dr. Wakkee noted that her 2009;160:1048-56). And no in- psoriasis was found to not be an added. In the absence of study findings are at odds with crease in cardiovascular mortal- independent risk factor for hos- The study relied definitive data, those of a much-publicized ity was identified in an earlier pitalization for ischemic heart upon hospital and physicians will analysis of the U.K. General Prac- long-term follow-up study of disease in a large Dutch study, pharmacy linked data- have to help tice Research Database (JAMA PUVA-treated patients. Dr. Marlies Wakkee reported at bases covering 2.5 mil- psoriasis patients 2006;296:1735-41), which con- So the question remains: Is the annual congress of the Eu- lion Dutch patients. minimize risks. cluded that psoriasis patients had psoriasis as a systemic inflam- ropean Society for Dermato- The 15,820 psoriasis a small but significantly increased matory state an independent logical Research. patients and 27,577 DR. WAKKEE risk of MI. It is possible, she said, risk factor for cardiovascular Even after subdividing the nonpsoriatic controls that the earlier finding was due to events, or does the increased 15,820 Dutch psoriasis patients (mean age 48 years) were fol- not surprising, said Dr. Wak- detection bias. This potential risk, if present, result from pso- in the study into those who used lowed for a mean of 6 years. kee, given that prior studies confounder could occur because riasis patients’ increased preva- only topical therapy versus pa- The IHD hospitalization rate have shown the prevalence of psoriasis patients have greater lence of obesity, smoking, meta- tients with more severe dis- was 611 cases per 100,000 person- metabolic syndrome to be ele- consumption of health care, as bolic syndrome, and other ease—as defined by use of sys- years in psoriasis patients and 599 vated in psoriasis patients. shown by the Dutch patients’ cardiovascular risk factors? temic therapies or hospi- in controls. MI hospitalization Psoriasis patients also had higher hospitalization rate. Dr. Wakkee said the only way talization for psoriasis—the rates were also similar: 234 per more hospitalizations for rea- Further muddying the wa- to resolve the controversy is to more severely affected patients 100,000 person-years in psoriasis sons other than psoriasis in the ters, investigators at the Uni- move beyond case-control stud- did not have a higher rate of is- patients and 235 in controls. prior 6 months. versity of Basel in Switzerland ies and conduct a large, detailed, chemic heart disease (IHD) hos- At study entry, the psoriasis In a multivariate analysis ad- recently analyzed the U.K. Gen- long-term prospective study. In pitalization, said Dr. Wakkee of patients had slightly, but statis- justed for age, gender, medica- eral Practice Research Database the absence of definitive data, Erasmus University Medical tically significantly, higher rates tions, and hospitalizations in the and found no overall increased physicians will have to help pa- Center, Rotterdam. of antihypertensive drug thera- prior 6 months, the relative risk risk of MI, stroke, or transient tients minimize their risks. ■ Five Newer or Atypical Exanthems Call for Reassurance

BY ROBERT FINN only if they know to look, because they exanthem likes to involve the outer arms, need to plate it on a different agar. the outer legs, the buttocks, and the hile most exanthems are self- Although A. haemolyticum will probably face. It almost always spares the trunk, or Wlimiting, some are not, making it resolve on its own with time, children can at least the trunk will be much less in- important to establish a specific diagno- be treated effectively with a macrolide an- volved than everywhere else,” he said. sis, according to Dr. Anthony J. Mancini. tibiotic such as an erythromycin, Physicians need to remember that, Parents want to know how long it’s go- azithromycin, or clarithromycin. Patients while they may have learned in residen- ing to take to go away, Dr. Mancini said do not respond well to penicillin antibi- cy that Gianotti-Crosti syndrome is as- in an interview. “If you can characterize otics, an important distinction from strep- sociated with hepatitis B, that’s rarely it ...at least they may have some answers. tococcal infection, he said. true in the United States. It is usually They know that it’s going to take a while caused by the Epstein-Barr virus and re- ANCINI to resolve, and that saves you from fol- Papular-Purpuric Gloves and Socks quires no treatment. It will resolve, but low-up phone calls and visits to the office Syndrome it may take up to 2 months. J. M when they’re frantic because it’s still Caused most often by parvovirus B19, there 4 weeks later.” papular-purpuric gloves and socks syn- Unilateral Laterothoracic Exanthem NTHONY . A R

Clinicians have learned to keep an eye drome is named for the characteristic Most physicians “have probably seen D out for the bad actors, like oral mucosa rash appearing on a child’s palms and unilateral laterothoracic exanthem, but necrosis that could signal Stevens-Johnson soles, with sharp cutoffs at the wrist and they may have misdiagnosed it as con- OURTESY syndrome, or the centripetal spread of ex- ankle, according to Dr. Mancini. tact dermatitis,” Dr. Mancini said. Be- C anthem with petechiae from a tick bite The virus is self-limited and typically ginning on one side of the body, usual- An infant with acute generalized that could signal Rocky Mountain spotted requires only symptomatic treatment, ly at the arm, armpit, or trunk, the exanthematous pustulosis is shown. fever, he said at a women’s and pediatric but it is important to establish a diagno- exanthem may initially look like a con- dermatology seminar sponsored by Skin sis because parvovirus B19 can cause fe- tact dermatitis but then begins to with fevers and numerous widespread Disease Education Foundation (SDEF). tal infections in utero and lead to a vari- spread. Even after spreading, the exan- nonfollicular pustules, which can look a Dr. Mancini—head of pediatric derma- ety of complications. them maintains predominance on the lot like pustular psoriasis,” Dr. Mancini tology at Children’s Memorial Hospital in Parvovirus B19 also causes Fifth dis- initial side of involvement. said. It’s self-limited, but children do Chicago—reviewed these five newer or ease, but there is an important difference, The cause is unknown, but it is proba- tend to appear more toxic with AGEP atypical exanthems: he pointed out. The “slapped cheeks” of bly viral, he said. It requires no treatment than with some of the other exanthems, Fifth disease are thought to appear only and typically takes 6-8 weeks to resolve. especially if they are young. They may Arcanobacterium haemolyticum after the child is no longer viremic. A have low-grade fevers, and their white Often masquerading as scarlet fever, A. child with papular-purpuric glove and Acute Generalized Exanthematous counts may be mildly elevated. haemolyticum typically appears in adoles- socks syndrome may still be viremic Pustulosis (AGEP) Treatment is supportive, with antihis- cents and young adults as a sore throat when they have a rash, however, and so AGEP is often mistaken for drug-induced tamines, cool compresses, and topical with a scarlet fever–like rash. It is im- should be kept away from pregnant pustular psoriasis, and the literature is steroids if patients are uncomfortable. portant for physicians to recognize and women who are early in gestation. filled with a wide range of reported AGEP will resolve over 2 weeks or so diagnose A. haemolyticum because it can drug associations, including amoxicillin, with desquamation. be treated, noted Dr. Mancini. Gianotti-Crosti Syndrome erythromycin, NSAIDs, and even pseu- Dr. Mancini disclosed being a consul- The first clue that it is not scarlet fever Most physicians have heard of Gianotti- doephedrine, but current thinking is that tant to SkinMedica and Galderma, and or mononucleosis is a negative throat cul- Crosti syndrome, but many have proba- it is often viral, at least in children. on the speakers bureau of Promius and ture for strep and a negative Monospot. bly not diagnosed it because they have “It’s an important entity to recognize, Galderma. SDEF and this news organi- Most labs can test for A. haemolyticum, but not looked closely at distribution. “This because AGEP can have a sudden onset, zation are owned by Elsevier. ■