eMedicine Specialties > Dermatology > Psychocutaneous Diseases

Brachioradial Pruritus

Julianne Mann, MD, Resident Physician, Department of Dermatology, Oregon Health and Science University
David J Elpern, MD, Consulting Staff, The Skin Clinic

Updated: Dec 8, 2008

Introduction

Background

Brachioradial pruritus is a neurogenic itch syndrome of the upper extremities. It is typically localized to the skin on the dorsolateral forearm overlying the proximal head of the brachioradialis muscle, but involvement of the upper arms and shoulders is also common.^1,2 It may be unilateral or bilateral. Scratching reportedly only makes the discomfort worse, and most patients discover that application of cold packs is often the only therapy that provides symptomatic relief.³ Brachioradial pruritus was first described in Florida in 1968 by Waisman⁴ and has since been reported from subtropical areas such as South Africa¹ and Hawaii.⁵ It is seen less frequently, but still with regularity, in temperate climes.

Pathophysiology

The condition appears to represent a primary neuropathy. Abnormalities in cutaneous innervation have been documented among patients with brachioradial pruritus. Massey and Massey⁶ reported altered sensation to temperature and pinprick in the distribution of the posterior cutaneous nerve of the forearm, which supplies the skin over the brachioradialis muscle that is typically pruritic. Among patients with brachioradial pruritus, heat hyperalgesia in the C5-C6 distribution⁷ and pinprick hyperesthesia in the C5-C8 distribution⁸ have been reported. Wallengren and Sundler⁹ used neuronally directed antibodies to show that patients with brachioradial pruritus have reduced numbers of dermal and epidermal nerve fibers, and, moreover, that this reduction in cutaneous innervation only occurs during symptomatic flares.

The pruritus experienced by patients with brachioradial pruritus is believed to be a variant of pain.⁶ However, the anatomic location of the neural injury or irritation producing this pain is controversial. Two prevailing hypotheses are proposed. The first postulates that brachioradial pruritus is caused by injury to peripheral cutaneous nerves from sunlight exposure. The second suggests that nerves are damaged at the level of the cervical spine. Both mechanisms appear to be active in many patients.

Evidence supporting the solar hypothesis includes the following:

• Many patients with brachioradial pruritus have a history of chronic sun exposure.^2,10,11 Kestenbaum and Kalivas¹² postulated that histamine release from mast cells in response to chronic sun exposure might play a pathophysiologic role; they reported a patient with brachioradial pruritus and an elevated serum histamine level.
• In some cases, sun exposure has been reported to exacerbate symptoms and photoprotection has been reported to provide amelioration.^4,13,14
• Patients typically only describe symptoms on the sun-exposed dorsal surface of the arms and shoulders.^2,5
• Left-sided symptoms are more common than right-sided symptoms in the United States, which may be the result of cumulative sun exposure to the arm from driving.⁵ In South Africa, where drivers sit on the right-hand side of cars, the distribution is more often on the right arm.¹
• Symptoms among patients living in temperate climates often remit in the late fall and recur in the summer.^2,4 Patients living in tropical climates, where it is sunny year round, tend to report symptoms that are more stable.⁵
• Biopsy of affected skin typically shows atrophy and signs of sun damage.^2,7
• The reduction in epidermal and dermal nerve fibers seen in brachioradial pruritus patients is also seen after serial phototherapy.⁷

Challenges to the solar hypothesis include the following:

• If the dorsal surfaces of the arms are affected because they are exposed to the sun, then why is the sun-exposed face unaffected? 
• Why does no lower extremity equivalent of brachioradial pruritus occur in people who wear shorts? 
• If brachioradial pruritus is a manifestation of sun-induced nerve damage, why are children, who are typically very sensitive to the sun, never affected?

