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Cosmeceuticals and Other Techniques to Reduce Bruising From Surgical and Cosmetic Procedures
Pub Date : 2025-01-14 DOI: 10.1002/der2.70013
Faraz Yousefian, Braden Van Alfen, Sujitha Yadlapati, David J. Goldberg, Michael Gold

Background

Bruising is the most common adverse event experienced after cosmetic procedures, dermatologic surgeries, and other surgeries. Bruising can cause significant distress to a patient and may be the reason for unnecessary additional office visits.

AIM

This review aims to outline the therapeutic remedies and prevention methods to decrease bruising after cosmetic procedures and other surgeries as described in the literature. A thorough in-depth understanding of the treatment of bruising can help improve the patient experience.

Methods

A literature search was conducted on PubMed reviewing remedies for bruising postsurgical and cosmetic procedures in the dermatological field.

Results

A broad variety of remedies for reducing and alleviating bruising after a procedure exist. These treatments include cold compression, ReFORM and RePAIR, various lasers, herbal supplements including Arnica Montana, inhance postinjection serum, vitamin K, peroxide, and tranexamic acid. Results are varied but do show there are treatment options to alleviate bruising.

Conclusions

Physicians performing dermatologic procedures, cosmetic injections, or other surgeries should be aware of the causes and supported remedies for bruising. By understanding the many options out there to decrease bruising, providers can help alleviate the distress that it often causes patients.

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引用次数: 0
An introduction to cosmeceuticals—What is new and trending part II
Pub Date : 2024-12-23 DOI: 10.1002/der2.227
Kavita Mariwalla
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引用次数: 0
Alopecia Areata Treatment: Past, Present, and Future 斑秃治疗:过去,现在和未来
Pub Date : 2024-12-19 DOI: 10.1002/der2.70008
Eliana L. Jolkovsky, David J. Goldberg

Background

Alopecia Areata (AA) is an autoimmune disorder resulting in non-scarring hair loss on the scalp, face, and body. AA research has experienced significant advancements within the last century with the discoveries of the autoimmune nature of the disorder and the role of genetic and psychosocial factors. This review provides a comprehensive dive into the history and evolution of AA management with a focus on the recently FDA-approved JAK inhibitors baricitinib, ritlecitinib, and deuruxolitinib, and sheds light on emerging therapies.

Methods

A search was conducted on PubMed to investigate literature on the history of AA treatment, current AA treatment with a focus on therapy with JAK inhibitors, and the future directions of AA treatment.

Results

Caustic topical agents were used as the main AA therapy until recent decades. The last century saw significant advancements in understanding the etiology of AA as autoimmune, genetic, and psychosocial, influencing the directions of treatment research. In recent years, JAK inhibitors were found to be an effective, systemic AA treatment. Non-systemic AA therapies such as corticosteroid injections, topical minoxidil, contact immunotherapy, and red-laser light therapy remain effective treatments. JAK inhibitors continue to be the focus of AA treatment research, although other targets and new treatment modalities are being studied.

Conclusion

The treatment of AA has undergone significant advances within recent years, especially with the application of JAK inhibitors as systemic therapy. Future research should investigate the therapeutic potential of stem cell therapy, gene therapy, and energy-assisted drug delivery (LEADD) for AA.

斑秃(AA)是一种自身免疫性疾病,导致头皮、面部和身体的非瘢痕性脱发。在过去的一个世纪里,由于发现了这种疾病的自身免疫性质以及遗传和社会心理因素的作用,AA的研究取得了重大进展。本综述全面探讨了AA治疗的历史和发展,重点介绍了最近fda批准的JAK抑制剂baricitinib、ritlecitinib和deuruxolitinib,并揭示了新兴疗法。方法在PubMed上检索AA治疗史、目前以JAK抑制剂为主的AA治疗现状及未来AA治疗方向的文献。结果近几十年来,外用腐蚀性药物一直是AA的主要治疗方法。上个世纪,人们对AA病因的理解取得了重大进展,包括自身免疫、遗传和社会心理,影响了治疗研究的方向。近年来,JAK抑制剂被发现是一种有效的系统性AA治疗方法。非系统性AA治疗,如皮质类固醇注射、局部米诺地尔、接触免疫治疗和红色激光治疗仍然是有效的治疗方法。尽管其他靶点和新的治疗方式正在研究中,但JAK抑制剂仍然是AA治疗研究的重点。结论近年来,AA的治疗取得了重大进展,特别是JAK抑制剂作为全身治疗的应用。未来的研究应探讨干细胞治疗、基因治疗和能量辅助药物传递(LEADD)对AA的治疗潜力。
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引用次数: 0
Cellulite & Skin Tightening: A Review of Pathophysiology and Topical Treatment 脂肪团与紧肤:病理生理学与局部治疗综述
Pub Date : 2024-12-19 DOI: 10.1002/der2.70011
Isabella Castellanos-García, Luisa Valentina Ramírez-Zuluaga, Laura Sofia Páez-Cárdenas, Dennys Lintsay Villalba-Moreno, María Daniela Caicedo-León, Elisha Singer, Thais Pincelli, Alison J. Bruce, Miguel A. Aristizabal

