Bryan E. Anderson

Treatment of Hidradenitis Suppurativa With Etanercept Injection

OBJECTIVES To observe the effects of etanercept treatment on the cutaneous manifestations of hidradenitis suppurative (HS) and to evaluate physician and patient global assessment scores of cutaneous manifestations. DESIGN Single-center, randomized, prospective, double-blind, placebo-controlled study. SETTING Academic dermatology practice. PATIENTS Twenty patients with active moderate to severe HS who fulfilled all inclusion criteria. INTERVENTION Etanercept, 50 mg, or placebo was administered subcutaneously (SC) twice weekly for 12 weeks. After 12 weeks, all patients received open-label etanercept, 50 mg, SC twice weekly for 12 more weeks. MAIN OUTCOME MEASURES Primary end point: physician global assessment of HS as clear or mild at week 12. Secondary end points: patient global assessment and Dermatology Life Quality Index (DLQI). RESULTS There was no statistically significant difference among physician global assessment, patient global assessment, and DLQI at 12 or 24 weeks between treatment and placebo groups (P > .05 for all comparisons). CONCLUSIONS Etanercept, 50 mg, SC administered twice weekly did not have significant efficacy in the improvement of HS. In light of our negative results, as well as those of previous studies, we suggest that future studies focus on other agents for the treatment of HS. Trial Registration clinicaltrials.gov Identifier: NCT00949546.

Improved survival and complete response rates in patients with advanced melanoma treated with concurrent ipilimumab and radiotherapy versus ipilimumab alone

ABSTRACT There is a growing body of evidence supporting the synergistic roles of radiotherapy and immunotherapy in the treatment of malignancy. Published case studies of the abscopal effect have been reported with the use of ipilimumab and radiotherapy in metastatic melanoma, but evidence supporting the routine use of this combination of therapy is limited. We conducted a retrospective analysis to evaluate patients treated with ipilimumab for advanced melanoma at a single institution from May 2011 to June 2015. Patients were grouped into those who had received concurrent radiotherapy while on ipilimumab (Ipi-RT), and those who did not. We then evaluated the treatment response following completion of ipilimumab. A total of 101 patients received ipilimumab in the prespecified time frame. 70 received Ipi-RT and 31 received ipilimumab without concurrent radiotherapy. Median overall survival (OS) was significantly increased in the concurrent Ipi-RT arm at 19 months vs. 10 months for ipilimumab alone (p = 0.01). Median progression free survival (PFS) was marginally increased in the Ipi-RT group compare with the ipilimumab alone group (5 months vs. 3 months, p = 0.20). Rates of complete response (CR) were significantly increased in the Ipi-RT group vs. ipilimumab alone (25.7% vs. 6.5%; p = 0.04), and rates of overall response (OR) in the groups were 37.1% vs. 19.4% (p = 0.11). No increase in toxicities was observed in the Ipi-RT group compare with ipilimumab alone. Prospective trials are needed to further clarify the role of radiotherapy with ipilimumab, but these encouraging preliminary observations suggest that this combination can induce more durable responses to immunotherapy.

Stinging nettle dermatitis.

The stinging nettle (Urtica dioica) is a common weed that can cause a wide range of cutaneous reactions. Contact with the hairs or spines on the stems and leaves of the stinging nettle causes the release of several biologically active substances. The released chemicals act to cause itching, dermatitis, and urticaria within moments of contact. Extracts from the stinging nettle may provide therapeutic value for some inflammatory medical conditions. There is no standard treatment for stinging nettle dermatitis.

Malignant melanoma—The cradle of anti-neoplastic immunotherapy

One of the defining characteristics of the malignant phenotype is the ability to evade the host immune system. Immunotherapy as a treatment modality represents a new dawn in the way we think about the treatment of a variety of malignancies. The story of immunotherapy traces its roots to its relationship with malignant melanoma. In this article, we review the intertwined history of immunotherapy and melanoma, including the early significant history, a discussion on immune mechanisms, resistance, local and systemic immunotherapeutic modalities, and speculate on possible novel future treatment options.

