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Pityriasis Alba

Teaser: 

Ou Jia (Emilie) Wang,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Pityriasis alba is a common, benign skin condition that primarily affects children and adolescents, characterized by hypopigmented patches and scaly plaques on the face and other areas of the body. It is likely a manifestation of post-inflammatory hypopigmentation from subtle or subclinical inflammation. Diagnosis is typically based on history and clinical presentation. Management involves the use of emollients and low-potency topical steroids to improve skin hydration, reduce inflammation, and alleviate symptoms such as pruritus. Pityriasis alba typically becomes less apparent as the patients age, but reassurance and symptomatic relief are critical components to managing the condition.
Key Words: Pityriasis alba, atopy, hypersensitivity, scaling, hypopigmentation, asymptomatic.

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Pityriasis alba presents as patches and plaques of hypopigmentation, which is more identifiable in darker skin types (Fitzpatrick skin types III to VI).
Pityriasis alba is a benign and self-limiting skin condition that often improves with time.
Pityriasis alba is often associated with atopic dermatitis and the atopic triad.
Diagnosis of pityriasis alba is made on history and exam and the exclusion of other conditions (e.g. fungal infections, atopic dermatitis, and psoriasis). Skin biopsy, laboratory tests, and Wood’s lamp examination are not necessary, but can be performed if other conditions are suspected.
The hypopigmentation in pityriasis alba does not result from reduction in melanocyte count.
Patient reassurance, education and lifestyle management is often sufficient, but emollients, low-potency topical steroids, and topical calcineurin can also be used.
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Related Terms: Dermatology, Pityriasis alba, atopy, hypersensitivity, scaling, hypopigmentation, asymptomatic
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Back and Neck Pain, Pain Clinics and Interventional Pain Management in Canada

Teaser: 

Arani Kulamurugan,1 Pranjan Gandhi,2 Markian Pahuta,3 Mohammad Zarrabian,4 Daipayan Guha,5

1Michael DeGroote School of Medicine, McMaster University, Hamilton, ON.
2Michael DeGroote School of Medicine, McMaster University, Hamilton, ON.
3Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, ON.
4Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, ON.
5Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: This paper examines the role of pain clinics in Canada, focusing on non-surgical interventions to manage cervical and lumbar degenerative pathologies. These pathologies have a substantial impact on health care and the economy. Since non-interventional management strategies are often insufficient, pain clinics can be effective in providing image-guided injections to reduce symptoms and rates of surgery. Given the challenges of access and long wait times for treatment, the expansion of pain clinics may be an interim solution to improve outcomes and alleviate the burden on Canadian healthcare.
Key Words: radiculopathy, myelopathy, back pain, neck pain, pain clinic.

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1. Identifying the specific type of back pain guides the choice of treatment, enhancing patient outcomes.
2. Interventional strategies have demonstrated significant benefits when combined with traditional medical and physical therapies.
3. Axial pain, radiculopathy, neurogenic claudication and myelopathy have distinct symptoms and relief mechanisms, making accurate diagnosis critical.
4. Improving the distribution and accessibility of multidisciplinary pain management services will improve the outcomes for patients with chronic pain.
Differentiating Pain Syndromes: It is essential to distinguish among axial neck/back pain, radicular pain, neurogenic claudication and myelopathy to institute proper back pain management. Axial pain is worsened by physical activity, radicular pain is limb dominant, neurogenic claudication is exacerbated by prolonged standing and relieved by sitting, and myelopathy produces upper motor neuron findings in both upper and lower limbs.
Role of Pain Clinics: Offering a wide range of services, pain clinics are cost-effective and improve quality of life and functionality through interventional pain management, mental health support, and physical therapy.
Barriers to Accessing Care: Access to multidisciplinary pain treatment facilities in Canada is limited by long wait times and significant regional variability.
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Related Terms: Back Health, radiculopathy, myelopathy, back pain, neck pain, pain clinic

Pediatric Scabies

Teaser: 

Ou Jia (Emilie) Wang,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Scabies, caused by the Sarcoptes scabiei var. hominis mite, is a common and highly contagious skin infestation that manifests with symptoms of intense itching and a generalized pruritic papular eruption. Crusted scabies, a severe form of the infestation, is more commonly seen in immunocompromised individuals. Scabies can affect individuals of all ages and is typically transmitted through close and prolonged skin-to-skin contact. Diagnosis relies heavily on clinical examination, with scabies preparation at multiple sites guided by dermoscopy. Management involves both treating the condition and preventing its spread to others, with the primary treatment being the application of topical scabicide medications to the entire body. Environmental decontamination measures are crucial in controlling the spread of scabies. Prompt diagnosis and treatment are essential to prevent complications and transmission to others.
Key Words: scabies, classic scabies, crusted scabies, infestations, pruritus, hypersensitivity reactions.