Evidence supporting the cervicogenic hypothesis includes the following:

• Several authors have reported a higher prevalence of cervical spine disease (eg, arthritis, spondylolytic changes) among patients with brachioradial pruritus.^1,7,15,16
• Treatment of cervical spine arthritis has been reported to provide relief in patients with brachioradial pruritus.^1,17
• Cervical spine tumors,¹⁸ cervical ribs, and hypertrophic cervical transverse processes¹⁹ have all been reported in case series to cause upper extremity pruritus.
• Electrophysiological studies on patients with brachioradial pruritus have shown bilateral delay of F responses of median and ulnar nerves.²⁰

Critics of the cervicogenic hypothesis note the following:

• Cervical spinal disease is generally a permanent disorder and, as such, should produce a continuous neuropathic itch, rather than relapsing and remitting symptoms.
• Cervical nerve blocks have been reported to be unhelpful. This may suggest that the location of the lesion is either more central (dorsal horn) or more peripheral (sensory nerve endings in the arm). 
• Degenerative cervical spinal changes are found in 70% of asymptomatic women and 95% of asymptomatic men older than 65 years²¹ ; thus, without age-matched controls, implicating cervical spinal disease as the cause of brachioradial pruritus is erroneous.²²
• Conventional electrophysiological testing may not be appropriate in investigating the pathophysiology of brachioradial pruritus because it measures conduction of myelinated fibers, while the afferent nerves that transmit itch are actually unmyelinated.⁷

Frequency

United States

The prevalence of brachioradial pruritus is unknown. Brachioradial pruritus was initially described as a disease of the tropics; however, in more recent years, it has also been documented in temperate climates.

Brachioradial pruritus is typically sporadic, although an autosomal dominant inheritance pattern has been reported in one family, with 11 members across 2 generations experiencing symptoms.¹⁰

Brachioradial pruritus has been reported among patients in California,⁸ Massachusetts,^3,16 North Carolina,⁶ Kansas,¹² Florida,⁴ and Hawaii.⁵

International

Brachioradial pruritus has been described among patients in South Africa,¹ Ireland,¹⁵ Sweden,¹⁰ France,²³ Denmark,^2,11 Belgium,⁷ Turkey,^18,22 Israel,²⁰ and Australia.¹⁷

Mortality/Morbidity

The intense tingling, burning, and itching associated with the disease often keeps patients awake at night.⁴ Frustration from a lack of relief of symptoms with conventional antipruritis agents is common.

Race

Brachioradial pruritus has been reported among patients with all skin types, but whites (Fitzpatrick skin types I-III) appear to be affected more often than darker-skinned individuals.⁵

Sex

Brachioradial pruritus was first reported among middle-aged male outdoor workers⁴ ; however, more recently, cases have been widely documented among both men and women.^2,10,16

Age

The onset of symptoms in persons with brachioradial pruritus typically occurs in the fourth to sixth decades of life. The youngest patient reported to have symptoms is an 18-year-old woman whose mother, sister, and 2 aunts also had brachioradial pruritus.¹⁰

Clinical

History

The itch of brachioradial pruritus is described as intense, burning, and prickling. It is localized to the dorsolateral aspects of the bilateral upper arms, forearms, and shoulders. Scratching is reported to make the discomfort worse, and many patients find that the only therapy that brings relief is the application of ice packs or cold, wet towels.^3,7,16 The discomfort is typically worse at night and, for some patients, may interfere with falling asleep.⁴ The median duration of symptoms has been reported as 4.5 years,² but patients have reported a continuation of symptoms from this condition for as long as 18 years.¹

Physical

Despite the severity of symptoms, no associated erythema or skin eruption is seen. Evidence of excoriation or lichenification may be present in the affected areas.

Altered sensation to pinprick and temperature in the distribution of the posterior cutaneous nerve of the forearm, which supplies the skin over the proximal brachioradialis muscle, may be observed.⁶ Pronounced heat hyperalgesia in the C5 and C6 dermatomal distribution⁷ and pinprick hyperesthesia in the C5-C8 distribution⁸ may be seen.