Background

Cellulite is a localized skin condition that affects many women, particularly after puberty. It results from a complex interplay of several factors that lead to the characteristic dimpled appearance of the skin. Cellulite may cause psychological stress and negatively impact quality of life. Additionally, body skin laxity may further exacerbate cosmetic concerns in these patients. Consequently, multiple therapeutic options, including topical treatments, have been explored to address both cellulite and skin laxity.

Objectives

To review the pathophysiology of cellulite and skin laxity, as well as topical skincare options for their management.

Methods

A literature search from 2000 to 2024 was conducted using the databases PubMed, EBSCOhost, Scopus, and Google Scholar, with the key terms “cellulite,” “cellulite management,” “cellulite topical treatment,” “skin sagging,” “skin laxity,” and “loose skin.” The search included clinical trials, observational studies, book chapters, and review articles in English and Spanish.

Results

The pathophysiologic mechanisms underlying cellulite involve a combination of histological, hormonal, genetic, and lifestyle factors. Several topical agents, including retinoids and methylxanthines, have shown potential in improving the cosmetic appearance of cellulite and may contribute to localized fat reduction. Emerging botanical extracts hold promise as topical treatments for cellulite and skin tightening.

Conclusions

Cellulite and skin laxity are prevalent cosmetic concerns with multifactorial and complex pathophysiologic origins. Topical treatments for cellulite and skin tightening require further investigation. Although some studies have demonstrated positive outcomes with skincare products and topicals, robust evidence and studies with extended follow-up are still lacking. Additional research is necessary to evaluate the long-term efficacy of topical treatments as standalone therapies for cellulite and skin tightening.

脂肪团是一种局部皮肤状况,影响许多女性,尤其是青春期后。它是几个因素复杂的相互作用的结果,这些因素导致了皮肤的特征凹陷外观。脂肪团可能造成心理压力,对生活质量产生负面影响。此外,身体皮肤松弛可能会进一步加剧这些患者的美容问题。因此,多种治疗选择,包括局部治疗,已经探索解决脂肪团和皮肤松弛。目的回顾脂肪团和皮肤松弛的病理生理学,以及局部皮肤护理的选择。方法检索PubMed、EBSCOhost、Scopus、谷歌Scholar数据库2000 - 2024年的相关文献,检索关键词为“cellulite”、“cellulite management”、“cellulite外用治疗”、“skin下垂”、“skin松弛”、“loose skin”。检索包括临床试验、观察性研究、书籍章节和英语和西班牙语的评论文章。结果脂肪团形成的病理生理机制涉及组织学、激素、遗传和生活方式等多种因素。一些局部药物,包括类维生素a和甲基黄嘌呤,已经显示出改善脂肪团外观的潜力,并可能有助于局部脂肪减少。新兴植物提取物有望作为局部治疗脂肪团和皮肤紧致。结论脂肪团和皮肤松弛是普遍存在的美容问题,具有多因素和复杂的病理生理起源。对脂肪团和皮肤紧致的局部治疗需要进一步的研究。虽然一些研究已经证明了护肤产品和外用药物的积极效果,但仍然缺乏强有力的证据和长期随访的研究。需要进一步的研究来评估局部治疗作为单独治疗脂肪团和皮肤紧致的长期疗效。
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引用次数: 0
Fezolinetant: A Non-hormonal NK3R Antagonist for the Treatment of Hot Flushes and Vasomotor Symptoms 非索内酯:治疗热潮红和血管运动症状的非激素 NK3R 拮抗剂
Pub Date : 2024-12-13 DOI: 10.1002/der2.70009
Arpita Yadav, Manoj K. Verma, Arun K. Sharma, Anu Chaudhary, Sudha Bhartiya