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A large range of prevalence exists with scabies and scabies is not reportable in Canada. It disproportionately affects individuals living in poverty and crowded conditions.
A definitive diagnosis of scabies can be made through visualization through microscopy of skin scrapings and tape samples or through dermoscopy.
Treatment of patients and close contacts and environmental measures must be taken to prevent further spread and infestation.
In scabies infestation, the female mite burrows under the skin and triggers a hypersensitivity reaction with symptoms of pruritus and inflammation.
Classic scabies is more common, while crusted scabies is rarer and more severe.
First-line treatment is topical 5% permethrin cream head to toe including the scalp in infants and young children and from the neck down in adults with retreatment in one week.
Environmental decontamination is important to preventing reinfestation.
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Related Terms: Dermatology, scabies, classic scabies, crusted scabies, infestations, pruritus, hypersensitivity reactions
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Current Concepts in Spinal Cord Injury: Pearls for Primary Care Management

Teaser: 

Karlo M. Pedro, MD,1 Francois Dantas, MD,2 Peyton Lawrence, MD,3 Michael G. Fehlings, MD, PhD,4

1Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
3Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
4Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Institute of Medical Science, University of Toronto, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada.

CLINICAL TOOLS

Abstract: Traumatic spinal cord injury (tSCI) is a devastating condition that can lead to severe and permanent sensory, motor, and autonomic dysfunction, significantly impacting an individual’s ability to function independently. Recent demographic changes have resulted in a notable increase in tSCI among the elderly, with falls emerging as the primary cause. Early recognition and prehospital management are crucial, emphasizing restriction of spinal motion and timely transfer to specialized centres. Since the time from injury to surgery significantly affects outcomes, decompression should not be delayed and offered in a timely manner to all tSCI patients. Additionally, emergent trauma care including conducting a thorough neurological assessment, maintaining adequate blood pressure and adopting a multidisciplinary approach, is essential for optimizing neurological outcomes and addressing long-term complications.
Key Words: Early surgery, geriatric trauma, neurotrauma, traumatic spinal cord injury.

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Falls are increasingly becoming the primary cause of traumatic spinal cord injury, particularly among the elderly population, underscoring the need for heightened awareness and proactive preventive measures.
Early recognition and appropriate prehospital management, including prompt transfer to specialized trauma centers, are crucial in saving the injured spine.
Neuroprotective strategies, such as maintaining adequate spinal cord perfusion and implementing early surgical decompression, are essential for attenuating the secondary injury cascade.
Multidisciplinary care is imperative for restoring functional independence, with a comprehensive approach addressing not only physical rehabilitation but also social, mental, and spiritual needs in patients with tSCI.
With an aging population and more fall-related mechanisms, the most common form of spinal cord injury (SCI) is an incomplete cervical SCI called central cord injury where the arms and hands are more affected than the legs. These patients usually have pre-existing degenerative changes and can experience cord contusion in the absence of a cervical fracture.
“Time is spine” is a key principle which guides spinal cord injury management. Most patients with a SCI require surgery, optimally within 24 hours after injury. Expeditious workup and referral/transfer of patients with a SCI to a specialized spine facility is important.
Be aware that 10-15% of patients with one spine fracture will have a second non-contiguous spine fracture. The presence of a spine fracture in one area should prompt a full spine CT.
Hemodynamic management of patients with a spinal cord injury is important to maintain cord perfusion. Mean arterial pressure should be maintained at greater than 80 mm Hg.
Methylprednisolone (a potent ant-inflammatory corticosteroid) and riluzole (a sodium-glutamate antagonist) are options in treating patients with an acute spinal cord injury and are optimally given within 8-12 hours after injury.
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Related Terms: Back Health, Early surgery, geriatric trauma, neurotrauma, traumatic spinal cord injury