Causes

Exposure of the affected areas to sun and wind may precipitate an episode, as may radiculopathy of the cervical spine. These are speculative, and the authors believe the etiology is multifactorial. In some cases, an emotional component to the symptoms seems apparent.

Differential Diagnoses

Atopic Dermatitis
Neurotic Excoriations
Notalgia Paresthetica
Zoster sine herpete

Other Problems to Be Considered

• Neurotic excoriations: Patients with brachioradial pruritus can excoriate the affected area, while the typical neurotic excoriation patient also has lesions on other accessible areas. An interface and a common etiology may exist between these 2 disorders.
• Notalgia paresthetica: This condition is typically associated with pruritus, pain, paresthesia, and hyperesthesia on the back.²² Often, a well-circumscribed hyperpigmented patch is present in the symptomatic area.
• Zoster sine herpete: This is an unusual manifestation of herpes zoster in which no cutaneous rash is observed. Unilateral paresthesias may be pronounced.
• Atopic dermatitis: Itch may be severe, although it usually involves flexor aspects of the elbows and is not associated with tingling. The Medscape Atopic Dermatitis Resource Center may be of interest.

Workup

Laboratory Studies

Imaging Studies

Consider cervical spine imaging to rule out tumor or cervical rib and to evaluate for cervical radiculopathy.

Procedures

Electromyography or nerve conduction velocity studies may show delay of F responses of median and ulnar nerves and may assist in diagnosis in ambiguous cases.⁶

Histologic Findings

Biopsy of skin reveals atrophy and signs of sun damage, along with reduced numbers of both dermal and epidermal nerve fibers. Evidence exists that this reduction in cutaneous innervation occurs only during symptomatic flares, with innervation normalizing during symptom-free periods; thus, biopsy should ideally be performed when patients are actively experiencing symptoms.⁹

Staging

No staging system currently exists for brachioradial pruritus.

Treatment

Medical Care

Patients with brachioradial pruritus need time, sympathy, and understanding. They appreciate being told that they have a defined entity and that treatment options are available. Ice packs are helpful for immediate symptomatic relief, and other treatments can be tried in an outpatient setting. Frequent follow-up is often helpful emotionally for patients. Most cases remit in weeks to months.

Cervical nerve blocks have been reported to be unhelpful,⁷ but cervical spine manipulation is effective in some patients.^1,17 Cutaneous field stimulation has also been used. In one study, patients receiving 20 minutes of this treatment to affected areas once daily reported significant symptomatic improvement after 5 weeks.²⁴

Acupuncture may be helpful for symptomatic relief. Stellon²⁵ performed a retrospective case series of 16 patients with brachioradial pruritus using deep intramuscular stimulation acupuncture to the paravertebral muscles in the dermatomal segments of the body affected by the pruritus. Treatment was also given to other segments of the body not affected by the pruritus if paravertebral spasm and tenderness was detected. After a median of 4 treatments, 12 of 16 patients reported complete resolution of symptoms and 4 patients reported partial resolution. Relapse occurred in 6 patients within 1-12 months of cessation of acupuncture.

Surgical Care

Surgical care is generally not indicated unless the patient has a documented cervical radiculopathy, cervical rib, or fibrous band impinging on the brachial plexus.

Consultations

Relief after physical therapy has been reported in case series, so consultation with a physical therapist or a chiropractor may be considered, particularly in patients with radiographic evidence of cervical spinal disease. Heyl¹ reported a case of one patient whose brachioradial pruritus developed after a neck injury, and symptoms were relieved by neck traction.
 
The authors have not found consultation with a neurologist or pain specialist to be of value.

Consultation with an acupuncturist may be helpful.

Some patients have psychiatric disorders that predispose to brachioradial pruritus, while others may develop anxiety, depression, obsessions/compulsions, or delusions of parasitosis in response to the exasperating symptoms.

Diet

No dietary modifications have been reported to alleviate symptoms.

Activity

Patients who notice exacerbation of symptoms with sunlight exposure benefit from restricting their time outdoors during peak sunlight hours (10 am to 2 pm). Often, wearing long-sleeved shirts when outdoors provides relief equal to that achieved with more sophisticated interventions. Sunscreens are typically less effective.