Background

Menopausal vasomotor symptoms (VMS), such as hot flashes (also known as night sweats), are experienced by 70% of women. These symptoms may be debilitating and last for many years. For 10%–20% of women, these symptoms are almost unbearable. Several pharmacotherapeutic approaches have been evaluated, and more are continually being developed. Although hormone therapy (HT) is often considered the most effective treatment, it is frequently accompanied by significant adverse effects. Consequently, there is a concerted effort to explore non-hormonal alternatives.

Objectives

The present study aims to provide a comprehensive overview of the key milestones and development trajectory of Fezolinetant from the preclinical stages to its FDA approval for the treatment of VMS.

Method

Fezolinetant's development trajectory was undertaken, employing a multifaceted information retrieval strategy. This approach leveraged scientific databases like PubMed, Google Scholar, and ScienceDirect, alongside authoritative resources including DrugBank and clinicaltrials.gov. Additionally, peer-reviewed journals and the official website of Astellas Pharma were meticulously examined to find the relevant information. The present study delves into various stages of Fezolinetant's development, including its medicinal chemistry, synthesis, mechanism of action, and pharmacodynamic and pharmacokinetic studies, as well as clinical data, and safety profiles.

Result

On May 12, 2023, the FDA approved Fezolinetant, a non-hormonal, selective neurokinin 3 (NK3) receptor antagonist, for treating mild to severe VMS marked on by menopause. It has been developed by Astellas Pharma under the brand name Veozah and is taken orally once a day, with or without meals, at a dose of 45 mg.

Conclusion

Fezolinetant represents a promising non-hormonal treatment option for women experiencing VMS. The key findings from the studies include the effectiveness of Fezolinetant in alleviating VMS symptoms and its favorable safety profile compared to hormonal therapy.

绝经期血管舒缩症状(VMS),如潮热(也称为盗汗),70%的女性都经历过。这些症状可能会使人衰弱并持续多年。对于10%-20%的女性来说,这些症状几乎无法忍受。已经对几种药物治疗方法进行了评估,并且正在不断开发更多的药物治疗方法。虽然激素疗法(HT)通常被认为是最有效的治疗方法,但它往往伴随着显著的不良反应。因此,人们共同努力探索非激素替代品。本研究旨在全面概述Fezolinetant从临床前阶段到FDA批准用于治疗VMS的关键里程碑和发展轨迹。方法采用多方面的信息检索策略,对Fezolinetant的发展轨迹进行分析。这种方法利用了PubMed、b谷歌Scholar和ScienceDirect等科学数据库,以及DrugBank和clinicaltrials.gov等权威资源。此外,同行评议的期刊和阿斯泰来制药的官方网站被仔细检查,以找到相关信息。本研究深入探讨了非唑啉奈坦发展的各个阶段,包括其药物化学、合成、作用机制、药效学和药代动力学研究,以及临床数据和安全性。2023年5月12日,FDA批准了非激素、选择性神经激肽3 (NK3)受体拮抗剂Fezolinetant用于治疗更年期轻度至重度VMS。它是由安斯泰来制药公司以Veozah品牌开发的,每天口服一次,含餐或不含餐,剂量为45毫克。结论非唑啉奈坦是非激素治疗VMS的理想选择。这些研究的主要发现包括Fezolinetant在缓解VMS症状方面的有效性以及与激素治疗相比其良好的安全性。
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引用次数: 0
Categorized Side Effect and Complications of Microneedling 微针美塑的副作用和并发症分类
Pub Date : 2024-12-13 DOI: 10.1002/der2.70010
Atefeh Mohammadnejad

Introduction

Facial microneedling (MN) represents a contemporary approach to skin rejuvenation that has garnered increasing popularity in recent years. This technique is distinguished by its cost-effectiveness and widespread adoption across various age groups. While MN is associated with substantial improvements in skin appearance and texture, it is also accompanied by a range of potential adverse effects.

Aim

This paper outlines to present the categorized side effect and complications of MN.

Methods

In this paper, published studies and colleagues’ experiences were used to classify and present the results.

