Martin A. Menter M.D.

Paul, C., C. Leonardi, A. Menter, K. Reich, L. S. Gold, R. B. Warren, A. Moller and M. Lebwohl (2017). “Calcipotriol plus betamethasone dipropionate aerosol foam in patients with moderate-to-severe psoriasis: Sub-group analysis of the pso-able study.” Am J Clin Dermatol: 2017 Feb [Epub ahead of print].

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BACKGROUND: Fixed-combination calcipotriol 50 mug/g plus betamethasone 0.5 mg/g (Cal/BD) aerosol foam is a new topical treatment for psoriasis. Although moderate-to-severe psoriasis is typically treated with systemic/biologic therapies, a topical treatment that is efficacious in these patients may be a significant cost-saving alternative to systemic therapy. OBJECTIVE: The objective of this study was to assess the response to Cal/BD foam and gel in patients with moderate-to-severe psoriasis enrolled in the phase III, 12-week PSO-ABLE study. METHODS: Patients eligible for this analysis had moderate-to-severe psoriasis, defined by the ‘Rule of Tens’: body surface area >/=10% or Psoriasis Area and Severity Index (PASI) [excluding head; modified PASI (mPASI)] >10 or Dermatology Life-Quality Index >10. Endpoints included: proportion of patients achieving mPASI75 or mPASI90; change in body surface area; proportion of patients clear/almost clear with a >/=2 grade improvement (i.e., treatment success); change in Dermatology Life-Quality Index. RESULTS: Seventy-seven Cal/BD foam patients and 82 gel patients had moderate-to-severe psoriasis. A greater proportion achieved mPASI75 and mPASI90 with Cal/BD foam than gel at weeks 4, 8, and 12 (57.1 vs. 35.4%; p = 0.006 and 15.6 vs. 12.2% at week 12, respectively); overall reduction in mPASI from baseline to week 12 was 64% with the foam vs. 51% with the gel. Overall reduction in body surface area at week 12 was 50% with the foam and 39% with the gel. Treatment success rates were higher with the Cal/BD foam than the gel at weeks 1, 2, 4, 8 (p = 0.0089), and 12, and a greater proportion of foam patients achieved a Dermatology Life-Quality Index score of 0/1 at weeks 4 (p = 0.004), 8, and 12 (p = 0.001). CONCLUSION: Cal/BD foam can be considered as a treatment option in some patients with moderate-to-severe psoriasis who are potential candidates for systemic therapy.

From the medical board of the national psoriasis foundation: Treatment targets for plaque psoriasis.” J Am Acad Dermatol 76(2): 290-298.

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Prostate cancer screening by PSA testing remains controversial, particularly in the elderly. Practice guidelines from most clinical societies suggest discontinuing PSA screening at age 70 while the USPSTF recommends against screening at any age. Recent reports have demonstrated an increased incidence of metastatic prostate cancer, with men aged 75 or older accounting for roughly half of those newly diagnosed at an incurable stage. We herein describe the case of an elderly gentleman with no history of prostate cancer screening who presented with anorexia and back pain of unclear etiology. Evaluation with bone marrow aspiration revealed a diagnosis of metastatic prostate cancer.

Vangipuram, R., M. E. Horner and A. Menter (2017). “Ethical dilemma in missed melanoma: What to tell the patient and other providers.” J Am Acad Dermatol 76(2): 365-367.

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Case scenario A 77-year-old man presented to his podiatrist for evaluation of a dystrophic left great toenail. A nail avulsion procedure was performed with debridement. At 6-month follow-up the patient had a persistent nonhealing lesion, resulting in a biopsy being performed by the podiatrist. Histopathological analysis revealed a “nodular lymphohistiocytic infiltrate without a neoplastic process.” The podiatrist reassured the patient that the lesion was not worrisome and continued regular debridements over the ensuing 15 months. Because of lack of improvement, the podiatrist then referred the patient to a dermatologist for further evaluation. At that time, the lesion demonstrated pigmentation extending focally to the cuticle (Hutchinson sign) with a nodular growth pattern. Repeated biopsy specimen reported “malignant melanoma with 2.4-mm Breslow depth.” Treatment included great toe amputation and sentinel lymph node biopsy, which indicated metastasis with micronodular involvement. Upon further histologic review of the original biopsy specimen taken 2 years prior, malignant melanoma was noted to be present to a depth of 2.2 mm.