Medication

Treatment of brachioradial pruritus remains a challenge. Most patients find relief with the application of cold packs that numb the skin; hence, a positive "ice-pack sign" is almost pathognomonic for this condition.³ Oral antihistamines and topical corticosteroids are only occasionally of value. If potent or superpotent topical corticosteroids are used, care must be taken to avoid cutaneous atrophy from overzealous use. Occasionally, patients are helped with topical anesthetics (eg, lidocaine cream or gel) or with 5% topical doxepin.

Substance P is a neurotransmitter important in the transmission of pain and itch neural signals. Topical capsaicin cream (0.025-0.05%) is a natural plant product that depletes substance P from cutaneous nerve endings.²⁶ It has been reported by a number of authors to provide relief of brachioradial pruritus within weeks,^11,15,27,28 although the authors have not found it to be useful in their patients.

Numerous oral medications have been tried with varying success. Case reports describe sustained symptomatic relief with gabapentin (1800 mg/d),²³ lamotrigine (200 mg/d),⁷ amitriptyline (25-150 mg qhs),¹⁵ and pimozide (1-2 mg/d). Oxcarbemazepine has proven effective in several patients reported by Savk and Savk.²² Risperidone has been used with some success in certain patients. No medication works predictably. When using psychotropic medications, obtaining a psychiatric opinion is advisable unless the treating physician commonly prescribes these agents.

Analgesic, Topical

Capsaicin (Zostrix High Potency, Trixaicin HP, Zostrix Sports)

Natural chemical derived from plants of Solanaceae family. Penetrates deep for temporary relief of minor aches and pains of muscles and joints associated with inflammatory reactions. May render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons. Has demonstrated effectiveness in several studies of diabetic neuropathic pain and in other types of neuropathic pain.

Dosing

Adult

Apply to affected area tid/qid for 3-4 consecutive wk and evaluate efficacy; not to exceed 4 applications/d; wash hands with soap and water after application

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; broken or irritated skin

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For external use only; avoid contact with eyes; do not use tight bandage; discontinue use if condition worsens or symptoms persist for 14-28 d

Antianxiety Agent

Doxepin (Prudoxin, Zonalon)

A TCA that has potent H1-blocking activity, making it quite useful for urticaria. However, has very potent sedative and anticholinergic effects. Can be quite effective if used at bedtime because the sedative effects can help a patient with pruritus sleep. Widespread use produces sedation, as does use in areas of high percutaneous absorption (eg, genitals). Many individuals develop allergy to topical doxepin.

Dosing

Adult

Apply sparingly to affected area qid, with at least 3-4 h between each application; not to exceed 1 wk

Pediatric

Not established

Interactions

Plasma levels attained are similar to oral administration and drug interactions may occur; do not administer within 14 d of MAOIs; cimetidine may increase serum levels; alcohol may exacerbate sedative effect; CYP 4502D6 inhibitors (eg, quinine, SSRIs) may decrease clearance

Contraindications

Documented hypersensitivity; do not administer within 14 d of MAOIs; narrow-angle glaucoma, urinary retention

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause sedation, especially when applied to >10% of body surface; may cause irritation at application site; occlusive dressings are likely to increase toxicity

Antiarrhythmic Agent, Class I-b

Lidocaine (Topicaine, Senatec)

Decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses

Dosing

Adult

Gel (5%): Apply to affected area prn
Patch (5%): Apply to most painful area, with up to 3 patches per application; patch may remain in place for up to 12 h in any 24-h period

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; Adams-Stokes syndrome, Wolff-Parkinson-White syndrome

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

For external or mucous membrane use only; do not use in eyes

Anticonvulsant

Gabapentin (Gabarone, Neurontin)

Membrane stabilizer, a structural analogue of the inhibitory neurotransmitter GABA, which paradoxically is thought not to exert effect on GABA receptors. Appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels. Used to manage pain and provide sedation in neuropathic pain.