Conclusion

There is currently insufficient research on the complications and side effects of MN, highlighting the need for a comprehensive and organized review in this area. This study systematically investigates MN-related complications in six key areas: operator, patient, procedures and materials, sterile devices and skin, aftercare, and standard device classification and evaluation.

面部微针(MN)代表了一种当代皮肤年轻化的方法,近年来越来越受欢迎。这种技术的特点是其成本效益和广泛采用在不同年龄组。虽然MN与皮肤外观和质地的显著改善有关,但它也伴随着一系列潜在的不良反应。目的概述MN的不良反应及并发症分类。方法采用已发表的研究和同行的经验对结果进行分类和呈现。结论目前对MN的并发症和副作用研究不足,需要对这一领域进行全面、有组织的综述。本研究系统地调查了六个关键领域的mn相关并发症:操作者、患者、程序和材料、无菌器械和皮肤、术后护理以及标准器械分类和评估。
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引用次数: 0
Triple Wavelength for Laser Hair Reduction: Parameter Selection and Optimisation of Results 三波长激光脱毛:参数选择和结果优化
Pub Date : 2024-11-08 DOI: 10.1002/der2.70006
Ganesh Srinivas Pai, Avitus John Raakesh Prasad, Anusha H. Pai, Rahul Pillai

Background

Triple wave hair removal is an advanced method for achieving permanent hair reduction which has always been challenging. This technique combines the benefits of three different wavelengths of laser light to target a broader range of skin types effectively. This study employed three different equipment.

Aims

To establish the efficacy of triple wavelength hair removal in various skin types, sites and type of hair. To give importance to parameter selection and various techniques to be employed in various situations to achieve permanent hair removal.

Patients and Methods

This was an Investigator initiated, two center study of female's patients with hirsutism above age 18 years with skin type III−V, areas included are face, chin, chest and others between the period of August 2017 to February 2024.

Results

The amount of hair reduction was assessed using the physician GAIS (Global Aesthetic Improvement Scale) score: No results 0% reduction, Poor 0%−25% reduction, Average 25%−50% reduction, good 50%−75% reduction, and excellent 75%−100% reduction. Patients who completed minimum of four to maximum of six sessions were included in the study. An excellent reduction in 80% of the treated patients and good reduction in 15% of treated patients was observed.

Conclusion

This current study shows that a synergistic combination of three diode laser wavelengths used for hair removal is effective and safe to use in subjects of all skin types for facial and body hair and is an alternative in treatment of patients who responds poorly to diode wavelength.

背景 三波长脱毛是一种先进的永久性脱毛方法,一直以来都具有挑战性。这种技术结合了三种不同波长激光的优点,能有效地针对更广泛的皮肤类型。本研究采用了三种不同的设备。 目的 确定三波长脱毛对不同皮肤类型、部位和毛发类型的功效。重视参数选择和在不同情况下使用的各种技术,以实现永久脱毛。 患者和方法 这是一项由研究者发起的双中心研究,研究对象为 18 岁以上、皮肤类型为 III-V 型的女性多毛症患者,部位包括脸部、下巴、胸部和其他部位,时间跨度为 2017 年 8 月至 2024 年 2 月。 结果 使用医生的 GAIS(全球美学改善量表)评分来评估毛发减少的程度:无效果 0%,差 0%-25%,一般 25%-50%,好 50%-75%,优秀 75%-100%。完成最少四次至最多六次治疗的患者均被纳入研究范围。研究结果显示,80% 的患者疗效极佳,15% 的患者疗效良好。 结论 本研究表明,三种二极管激光波长的协同组合用于脱毛,对各种肤质的面部和体毛脱毛均有效且安全,是对二极管波长反应不佳的患者的一种替代治疗方法。
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引用次数: 0
Dupilumab Efficacy and Safety Assessment in the Treatment of Atopic Dermatitis in Pediatric Patients: A Systematic Review 杜匹单抗治疗儿童特应性皮炎的疗效和安全性评估:系统回顾
Pub Date : 2024-11-07 DOI: 10.1002/der2.70002
Valeria Antoniou, Elena Thomaidou, Ekatherine Prokopiou

Background/Objectives

Atopic dermatitis (AD) is a chronic inflammatory skin condition, commonly first occurring in early childhood. Although many treatments have currently been established, their effectiveness often varies, and it is not always adequate. The first biologic agent approved in the pediatric population, in severe AD cases, is dupilumab. In this review we aim to present the current data on dupilumab effectiveness and safety in the pediatric population.