Xerosis and Ichthyosis: A Brief Review

Teaser: 

Manish Toofany,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Xerosis is a common skin condition that becomes more prevalent with age and is a prominent feature in ichthyosis. It primarily resulting from abnormalities in the stratum corneum, influenced by factors like natural moisturizing factors, lipid synthesis, and genetic pathologic variants. The diagnosis of xerosis and ichthyosis is usually made clinically, though specific investigations may aid in the diagnosis of specific ichthyoses. Both conditions can have a considerable negative impact on the quality of life of patients. Management includes moisturization and taking preventive measures to maintain skin health and to prevent xerosis.
Key Words: xerosis, ichthyosis, stratum corneum, natural moisturizing factors.

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Xerosis is a common condition worldwide and it is a prominent feature of both syndromic and non-syndromic ichthyoses.
Both xerosis and ichthyosis can have a considerable negative impact on the quality of life of patients.
The diagnosis of xerosis and inherited ichthyoses is based on history, clinical manifestations, associated abnormalities, and family history, but several specific investigations may aid in the diagnosis of syndromic ichthyoses.
Managing xerosis includes applying topical moisturizers with key components like lipids and humectants while proactive preventive measures are vital for preventing triggers of the condition.
Understanding and addressing triggers such as temperature, low humidity, sunlight exposure, and environmental conditions like air conditioning or heating can be essential in managing xerosis effectively.
Evaluating the overall severity of xerosis and ichthyosis may include the use of established tools like the Dermatology Life Quality Index (DLQI) and the newer Ichthyosis Scoring System (ISS) to assess their impact on patients’ quality of life.
Identifying signs such as brittle hair, neurological abnormalities, and palmoplantar keratoderma can be suggestive of syndromic ichthyoses. These indicators are valuable for recognizing these rare conditions and guiding further examination or evaluation.
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Related Terms: Dermatology, xerosis, ichthyosis, stratum corneum, natural moisturizing factors
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Cervical Disc Arthroplasty: A Movement-Sparing Surgical Option in Cervical Disc Degeneration

Teaser: 

Simon Harris, MA, MB, BChir, FRCSC,

Orthopaedic Spine Surgeon, Trillium Health Partners, Mississauga, Ontario.

CLINICAL TOOLS

Abstract: Degeneration of the cervical discs is a common problem and can cause compression of cervical nerve roots and/or the spinal cord. This in turn may lead to permanent neurological injury, disability and socioeconomical impact for the patient. Surgical management typically includes either an Anterior Cervical Decompression and Fusion (ACDF) or a Posterior Decompression with or without fusion or laminoplasty. Over the past 20 years, Cervical Disc Arthroplasty (CDA) has been an increasingly viable alternative to the “Gold Standard” ACDF, after failure of conservative management in the appropriately selected patient. Single and multilevel CDA has a growing body of evidence to support its equivalency - and even superiority - to ACDF in long-term clinical outcomes.
Key Words: Cervical degenerative disc disease; Cervical Disc Replacement; Cervical Disc Arthroplasty; Radiculopathy; Myelopathy.

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Cervical radiculopathy symptoms include pain, paresthesia, numbness, and weakness in a recognised dermatomal and myotomal pattern.
First-line conservative treatment for cervical radiculopathy includes physiotherapy, analgesia, and non-steroidal anti-inflammatories.
Cervical disc replacement is an evidence-supported intervention for upper extremity radiculopathy that has failed conservative treatment.
Many designs of cervical disc arthroplasty are currently available for implantation in North America.
Cervical degenerative disc disease is a common radiographic finding present in both the symptomatic and asymptomatic population.
Axial neck pain, in the absence of red flag symptoms is best managed with an active physiotherapy program and pain management strategies.
Cervical disc arthroplasty is an evidence-supported surgical option to address central or foraminal cervical stenosis at the disc level.
1 or 2-level cervical disc arthroplasty has a lower re-operation rate than anterior cervical decompression and fusion.
Cervical disc arthroplasty procedure can be performed through a 4cm incision in the front of the neck.
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Related Terms: Back Health, cervical degenerative disc disease, cervical disc replacement, cervical disc arthroplasty, radiculopathy, myelopathy

Neuromodulation for the Management of Chronic Pain After Spinal Surgery

Teaser: 