Dosing

Adult

300 mg/d PO initially; gradually increase; mean dose is 2400 mg/d; efficacy may be achieved at 1800 mg/d

Pediatric

Not established

Interactions

Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may significantly increase norethindrone levels; cimetidine, hydrocodone, and morphine may increase AUC; naproxen may increase absorption

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include drowsiness, dizziness, somnolence, and unwanted eye movements; children may experience emotional ability hostility, thought disorder, and hyperkinesia; caution in elderly persons and patients with severe renal impairment; abrupt withdrawal may precipitate seizures

Antidepressant, Tricyclic

Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain. Blocks reuptake of norepinephrine and serotonin, which increases concentration in CNS. Decreases pain by inhibiting spinal neurons involved in pain perception. Highly anticholinergic. Often discontinued because of somnolence and dry mouth.
Cardiac arrhythmia, especially in overdose, has been described; monitoring QTc interval after reaching target level is advised. Up to 1 mo may be needed to obtain clinical effects.

Dosing

Adult

30-100 mg PO qhs

Pediatric

Not applicable

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Documented hypersensitivity; MAOIs within 14 d of initiating therapy; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal impairment, or hepatic impairment; avoid use in elderly persons

Follow-up

Further Outpatient Care

Frequent outpatient follow-up of patients with brachioradial pruritus is often helpful.

Deterrence/Prevention

Strict photoprotection with sunscreen and long-sleeved shirts can prevent recurrence of symptoms in some patients. The Medscape Skin Cancer Resource Center may be of interest.

Complications

Psychiatric symptoms (eg, anxiety, depression) may develop over time in patients with unremitting symptoms.

Prognosis

Most patients with brachioradial pruritus have remissions, but a small percentage have chronic disease. Emotional or psychiatric factors likely play a role in prognosis.

Patient Education

Education regarding sun protection and avoidance of peak sunlight hours is worthwhile.

Multimedia

Media file 1: Area of pruritus demarcated in pen in a middle-aged woman with brachioradial pruritus. Macroscopically, no skin changes are visible.

Media file 2: Subtle excoriations on the dorsal forearm of a middle-aged woman with brachioradial pruritus.

References

1. Heyl T. Brachioradial pruritus. Arch Dermatol. Feb 1983;119(2):115-6. [Medline].

2. Veien NK, Hattel T, Laurberg G, Spaun E. Brachioradial pruritus. J Am Acad Dermatol. Apr 2001;44(4):704-5. [Medline].

3. Bernhard JD, Bordeaux JS. Medical pearl: the ice-pack sign in brachioradial pruritus. J Am Acad Dermatol. Jun 2005;52(6):1073. [Medline].

4. Waisman M. Solar pruritus of the elbows (brachioradial summer pruritus). Arch Dermatol. Nov 1968;98(5):481-5. [Medline].

5. Walcyk PJ, Elpern DJ. Brachioradial pruritus: a tropical dermopathy. Br J Dermatol. Aug 1986;115(2):177-80. [Medline].

6. Massey EW, Massey JM. Forearm neuropathy and pruritus. South Med J. Oct 1986;79(10):1259-60. [Medline].

7. Crevits L. Brachioradial pruritus--a peculiar neuropathic disorder. Clin Neurol Neurosurg. Dec 2006;108(8):803-5. [Medline].

8. Fisher DA. Brachioradial pruritus wanted: a sure cause (and cure) for brachioradial pruritus. Int J Dermatol. Nov 1997;36(11):817-8. [Medline].

9. Wallengren J, Sundler F. Brachioradial pruritus is associated with a reduction in cutaneous innervation that normalizes during the symptom-free remissions. J Am Acad Dermatol. Jan 2005;52(1):142-5. [Medline].

