Dermatology

Mansouri, B., D. Kivelevitch, B. Natarajan, A. A. Joshi, C. Ryan, K. Benjegerdes, J. M. Schussler, D. J. Rader, M. P. Reilly, A. Menter and N. N. Mehta (2016). “Comparison of coronary artery calcium scores between patients with psoriasis and type 2 diabetes.” JAMA Dermatol: 2016 Aug [Epub ahead of print].

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Psoriasis is associated with an increased risk of cardiovascular diseases. Subclinical atherosclerosis in patients with psoriasis has not been compared with other conditions associated with increased cardiovascular risk and more rigorous cardiovascular disease screening, such as type 2 diabetes. Objective: To assess the burden of asymptomatic coronary atherosclerosis measured by coronary artery calcium score in patients with moderate to severe psoriasis compared with patients with type 2 diabetes and healthy controls. Design, Setting, and Participants: Three single-center, cross-sectional studies were performed in patients recruited from specialty outpatient clinics with moderate to severe psoriasis without type 2 diabetes (recruited from November 1, 2013, through April 31, 2015), patients with type 2 diabetes without psoriasis or other inflammatory diseases (recruited from July 1, 2009, through June 20, 2011), and age- and sex-matched healthy controls without psoriasis, type 2 diabetes, or other inflammatory diseases (recruited from July 1, 2009, through June 20, 2011). Exposures: Psoriasis, type 2 diabetes, and healthy control effect on coronary artery calcium score. Main Outcomes and Measures: Coronary artery calcium measured by Agatston score. Results: A total of 387 individuals participated in the study. Mean (SD) age was 51 (7.7), 52 (8.0), and 52 (8.0) years in the psoriasis, type 2 diabetes, and healthy control cohorts, respectively. There were 64 men (49.6%) in each group, and most patients were white (119 [92.2%], 123 [95.3%], and 128 [99.2%] in the psoriasis, type 2 diabetes, and healthy control cohorts, respectively). Patients with psoriasis had low cardiovascular risk measured by the Framingham Risk Score but had a high prevalence of cardiovascular and cardiometabolic risk factors, similar to patients with type 2 diabetes. In a fully adjusted model, psoriasis was associated with coronary artery calcium (Tobit regression ratio, 0.89; P < .001) similar to the association in type 2 diabetes (Tobit regression ratio, 0.79; P = .04). Likelihood ratio testing revealed incremental value for psoriasis in a fully adjusted model (chi2 = 4.48, P = .03) in predicting coronary artery calcium. Psoriasis was independently associated with the presence of any coronary artery calcium (odds ratio, 2.35; 95% CI, 1.12-4.94) in fully adjusted models, whereas the association of coronary artery calcium with type 2 diabetes was no longer significant after adding body mass index to the model (odds ratio, 2.18; 95% CI, 0.75-6.35). Conclusions and Relevance: Patients with psoriasis have increased coronary artery calcium by mean total Agatston scores, similar to that of patients with type 2 diabetes, suggesting that patients with psoriasis harbor high rates of subclinical atherosclerosis beyond adjustment for body mass index. Major educational efforts for patients and physicians should be undertaken to reduce the burden of cardiovascular disease in patients with psoriasis.

Gupta, A. K., J. L. Carviel and W. Abramovits (2016). “Efficacy of tofacitinib in treatment of alopecia universalis in two patients.” J Eur Acad Dermatol Venereol: 2016 June [Epub ahead of print].