Menter, A., J. C. Cather, M. Jarratt, X. Meng, A. Guana and J. Nyirady (2016). “Efficacy of Secukinumab on Moderate-to-severe Plaque Psoriasis Affecting Different Body Regions: a Pooled Analysis of Four Phase 3 Studies.” Dermatol Ther (Heidelb) 6(4): 639-647.

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INTRODUCTION: The impact of psoriasis varies with the body region affected. In addition, patients have different perceptions of disease improvement and treatment satisfaction based on the location of skin clearance with treatment. The monoclonal antibody secukinumab selectively targets interleukin-17A-a central cytokine of psoriasis-and provides rapid and sustained clearance for moderate-to-severe psoriasis affecting all body regions. The objective of this study was to evaluate the efficacy of secukinumab on moderate-to-severe psoriasis affecting the trunk, upper limbs, and lower limbs. METHODS: Data were pooled from four phase 3 studies. To be included in the analysis for each body region, patients were required to have a Psoriasis Area and Severity Index (PASI) score >/=12 for that body region and psoriasis covering >/=10% of the surface area of that region. Secukinumab was administered at Baseline, Weeks 1, 2 and 3, and then every 4 weeks from Week 4 to 48. RESULTS: Across the trunk, upper limbs, and lower limbs, initial PASI subscore responses were sustained to Week 52. At Week 52, trunk (T) PASI 90/100 responses were achieved by 78.4%/71.1% of patients receiving secukinumab 300 mg, respectively, and by 66.3%/56.9% of patients receiving secukinumab 150 mg, respectively. At Week 52, upper limb (UL) PASI 90/100 responses were achieved by 67.3%/59.1% of patients receiving secukinumab 300 mg, respectively, and by 50.3%/43.3% of patients receiving secukinumab 150 mg, respectively. At Week 52, lower limb (LL) PASI 90/100 responses were achieved by 63.9%/55.3% of patients receiving secukinumab 300 mg, respectively, and by 45.1%/36.4% of patients receiving secukinumab 150 mg, respectively. A 50% reduction in mean PASI subscore occurred after 2.8, 2.9, and 3.4 weeks with secukinumab 300 mg on the trunk, upper limbs, and lower limbs, respectively. CONCLUSION: Secukinumab provided robust and sustained efficacy for moderate-to-severe psoriasis affecting the trunk, upper limbs, and lower limbs.

Armstrong, A. W., M. P. Siegel, J. Bagel, E. E. Boh, M. Buell, K. D. Cooper, K. Callis Duffin, L. F. Eichenfield, A. Garg, J. M. Gelfand, A. B. Gottlieb, J. Y. Koo, N. J. Korman, G. G. Krueger, M. G. Lebwohl, C. L. Leonardi, A. M. Mandelin, M. A. Menter, J. F. Merola, D. M. Pariser, R. B. Prussick, C. Ryan, K. N. Shah, J. M. Weinberg, M. O. Williams, J. J. Wu, P. S. Yamauchi and A. S. Van Voorhees (2016). “From the medical board of the national psoriasis foundation: Treatment targets for plaque psoriasis.” J Am Acad Dermatol: 2016 Nov [Epub ahead of print].

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BACKGROUND: An urgent need exists in the United States to establish treatment goals in psoriasis. OBJECTIVE: We aim to establish defined treatment targets toward which clinicians and patients with psoriasis can strive to inform treatment decisions, reduce disease burden, and improve outcomes in practice. METHODS: The National Psoriasis Foundation conducted a consensus-building study among psoriasis experts using the Delphi method. The process consisted of: (1) literature review, (2) pre-Delphi question selection and input from general dermatologists and patients, and (3) 4 Delphi rounds. RESULTS: A total of 25 psoriasis experts participated in the Delphi process. The most preferred instrument was body surface area (BSA). The most preferred time for evaluating patient response after starting new therapies was at 3 months. The acceptable response at 3 months postinitiation was either BSA 3% or less or BSA improvement 75% or less from baseline. The target response at 3 months postinitiation was BSA 1% or less. During the maintenance period, evaluation every 6 months was most preferred. The target response at every 6 months maintenance evaluation is BSA 1% or less. LIMITATIONS: Although BSA is feasible in practice, it does not encompass health-related quality of life, costs, and risks of side effects. CONCLUSION: With defined treatment targets, clinicians and patients can regularly evaluate treatment responses and perform benefit-risk assessments of therapeutic options individualized to the patient.