Vishal Varshney MD FRCPC,1 Jill Osborn PhD, MD, FRCPC,2 Philippe Magown PhD, MD, FRCSC,3 Scott Paquette MEd, MD, FRCSC,4 Ramesh Sahjpaul MD, MSc, FRCSC,5

1Department of Anesthesia, Providence Healthcare, Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
2Department of Anesthesia, Providence Healthcare, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
3Department of Surgery, Section of Neurosurgery, University of Manitoba, Health Sciences Centre, Winnipeg, MB, Canada.
4Department of Anesthesia, Providence Healthcare, Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
5Department of Anesthesia, Providence Healthcare, Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia,  Department of Surgery, University of British Columbia, Vancouver, BC, Canada.

CLINICAL TOOLS

Abstract: Chronic neuropathic pain is associated with substantial disability and societal economic impact. Formerly called Failed Back Surgery Syndrome, and now labelled as Chronic Pain after Spinal Surgery by the ICD-11, this entity represents persistent neuropathic leg pain following structurally corrective spinal surgery, often refractory to pharmacological and interventional management,. In appropriately selected patients where medical management has been unsuccessful, the minimally invasive surgical technique of spinal cord stimulation can reduce disability and pain. Technological advances continue to improve this approach with greater success, lessened morbidity, and expanding indications.
Key Words: chronic pain after spinal surgery, failed back surgery syndrome, neuropathic pain, spinal cord stimulation, neuromodulation.

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1. Managing chronic pain after spinal surgery is a challenging and requires combined pharmacological and interventional options.
2. Spinal cord stimulation is a modality with strong evidence to supports its efficacy in the management of patients with chronic pain after spinal surgery.
3. The workup of patients with chronic pain after spinal surgery must include multi-tier pharmacological approaches, psychological optimization, and structural spinal assessment from a multidisciplinary group of clinicians.
Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system1. Spontaneous features include burning pain and tightness with unpredictable lancinating features.
The mechanism of spinal cord stimulation involves multiple sites within the central and peripheral nervous system. SCS can influence levels of cerebrospinal fluid neurotransmitters including increases in GABA, serotonin, Substance-P, norepinephrine, acetylcholine, and adenosine, and decreases in glutamate and aspartate.
The differential target multiplexed (paresthesia-free) spinal cord stimulation programs appear superior to the older standard paresthesia-based approach.
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Related Terms: Back Health, failed back surgery syndrome, neuropathic pain, spinal cord stimulation, neuromodulation, chronic pain after spinal surgery

Urticaria: A Brief Review

Teaser: 

Yvonne Deng,1 Amir Gohari,2 Joseph M. Lam, MD, FRCPC,3

1Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
3Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Urticaria is a common, mast cell-driven disorder that presents with transient wheals, angioedema, or both. Clinically, it is classified into acute or chronic, depending on the duration of symptoms, and further classified by the presence or absence of inducible stimuli. Although urticaria is rarely life-threatening, it can reduce quality of life and carry significant socioeconomic burden on patients. While there is no cure to the disease, the treatment algorithm for urticaria focusses on the control of symptoms with antihistamines as the mainstay of therapy and immunosuppressive/immunomodulating therapies for severe cases.
Key Words: urticaria; pediatric urticaria; angioedema; acute urticaria; chronic spontaneous urticaria.

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Urticaria is a common pruritic condition that is divided into acute or chronic forms. It can be idiopathic or inducible by triggers that including foods, medications, infections, environmental factors, physical stimuli, and medications.
Acute and chronic urticaria are clinical diagnoses guided by a detailed history and physical examination, and diagnostic testing is not routinely indicated, unless clinical suspicion warrants exclusion of underlying causes.
Pathogenesis of urticaria involves mast cells and subsequent release of histamines and proinflammatory mediators that result in sensory nerve activation, vasodilatation, and plasma extravasation with leukocyte recruitment to lesions.
Second-generation, non-sedating H1-antihistamines are the mainstay of treatment for all types of urticaria and dosed up to fourfold to achieve adequate control.
Individual wheals typically resolve within 24 hours without leaving residual changes on the skin. If the duration of wheals is unclear, patients or clinicians can draw a line around the lesion to observe for changes or resolution
In addition to the physical stimuli in chronic inducible urticaria, other triggers of chronic urticaria include psychosocial stress, work exposures, surgical implants, and menses.
Investigations are not needed to make a diagnosis. However, a limited work-up can be considered for potential comorbidities (e.g. thyroid hormones and autoantibodies for active thyroid disease) or to exclude other diagnoses in the appropriate clinical context (e.g. skin biopsy for urticarial vasculitis).
With the exception of avoiding alcohol consumption, pseudoallergen-free or other food elimination diets should not be routinely recommended to patients for symptom control. In fact, IgE-mediated food allergy is rarely an underlying cause of urticaria.
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Related Terms: Dermatology, Urticaria, pediatric urticaria, angioedema, acute urticaria, chronic spontaneous urticaria
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Pediatric Psoriasis