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BACKGROUND: Autoimmune-triggered non-scarring hair loss is a feature of alopecia areata (AA). Initially patchy and often self-limited, severe hair loss forms include the complete loss of scalp hair or alopecia totalis (AT) and complete loss of all hair or alopecia universalis (AU). For AT and AU a reliable treatment has remained elusive. The targeted kinase inhibitor tofacitinib, in current use for treatment of other immune diseases, has been hypothesized as a viable option for AA, AT and AU therapy and a few case reports support this. OBJECTIVE: Our study aims to provide evidence for the effectiveness of tofacitinib in the treatment of AU. METHODS: Two patients diagnosed with long-term AU were prescribed tofacitinib citrate at a dosage of 5 mg twice daily and observed for eight months. RESULTS: In the first patient, beard growth was significant by 3 months of treatment. By 6 months of treatment, hair growth was apparent throughout the entire body. By 8 months of treatment, scalp hair continued to grow longer and thicker. In addition, eyelashes and eyebrows were established. In the second patient, a noticeable increase in scalp hair was present just 1 month into treatment. By 4 months into treatment, significant scalp regrowth was observed as well as eyelash, eyebrow and beard regrowth. Axillary hair regrowth and isolated leg hair was noted by 8 months. CONCLUSION: In our patients, tofacitinib successfully alleviated AU in the absence of significant adverse side-effects. We recommend that further study be required to establish safety and confirm efficacy.

Alikhan, A., J. R. Griffin and C. C. Newman (2016). “Use of candida antigen injections for the treatment of verruca vulgaris: A two-year mayo clinic experience.” J Dermatolog Treat 27(4): 355-358.

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Common warts (verruca vulgaris) are one of the most common problems encountered in dermatology and may present a difficult treatment dilemma, as no particular therapy has demonstrated complete efficacy. Intralesional injection of purified Candida antigen has produced impressive treatment results in small prospective and retrospective studies and is thought to produce its effect through stimulation of a cell-mediated immune response. We report a retrospective study of adult and pediatric patients treated with Candida antigen therapy in clinical practice. Of the 100 patients treated, 80% responded to therapy: 39% demonstrated a complete response and 41% demonstrated a partial response. In addition, 6 out of 7 immunocompromised patients who were treated demonstrated a partial or complete response. Injections were generally well-tolerated and adverse events were minimal and short-lived. Our data indicate that intralesional Candida antigen therapy for cutaneous warts is an efficacious option in a clinical practice setting. The treatment may also be effective in immunosuppressed patients with cutaneous warts. Our results add to the literature one of the largest retrospective series reported to date and treatment outcomes are similar to previously reported studies evaluating this therapeutic modality.

Cizenski, J., J. Griffin and A. Menter (2016). “Image gallery: Cutaneous t-cell lymphoma mimicking a gyrate erythema.” Br J Dermatol 174(5): e42.

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A 22-year-old white man was evaluated for a mildly pruritic scaly rash of 6 years’ duration, which began on his chest and recently spread to the axillae and back. He initially presented to his primary doctor, who provided him with topical steroids without benefit. The eruption never ulcerated. Examination revealed pink annular and polycyclic patches on the chest, axillae and flanks without nodules, tumours or adenopathy. There was very faint scale at the borders of the lesions. A potassium hydroxide stain was negative for dermatophytes. Two biopsies revealed a CD8 predominant epidermotropic infiltrate of atypical lymphocytes with a clonal T-cell receptor rearrangement. Complete staging revealed stage IA disease. The indolent behaviour is consistent with mycosis fungoides with aberrant CD8+ phenotype. Current treatment includes a potent topical corticosteroid and close follow-up.

Campa, M., C. Ryan and A. Menter (2016). “Developing more open and equitable relationships with industry to improve advancements in clinical research in dermatology.” Br J Dermatol 174(6): 1365-1369.

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Relationships between physicians, scientists, and the pharmaceutical industry can be complicated by conflicts of interest. Honest and equitable relationships, however, are essential to the advancement of dermatologic clinical research. Several factors can increase transparency in clinical trials including preregistration of clinical trials, reporting of all data produced from clinical trials, non-industry ownership of clinical trial data, clarity of statistical methods and publication of both positive and negative results. Through collaborative, scientifically rigorous studies, physicians and industry can achieve significant advances in dermatologic care.