Current leadership training in dermatology residency programs: A survey

BACKGROUND Residents and physicians frequently find themselves in leadership roles. Current residency curricula focus on the development of clinical knowledge and technical skills. A previous survey of Penn State Dermatology graduates demonstrated the perceived need and benefit of a formalized leadership curriculum in this selected group. OBJECTIVES We sought to identify and measure the perceived need and benefit of formalized leadership training and investigate opinions regarding leadership theory from the perspective of dermatology residency program directors and chief residents nationally. METHODS A survey containing 26 questions related to leadership theory and training were mailed to all US dermatology residency programs. RESULTS In all, 91% of program directors and chief residents agreed that leadership skills could be taught through observation and training. A total of 78% of respondents agreed that leadership training is important during dermatology residency training. In all, 66% agreed that a formalized leadership curriculum would help residents become better resident supervisors and physicians. Only 13% reported having a formalized leadership curriculum. Participants most frequently reported learning leadership through observation and modeled behavior. A total of 15% of chief residents believed their faculty did not effectively model leadership, whereas only 2% of the program directors believed the same (P = .01). LIMITATIONS In all, 62% (68/109) of programs surveyed returned at least one response from the program director or chief resident. A total of 39% (42/109) had responses from both the program director and the chief resident. Because of the voluntary nature of the survey, response bias could not be excluded. CONCLUSION Most program directors and chief residents believe leadership skills can be cultivated through observation and training. Leadership curriculum is not part of most residency programs.

Allergic contact dermatitis from cinnamic aldehyde found in an industrial odour-masking agent.

Astronium urundeuva (allemão) Engl. (Anacardiaceae) is used in northeastern Brazilian folk medicine largely for the treatment of gynaecological and dermatological problems (1). Previous studies of this plant have shown antiulcerogenic (2), analgesic and anti-inflammatory (3, 4) effects. In clinical practice, there is anecdotal evidence that the use of A. urundeuva in topical preparations may cause, maintain or worsen cutaneous lesions, such as acute, subacute and chronic dermatitis. The present study deals with the preparation of extracts of A. urundeuva to be used in patch tests to determine prevalence of sensitivity and the dominant allergens involved with sensitization. It was accomplished in a transverse study of cases of contact dermatitis and sensitization to A. urundeuva in 137 patients attended at Dermatology Center of Walter Cantı́dio University Hospital/Federal University of Ceará, Brazil. The patients were submitted to patch test using hexane and ethanol extract of A. urundeuva and derived fractions. The plant was collected in Meruoca Hill, situated in Ceará State, and identified by Dr Afrânio Fernandes from the Prisco Bezerra Herbarium of Federal University of Ceará, where a voucher specimen is deposited under number 29851. The patch testing was preceded by anamnese and physical examination then applied using: Standard series (PATCHKIT STANDARD – FDA Allergenic), hexane and ethanol extracts in 2.5%, 5% and 10%; fractions of the hexane (Aur1, Aur2) and ethanol extracts (Aur3, Aur4) in 1% and 2% and cardol in 1% concentrations. All the samples and the constituents of the complementary series were diluted in ethyl alcohol (92.8 ̊ ) that was used as negative control. 3 of 137 (2%) patients showed 1 or more positive reactions to the hexane and ethanol extracts and fractions of A. urundeuva in the patch tests. Patient 1 had a positive test to 5% and 10% EtOH extract. He reported using topical preparation of A. urundeuva to treat a cutaneous rash, but instead of improvement, had accentuation of the lesions. Lesions resolved once treatment with the A. urundeuva preparation was stopped. Patient 2 showed positive results for the hexane extract, fraction Aur4 (2%) and cardol (1%). The patient also reported an improvement of the dermatitis, after suspension of topical use of A. urundeuva. Patient 3 had positive results with the fractions Aur3 (1%) and Aur4 (2%). Phytochemical tests (5) were performed with the fractions Aur1 and Aur2 which were classified as triterpenes; Aur3 showed to contain flavonoids and Aur4 contains pyrogallic tannins. In conclusion, ethanol soluble extractives and to a lesser extent hexane soluble extractives from the bark of A. urundeuva are capable of eliciting positive patch test reactions in persons who have apparently become sensitized to the plant material following its topical use.

Allergic contact dermatitis Patient diagnosis and evaluation

Allergic contact dermatitis resulting from exposure to a chemical or chemicals is a common diagnosis in the dermatologists office. We are exposed to hundreds of potential allergens daily. Patch testing is the criterion standard for diagnosing the causative allergens responsible for allergic contact dermatitis. Patch testing beyond standard trays is often needed to fully diagnose patients, but not all dermatology practices have access to this testing procedure or these allergens. In order to adequately evaluate patients, physicians must understand the pathophysiology of the disease process and be well versed in the proper evaluation of patients, indications for patch testing, proper testing procedure, and other diagnostic tools available and be aware of new and emerging allergens.

