Caitriona Ryan

Continuing medical educationThe use of cyclosporine in dermatology: Part II

UNLABELLEDnCyclosporine is highly effective in the treatment of a multitude of dermatoses. Concern over its side effect profile has limited its use in dermatology. Adverse effects are, for the most part, dose dependent and related to duration of therapy. Using the recommended monitoring protocols results in a significant decrease in the incidence of cyclosporine-related toxicities. This article provides a comprehensive review of the pharmacokinetics of cyclosporine, potential drug interactions, adverse effects, and recommendations for monitoring in patients treated with cyclosporine. The use of cyclosporine in pregnancy and in the pediatric population is also addressed.nnnLEARNING OBJECTIVESnAfter completing this learning activity, participants should be familiar with the monitoring guidelines of cyclosporine, its contraindications, its possible drug interactions, its adverse effect profile, and its use in pregnancy and the childhood and adolescent populations.

The use of ustekinumab in autoimmune disease

Importance of the field: The advent of biologic therapies has revolutionized the treatment of autoimmune diseases including psoriasis, autoimmune arthritides and inflammatory bowel disease. With recent advances in our understanding of the immunogenetic pathways involved in the pathogenesis of these conditions, newer, more targeted biologic therapies have been developed. Ustekinumab is an antibody to the common p40 subunit of IL-12 and IL-23, which has been studied in the treatment of psoriasis, psoriatic arthritis, Crohns disease and multiple sclerosis. Areas covered in this review: This review details the efficacy and safety of ustekinumab in all clinical studies to date, using PubMed listed publications and official product websites. What the reader will gain: Readers will gain a comprehensive understanding of the mechanism of action of ustekinuamb, its pharmacodynamic and pharmacokinetic profile, and its clinical efficacy and safety in the treatment of psoriasis, psoriatic arthritis, Crohns disease and multiple sclerosis. Take home message: Ustekinumab has shown significant efficacy in the treatment of chronic plaque psoriasis in Phase III studies, and promising results in Phase II studies in psoriatic arthritis. Efficacy has been shown in Crohns disease only in non-responders to infliximab. Ustekinumab did not show benefit in the treatment of multiple sclerosis.

Psoriatic Arthritis: An Update

Psoriatic arthritis is a debilitating condition, which affects approximately one-quarter of psoriasis patients. Recent findings have furthered our understanding of the complex pathophysiology of PsA. There have been major advances in the identification of genes associated with joint involvement but not with cutaneous disease alone. The elucidation of key immunologic pathways has allowed the development of novel targeted therapies that are in the research pipeline. Currently, good screening tests and biomarkers to diagnose early PsA and to guide therapy are limited. In this paper, we present recent findings with regard to the immunopathogenesis and genetics of PsA, biomarkers, and screening tools and review the targeted therapies currently in clinical trials.

The Latest Advances in Pharmacogenetics and Pharmacogenomics in the Treatment of Psoriasis

Systemic and biologic treatments used for the treatment of moderate to severe psoriasis show significant variability in efficacy, are associated with varying degrees of toxicity and, in the case of biologic therapies, are expensive. There is a great need for non-invasive biomarkers to predict treatment outcomes from these therapies and individualize care for psoriasis patients. Identification of pharmacogenetic and pharmacogenomic markers of treatment response may be useful in predicting clinical response to psoriasis therapies and would help in the development of individually tailored treatment. This would increase the cost effectiveness of treatment and reduce unnecessary exposure to treatment toxicity. This review details the current status of pharmacogenetic and pharmacogenomic markers in psoriasis and explores how these research tools may ultimately lead to safer, more directed treatments. Until now, pharmacogenetic studies in psoriasis have been underpowered to produce reliable results, and many have not recorded treatment response or toxicities prospectively in an objective and reproducible manner. Large-scale collaborations and use of patient registries for systemic and biologic treatments in well characterized patient populations that are uniformly treated and systemically evaluated could play a valuable role in advancing the field of pharmacogenetics and pharmacogenomics of psoriasis.

Cytomegalovirus-induced cutaneous vasculopathy and perianal ulceration

(peripheral) in our patient rather than midbrain (central) denervation. Arnaud Duval, MD, Nassos Kalempokas, MD, Anne Penicaud-V edrine, MD, Anne GuiochonMantel, MD, PhD, and Claude Bachmeyer, MD Service de Dermatologie, CHU Saint-Louis (APHP), Paris; Explorations Fonctionnelles, CHU Tenon (AP-HP), Paris; Laboratoire de G en etique Mol eculaire, Pharmacog en etique et Hormonologie, CHU Bic etre (AP-HP), Le Kr emlin-Bic etre; and Service de M edecine Interne, CHU Tenon (AP-HP), Paris, France

The Development of a Patient-Reported Outcome Measure for Assessment of Genital Psoriasis Symptoms: The Genital Psoriasis Symptoms Scale (GPSS)

IntroductionPatient-reported outcome measures (PROs) specific for genital psoriasis (GenPs) have not been described.MethodsIn this cross-sectional, qualitative study in patients with moderate-to-severe GenPs, we sought to develop a PRO useful for GenPs symptom assessment. A literature review was performed to identify relevant psoriasis or GenPs symptoms and existing PROs that may be useful in the evaluation of symptom severity in GenPs patients. The literature review findings were discussed with clinicians, and then patients with GenPs.ResultsRelevant psoriasis or GenPs symptoms from the literature review included itch, pain, scaling, redness/erythema, and stinging/burning. The validity of these symptoms for GenPs and potentially relevant PROs was corroborated by clinical experts. After gap analysis, a draft symptom scale consisting of Numeric Rating Scale (NRS) items was constructed. We then conducted interviews with GenPs patients (nxa0=xa020) to support content validity and use of the draft symptom NRS items in routine practice and in clinical trials. Participants identified and confirmed relevant symptoms and evaluated the utility of the draft PRO. A new PRO was developed: the Genital Psoriasis Symptoms Scale (GPSS). Cognitive debriefing and cultural adaptation/translation interviews with a second group of patients confirmed cultural appropriateness of the GPSS.ConclusionThe GPSS may be useful for assessing symptoms before, during, and after treatment in routine clinical practice and in clinical trials involving patients with GenPs.FundingEli Lilly & Company.Plain Language SummaryPlain language summary available for this article.

Disseminated cutaneous histoplasmosis in newly diagnosed HIV

We present a woman with a widespread severe papulopustular eruption, fever, and fatigue of 5 weeks duration. HIV infection was diagnosed, with an absolute CD4+ count of 3 cells/μL. The eruption was consistent with disseminated cutaneous histoplasmosis. The clinical manifestations and management of cutaneous histoplasmosis are reviewed.