Ami Saraiya

Treatment of vitiligo with the topical Janus kinase inhibitor ruxolitinib

Background Existing therapies for vitiligo are limited in efficacy and can be associated with undesirable side effects. Topical Janus kinase inhibitors may offer a new therapeutic option for vitiligo. Objective We sought to assess the role of topical ruxolitinib 1.5% cream, a Janus kinase inhibitor, in vitiligo treatment. Methods This 20‐week, open‐label, proof‐of‐concept trial of twice‐daily topical ruxolitinib 1.5% cream was conducted in 12 patients with a minimum of 1% affected body surface area of vitiligo. The primary outcome was percent improvement in Vitiligo Area Scoring Index from baseline to week 20. Results Of 12 patients screened, 11 were enrolled and 9 completed the study (54.5% men; mean age, 52 years). Four patients with significant facial involvement at baseline had a 76% improvement in facial Vitiligo Area Scoring Index scores at week 20 (95% confidence interval, 53‐99%; P = .001). A 23% improvement in overall Vitiligo Area Scoring Index scores was observed in all enrolled patients at week 20 (95% confidence interval, 4‐43%; P = .02). Three of 8 patients responded on body surfaces and 1 of 8 patients responded on acral surfaces. Adverse events were minor, including erythema, hyperpigmentation, and transient acne. Limitations Limitations of the study include the small sample size and open‐label study design. Conclusions Topical ruxolitinib 1.5% cream provided significant repigmentation in facial vitiligo and may offer a valuable new treatment for vitiligo.

Treatment of coexistent psoriasis and lupus erythematosus

BACKGROUND The coexistence of psoriasis and lupus erythematosus (LE) is rare. Anecdotal evidence suggests that anti-tumor necrosis factor alfa (TNF-α) agents may be efficacious in LE, although their use is commonly avoided in this disease because of concern for lupus flare. OBJECTIVE We sought to describe the epidemiology, serologic findings, and therapeutic choices in patients with coexistent psoriasis/psoriatic arthritis and LE and to determine the risk of lupus flares with TNF-α inhibitors. METHODS We performed a retrospective multicenter study of patients given the diagnoses of psoriasis (or psoriatic arthritis) and lupus erythematosus (systemic LE or cutaneous LE, including either subacute cutaneous LE or discoid LE) at 2 academic tertiary-care centers. RESULTS A total of 96 patients with a mean age of 56 years was included. We report higher-than-expected rates of white race and psoriatic arthritis. One clinical lupus flare was observed in a patient receiving a TNF-α inhibitor, resulting in an incidence of 0.92% lupus flares per patient-year of TNF-α inhibitor use. LIMITATIONS Retrospective chart review, small sample size, and limited documentation. CONCLUSION Anti-TNF-α agents, ustekinumab, and abatacept may be valid treatment options for patients with concomitant LE and psoriasis. Clinical lupus flares in LE patients treated with TNF-α inhibitors were infrequent.

International Dermatology Outcome Measures Initiative as Applied to Psoriatic Disease Outcomes: An Update

Previous publications have described the International Dermatology Outcome Measures (IDEOM) group, comprising patients, physicians, health economists, participating pharmaceutical industry partners, payers, and regulatory agencies. The goal of IDEOM is to create patient-centered, validated measures of dermatologic disease progression and treatment efficacy for use in both clinical trials and clinical practice. We provide an update of IDEOM activities as of our 2015 IDEOM meeting in Washington, DC, USA.