Teaser: 

Yvonne Deng,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Psoriasis is a chronic inflammatory skin disease that affects up to 1.4% of children (aged <18 years) with a strong genetic predisposition and is mediated by dysregulation in the crosstalk between the innate and adaptive immune responses. It can have significant impact on quality of life for many patients. There are various subtypes of psoriasis with plaque psoriasis being the most common presentation in both adults and children. Pediatric psoriasis is primarily a clinical diagnosis. With the advent of biologics, the treatment landscape for pediatric psoriasis has shifted and encompasses diverse modalities of therapeutics, including topical and systemic treatments, as well as phototherapy.
Key Words: pediatric psoriasis, psoriasis, chronic, inflammatory, skin disease.

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Psoriasis affects the pediatric population and is associated with negative effects on quality of life and psychological impairments.
Lesions of pediatric plaque psoriasis may be thinner, smaller, more macerated than those classically in adult and present more commonly on the scalp, face, intertriginous areas, and extremities (flexural surfaces for younger children and extensor surfaces for older children).
Psoriasis is not an isolated condition and is correlated with higher rates of myocardial infarction, diabetes mellitus, hypertension, obesity, arthritis and liver disease.
In mild to moderate cases of psoriasis, topical therapies with a short course of corticosteroids and/or vitamin D analogue are first-line. In moderate to severe cases, narrowband UVB phototherapy, systemic agents, such as methotrexate, and biologics should be considered.
Pediatric patient should be assessed for risk factors for associated comorbidities.
A history of preceding streptococcal or viral infection can be suggestive of guttate psoriasis, which is more common in children than adults.
Approach to treatment should be guided by the extent and severity of disease, which can be quantified by BSA, the PASI score and quality of life index surveys.
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Related Terms: Dermatology, pediatric, psoriasis, chronic, inflammatory, skin disease
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Hyperhidrosis: A Brief Review

Teaser: 

Mahan Maazi, MEng,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Hyperhidrosis (HH) is a disorder of the eccrine sweat glands causing excessive sweating. It is caused by hyperactivity of the sympathetic nervous system resulting in excessive release of acetylcholine and activation of the sweat glands. Primary essential HH is thought to have a large genetic component, while secondary HH is the result of an underlying condition or medications. HH will often cause excessive sweating in areas with a high density of eccrine sweat glands that include the palms, soles, face, head, or axillae. Diagnosis is largely based on history and physical which can help differentiate between primary and secondary HH. Hyperhidrosis can have a significant impact on quality of life. Management includes identifying and avoiding triggers, the use of topical antiperspirants, and advanced therapies in recalcitrant cases (such as tap water iontophoresis, botulinum toxin injection and surgical options).
Key Words: hyperhidrosis (HH), primary (essential) hyperhidrosis, secondary hyperhidrosis, excessive sweating, eccrine sweat gland.

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Hyperhidrosis is common and affects about 5% of the population
A simple measure of the severity of hyperhidrosis can be done with the 4-question hyperhidrosis disease severity score
Secondary hyperhidrosis should be ruled out with a good history and physical exam
Patients who fail treatment with topical antiperspirants can be treated with tap-water iontophoresis, botulinum toxin injections, oral anticholinergics and surgical options.
Hyperhidrosis is excessive sweating that can be most commonly primary but can have secondary causes
Patients with hyperhidrosis can experience significant impairment on quality of life and this should be explored
First-line treatment consists of topical antiperspirants
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Related Terms: Dermatology, hyperhidrosis, primary (essential) hyperhidrosis, secondary hyperhidrosis, excessive sweating, eccrine sweat gland
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