Methods

Systematic search was conducted throughout PubMed, ScienceDirect, and clinicaltrials.gov, from which three clinical trials and four real-life studies were included. The studies were analyzed in terms of drug effectiveness (using EASI, IGA and SCORAD scoring systems) and safety profile (presence and occurrence of adverse events).

Results

EASI, SCORAD, and IGA scores were significantly improved in patients receiving dupilumab treatment irrespective of dosage. Conjunctivitis was the most consistently and commonly reported adverse event in both clinical trials (relative risk; RR = 2.4, 95% confidence interval [CI] [1.20, 4.84], p = 0.01) and real-life studies (10.8% of patients). Injection-site reactions and nasopharyngitis demonstrated an increased, yet nonsignificant RR. Compared to placebo, dupilumab exhibited a reduced RR of 36% in AD exacerbations (95% CI [0.43, 0.94], p = 0.0234) and 44% in skin infections (95% CI [0.36, 0.88], p = 0.0106).

Conclusions

Dupilumab appears to be a promising drug in the treatment of moderate to severe AD in pediatric population, with noticeable improvement in outcome scores. Among the adverse events, conjunctivitis is the most common; however, no long-term or life-threatening events were reported.

背景/目的 特应性皮炎(AD)是一种慢性炎症性皮肤病,通常在儿童早期发病。尽管目前已确立了许多治疗方法,但其疗效往往参差不齐,而且并不总是充分的。杜必鲁单抗是首个获准用于治疗儿童重症过敏性皮炎的生物制剂。在这篇综述中,我们旨在介绍目前有关杜比单抗在儿科人群中的有效性和安全性的数据。 方法 在PubMed、ScienceDirect和clinicaltrials.gov上进行了系统检索,从中纳入了三项临床试验和四项实际研究。从药物有效性(采用 EASI、IGA 和 SCORAD 评分系统)和安全性(不良反应的存在和发生)方面对这些研究进行了分析。 结果 无论剂量大小,接受杜比鲁单抗治疗的患者的 EASI、SCORAD 和 IGA 评分均有明显改善。在临床试验(相对风险;RR = 2.4,95% 置信区间 [CI] [1.20,4.84],p = 0.01)和实际研究(10.8% 的患者)中,结膜炎都是最常见的不良事件。注射部位反应和鼻咽炎的RR有所增加,但不显著。与安慰剂相比,杜匹单抗可使 AD 恶化的 RR 降低 36%(95% CI [0.43,0.94],p = 0.0234),皮肤感染的 RR 降低 44%(95% CI [0.36,0.88],p = 0.0106)。 结论 杜匹单抗似乎是一种治疗儿童中重度AD的有前途的药物,其疗效评分有明显改善。在不良反应中,结膜炎是最常见的一种,但没有长期或危及生命的不良反应报告。
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引用次数: 0
Eczematous Drug Eruptions: Identification and Management of Pharmacological Culprits in Primary Care 药物性湿疹:初级保健中药物致病因素的识别与管理
Pub Date : 2024-11-07 DOI: 10.1002/der2.70004
Joseph Gofman, Darcy Tocci, Daniel L. Fischer, Charles Gropper
<div> <section> <h3> Introduction</h3> <p>Eczematous drug eruptions (EDEs) can mimic common skin conditions like eczema or psoriasis, complicating diagnosis and treatment. These eruptions often present as papular or vesicular lesions, sometimes pruritic, with scaling and crusting. EDEs can manifest anywhere from days to years after initiating medications commonly prescribed in the primary care setting such as calcium channel blockers, ACE inhibitors, ARBs, thiazides, and statins. Misdiagnosis can lead to prolonged patient discomfort and unnecessary treatments. This review emphasizes the importance of accurate differentiation between EDEs and other dermatoses for improved patient outcomes.</p> </section> <section> <h3> Objective</h3> <p>This review aims to aid clinicians in the differentiation of EDEs from clinically similar conditions, such as eczema and psoriasis. It focuses on identifying commonly prescribed medications in primary care settings that trigger EDEs, discusses diagnostic strategies, and explores effective treatment options for managing these eruptions.