10. Wallengren J, Dahlbäck K. Familial brachioradial pruritus. Br J Dermatol. Nov 2005;153(5):1016-8. [Medline].

11. Bech-Thomsen N, Thomsen K. Solar pruritus. Acta Derm Venereol. Nov 1995;75(6):488-9. [Medline].

12. Kestenbaum T, Kalivas J. Solar pruritus. Arch Dermatol. Nov 1979;115(11):1368. [Medline].

13. Orton DI, Wakelin SH, George SA. Brachioradial photopruritus--a rare chronic photodermatosis in Europe. Br J Dermatol. Sep 1996;135(3):486-7. [Medline].

14. Armstrong DK, Bingham EA. Brachioradial pruritus--an uncommon photodermatosis presenting in a temperate climate. Dermatology. 1997;195(4):414-5. [Medline].

15. Barry R, Rogers S. Brachioradial pruritus--an enigmatic entity. Clin Exp Dermatol. Nov 2004;29(6):637-8. [Medline].

16. Goodkin R, Wingard E, Bernhard JD. Brachioradial pruritus: cervical spine disease and neurogenic/neuropathic [corrected] pruritus. J Am Acad Dermatol. Apr 2003;48(4):521-4. [Medline].

17. Tait CP, Grigg E, Quirk CJ. Brachioradial pruritus and cervical spine manipulation. Australas J Dermatol. Aug 1998;39(3):168-70. [Medline].

18. Kavak A, Dosoglu M. Can a spinal cord tumor cause brachioradial pruritus?. J Am Acad Dermatol. Mar 2002;46(3):437-40. [Medline].

19. Rongioletti F. Pruritus as presenting sign of cervical rib. Lancet. Jan 4 1992;339(8784):55. [Medline].

20. Cohen AD, Masalha R, Medvedovsky E, Vardy DA. Brachioradial pruritus: a symptom of neuropathy. J Am Acad Dermatol. Jun 2003;48(6):825-8. [Medline].

21. Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine. Jul-Aug 1986;11(6):521-4. [Medline].

22. Savk E, Savk SO. On brachioradial pruritus and notalgia paresthetica. J Am Acad Dermatol. May 2004;50(5):800-1. [Medline].

23. Kanitakis J. Brachioradial pruritus: report of a new case responding to gabapentin. Eur J Dermatol. May-Jun 2006;16(3):311-2. [Medline].

24. Wallengren J, Sundler F. Cutaneous field stimulation in the treatment of severe itch. Arch Dermatol. Oct 2001;137(10):1323-5. [Medline].

25. Stellon A. Neurogenic pruritus: an unrecognised problem? A retrospective case series of treatment by acupuncture. Acupunct Med. Dec 2002;20(4):186-90. [Medline].

26. Bernstein JE. Capsaicin and substance P. Clin Dermatol. Oct-Dec 1991;9(4):497-503. [Medline].

27. Goodless DR, Eaglstein WH. Brachioradial pruritus: treatment with topical capsaicin. J Am Acad Dermatol. Nov 1993;29(5 Pt 1):783-4. [Medline].

28. Knight TE, Hayashi T. Solar (brachioradial) pruritus--response to capsaicin cream. Int J Dermatol. Mar 1994;33(3):206-9. [Medline].

29. Fisher DA. Brachioradial pruritus: a recurrent solar dermopathy. J Am Acad Dermatol. Oct 1999;41(4):656-8. [Medline].

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Keywords

solar pruritus, photodermatosis, nostalgia paresthetica, neurogenic itch

Contributor Information and Disclosures

Author

Julianne Mann, MD, Resident Physician, Department of Dermatology, Oregon Health and Science University
Julianne Mann, MD is a member of the following medical societies: Alpha Omega Alpha and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

David J Elpern, MD, Consulting Staff, The Skin Clinic
David J Elpern, MD is a member of the following medical societies: American Academy of Dermatology and Hawaii Medical Association
Disclosure: Emedicine None Employment

Medical Editor

Jacek C Szepietowski, MD, PhD, Professor, Vice-Head, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University; Director of the Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Poland
Disclosure: Stiefel Salary Employment

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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