Dermal eosinophilic infiltrate in junctional epidermolysis bullosa

Junctional epidermolysis bullosa (JEB) is a rare genodermatosis characterized by a split in the lamina lucida usually because of mutations in LAMA3, LAMB3 and LAMC2 resulting in absence or reduction of laminin‐332. Rare subtypes of JEB have mutations in COL17A1, ITGB4, ITGA6 and ITGA3 leading to reduction or dysfunction of collagen XVII, integrin α6β4 and integrin α3. The classic finding under light microscopy is a paucicellular, subepidermal split. We describe the unusual presence of an eosinophilic infiltrate in the bullae and subjacent dermis in a neonate with JEB, generalized intermediate (formerly known as non‐Herlitz‐type JEB), discuss the histologic differential diagnosis for a subepidermal blister in a neonate, review the literature regarding cases of epidermolysis bullosa (EB) presenting with inflammatory infiltrates, and discuss mechanisms to explain these findings. This case highlights that eosinophils can rarely be seen in EB and should not mislead the dermatopathologist into diagnosing an autoimmune blistering disorder.

Immunopathogenesis of Psoriasis Skin and Nail

In this chapter, an overview will be presented of the current understanding of the immunopathogenesis of psoriatic skin disease, nail pathology, and the important clinical and therapeutic implications. Psoriasis is an immune-mediated disorder with varying global prevalence and is associated with environmental triggers, including stress, trauma, medications, and infections.

Analysis of Gender Differences in the Efficacy of Psoriasis Treatment Modalities Resulting in Clearance

Background/Objective Characterize gender differences in efficacy of psoriasis treatments, as this has not been well studied. Methods In this retrospective cohort study, data were collected on patients with psoriasis seen at Tufts Medical Center between 2008 and 2014. Treatment courses lasting ≥ 4 weeks in patients with baseline moderate to severe psoriasis were included. Clearance was defined as an S-MAPA (simple measure for assessing psoriasis activity, the product of body surface area and physician global assessment) ≤ 3. Results Of the 172 biologic treatment courses, 81 (47%) resulted in clearance, 56% of females and 39% of males (RR=1.43, p=0.032). Women were more likely to clear on infliximab (88% compared to 27% of males, RR=3.21, p=0.02) despite a significantly higher baseline S-MAPA in females in this subgroup (166.63 versus 94.86 in men, p=0.05). There was no statistically significant gender difference in clinical outcomes for patients on conventional systemics or combination treatment courses. Conclusion Clinical outcomes are better for biologics, especially infliximab, in females compared to males with moderate to severe psoriasis. Further investigation of possible biologic or pharmacokinetic explanations for this finding is warranted.

Assessment of the Use of Adrenocorticotropic Hormone in Psoriatic Arthritis

Background A 39-amino-acid peptide of the natural form of adrenocorticotropic hormone (ACTH) was designed to provide a prolonged release after administration by intramuscular or subcutaneous injection. It is FDA-approved as adjunctive therapy for psoriatic arthritis for short-term administration. Clinical data on the safety of ACTH in psoriatic arthritis is limited. Objective To assess the safety data for the use of ACTH in psoriatic arthritis and compare it with the safety data for corticosteroids. Methods We conducted a systematic review of the literature pertaining to the safety of ACTH versus corticosteroids in psoriatic arthritis. We queried the PubMed database for studies evaluating (i) ACTH and Acthar in psoriatic arthritis using the search terms “psoriatic arthritis” and “ACTH” or “acthar” or “adrenocorticotropic hormone” and (ii) ACTH and Acthar in RA or psoriatic arthritis using the terms “rheumatoid arthritis” or “psoriatic arthritis” and “ACTH” or “acthar” or “adrenocorticotropic hormone.” We placed no time limits on either search. From the search results, we selected studies that emphasize safety data. Due to limited psoriatic arthritis-related data, we included data related to rheumatoid arthritis (RA). Results The current body of knowledge surrounding the safety of ACTH in psoriatic arthritis is limited. Twenty studies met our inclusion criteria, 14 of which directly compared ACTH to corticosteroids in either psoriatic arthritis or RA. Of these, five studies reported comparable safety between the two, four studies reported more adverse events with ACTH, two studies reported more adverse events with corticosteroids, and three studies were inconclusive. Conclusion There is no clear evidence that ACTH is safer than corticosteroids for psoriatic arthritis.

Magic of the Skin

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