</p> </section> <section> <h3> Methods</h3> <p>A comprehensive literature review was conducted using databases such as PubMed, Google Scholar, and the Cochrane Library, covering the period from January 1980 to January 2023. The search included terms like “eczematous,” “drug eruption,” “medication,” “drug induced,” “skin reactions,” “adverse cutaneous,” and “side effects.” Studies selected for review included literary reviews, systematic reviews, case reports, and case series focusing on the pharmacological agents responsible for EDEs. Articles were selected based on their focus on primary care medications and their connection to EDEs.</p> </section> <section> <h3> Results</h3> <p>The review identified a broad spectrum of medications implicated in EDEs, including calcium channel blockers, ACE inhibitors, ARBs, thiazides, and statins. Among these, calcium channel blockers were the most frequently associated with chronic, diffuse, and pruritic scaly papules and plaques. Other common offenders include ACE inhibitors and ARBs, which primarily trigger eczema-like rashes in elderly patients. Thiazide diuretics were associated with photosensitivity reactions leading to eczematous eruptions. Statins were found to compromise the skin barrier, contributing to the development of eczematous reactions, particularly in older individuals. The histopathological findings across cases frequently showed spongiosis, eosinophilic infiltrates, and acanthosis, complicating the differentiation from eczema without a thorough medication history.</p> </section> <sec
引言 湿疹性药物疹(EDEs)可与湿疹或银屑病等常见皮肤病相似,从而使诊断和治疗复杂化。这些疹子通常表现为丘疹或水泡状皮损,有时伴有瘙痒、脱屑和结痂。EDE 可在开始服用初级保健常用药物(如钙通道阻滞剂、ACE 抑制剂、ARB、噻嗪类药物和他汀类药物)后数天至数年内出现。误诊可导致患者长期不适和不必要的治疗。本综述强调了准确区分 EDE 和其他皮肤病以改善患者预后的重要性。 目的 本综述旨在帮助临床医生区分 EDE 与湿疹和银屑病等临床类似疾病。本综述的重点是确定引发 EDEs 的初级医疗机构常用处方药,讨论诊断策略,并探讨管理这些疹子的有效治疗方案。 方法 使用 PubMed、Google Scholar 和 Cochrane Library 等数据库进行了一次全面的文献综述,时间跨度为 1980 年 1 月至 2023 年 1 月。搜索关键词包括 "eczematous"、"drug eruption"、"medication"、"drug induced"、"skin reactions"、"adverse cutaneous "和 "side effects"。被选中进行审查的研究包括文学评论、系统综述、病例报告和病例系列,重点关注导致 EDEs 的药物。文章的选择基于其对初级保健药物及其与 EDEs 的关系的关注。 结果 该综述确定了与 EDEs 有关的多种药物,包括钙通道阻滞剂、ACE 抑制剂、ARBs、噻嗪类药物和他汀类药物。其中,钙通道阻滞剂最常与慢性、弥漫性和瘙痒性鳞状丘疹和斑块有关。其他常见的药物包括 ACE 抑制剂和 ARBs,它们主要在老年患者中引发湿疹样皮疹。噻嗪类利尿剂与导致湿疹的光敏反应有关。研究发现,他汀类药物会损害皮肤屏障,导致湿疹反应的发生,尤其是在老年人中。不同病例的组织病理学结果经常显示海绵状增生、嗜酸性粒细胞浸润和棘层增生,这使得在没有详尽用药史的情况下与湿疹的鉴别变得更加复杂。 结论 早期识别 EDEs 并将其与湿疹或银屑病等常见皮肤病区分开来,对于有效治疗至关重要。综述强调了对服用常见心血管药物的患者的药物诱发疹保持高度怀疑的重要性。及时停用违规药物,并结合其他治疗方法,可以显著改善患者的预后。皮肤科医生和初级保健提供者应通力合作,优化治疗,尤其是在使用多种药物的情况下。需要进一步开展研究,以加深对 EDE 背后机制的了解,并完善诊断策略,从而最大限度地降低患者的发病率。
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引用次数: 0
Introduction—Dermatological Reviews—October 2024 导言-皮肤病学评论-2024 年 10 月
Pub Date : 2024-10-01 DOI: 10.1002/der2.70007
Michael H. Gold
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引用次数: 0
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Dermatological Reviews
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