Patch-test reactions to formaldehydes, bioban, and other formaldehyde releasers.

Background: Contact allergy to formaldehyde, Bioban, and other formaldehyde releasers and cross‐reactivity between them have been reported in the literature; however, not many studies have data on this cross‐reactivity. Objective: To study (1) the rates of allergy to formaldehyde and to Bioban and other formaldehyde releasers and (2) the rates of cross‐reactivity between them. Methods: We present a retrospective chart analysis of patch‐test results for all patients referred for allergic contact dermatitis testing at the Milton S. Hershey Medical Center from June 2004 to September 2005. Anyone allergic to formaldehyde, Bioban, or other formaldehyde releasers was included. Cross‐reactivity between the agents was then analyzed. Results: The charts of 210 patients were analyzed. Of these patients, 24 (11%) were allergic to formaldehyde, Bioban, or other formaldehyde‐releasing agents. Seventeen (8.1%) of the patients were allergic to formaldehyde, 15 (7.1%) were allergic to Bioban, and 20 (9.5%) were allergic to other formaldehyde‐releasing agents. Eleven (65%) of the 17 formaldehyde‐allergic patients were also allergic to Bioban. Of the 20 patients allergic to formaldehyde‐releasing agents, 14 (70%) were also allergic to one of the three Bioban products tested. Of the 15 patients allergic to Bioban, 11 (73%) were allergic to formaldehyde, 14 (93%) were allergic to formaldehydereleasing agents, and 11 (73%) were allergic to both formaldehyde and formaldehyde‐releasing agents. Conclusion: A high cross‐reactivity rate between formaldehyde, Bioban, and other formaldehyde‐releasing agents was found.

A survey of dermatology resident education in cosmetic procedures

BACKGROUND The demands for cosmetic procedures are increasing. Dermatologists perform many of these procedures, therefore adequate education and training during residency is important. Surveys demonstrate dermatology residents desire more training even while faculty members believe this has already become a more prominent feature of resident education. OBJECTIVE We sought to assess the time and methods dedicated to education and training of cosmetic procedures in dermatology residency. METHODS A 26-question survey was developed and electronically distributed in May 2010 to dermatology program directors via the Association of Professors of Dermatology list-serve with their approval. Program directors were asked to forward the e-mail to their instructors of cosmetic/procedural dermatology, and chief residents. Responses were anonymous. RESULTS A total of 86 responses were collected. In all, 67% (n = 54) of respondents had formal lectures focusing on cosmetic dermatology. Lecture topics reported by more than 50% of respondents included botulinum toxin injection, lasers, soft tissue augmentation, chemical peels, and sclerotherapy. Topics such as dermabrasion, liposuction, and scar revision were less commonly taught. The most commonly encountered and performed procedures were botulinum toxin injection and lasers (100%, n = 86); 98.8% (n = 85) encounter soft tissue augmentation and 95.4% (n = 82) encounter both chemical peels and sclerotherapy. Resident experience performing procedures as the first assistant or as the first surgeon varied widely. LIMITATIONS The limitations of this study are that the data were subjectively reported so results may differ from the true amount of time spent in any activity. The data may be biased by the population that responded as they may have strong opinions supporting or opposing training in cosmetic procedures. The data also may have been skewed by the small percentage of participants who were instructors of cosmetic dermatology (21%), chief residents (20%), and others respondents (8% total). CONCLUSION The results demonstrate the variability of training in cosmetic procedures. The challenge for programs is to find the balance between insufficiency and overemphasis. The results of this study will hopefully assist programs in determining the quantity and methods of resident training in cosmetic procedures.

Irritant contact dermatitis to the brown marmorated stink bug, Halyomorpha halys.

The brown marmorated stink bug, Halyomorpha halys, is native to Asia (China, Taiwan, Japan, and the Korean peninsula). It was first found in Allentown, Pa, in 1996 and has since spread across wide areas of the Eastern United States. As of October 2010, at least 26 states have reported the presence of the brown marmorated stink bug. It is considered an invasive species, and to the best of scientific knowledge, it was accidently introduced into the United States through transportation of goods from Asia. To date, no reports of human disease have been published in the literature. Fruit crop workers have complained of a slight allergic reaction to the chemicals released by the bug.