Charles Chiang

Hydroxychloroquine and lichen planopilaris: Efficacy and introduction of Lichen Planopilaris Activity Index scoring system

BACKGROUND Lichen planopilaris (LPP) and its variant frontal fibrosing alopecia (FFA) are primary lymphocytic cicatricial alopecias for which there is no evidence-based therapy. OBJECTIVE We assessed the efficacy of hydroxychloroquine in active LPP and FFA using the LPP Activity Index (LPPAI), a numeric score that allows quantification of the symptoms and signs of the condition for statistical comparison. In addition, we determined with the LPPAI if any improvement (reduction) in the numeric score pretreatment and posttreatment reached statistical significance. METHODS This was a retrospective, single-center chart review of 40 adult patients with LPP, FFA, or both who were treated with hydroxychloroquine for up to 12 months from 2004 to 2007 at the University of California, San Francisco Hair Center. Symptoms, signs, activity, and spreading were scored at each visit in the standardized cicatricial alopecia flow chart. A numeric score was assigned to these markers of disease activity and a numeric score was calculated at each visit. RESULTS There was significant reduction (P < .001) in the LPPAI at both 6 and 12 months. After 6 months, 69% had improved (reduced) symptoms and signs. At 12 months, 83% had improvement (reduction) in symptoms and signs. LIMITATIONS Retrospective analysis and uncontrolled study are limitations. CONCLUSIONS Hydroxychloroquine is effective in decreasing symptoms and signs in LPP and FFA as shown by significant reduction in the LPPAI in 69% and 83% of patients after 6 and 12 months of treatment, respectively.

Efficacy and safety of mycophenolate mofetil for lichen planopilaris

BACKGROUND Lichen planopilaris (LPP) is a chronic inflammatory disorder that causes permanent scalp hair loss and significant patient discomfort. OBJECTIVES We sought to determine the efficacy and safety of mycophenolate mofetil (MMF) for treatment of LPP in patients who had failed prior topical, intralesional, or oral anti-inflammatory medications such as hydroxychloroquine or cyclosporine. METHODS We conducted a retrospective chart review of 16 adult patients with LPP treated with at least 6 months of MMF in an open-label, single-center study from 2003 to 2007. Subjective and objective end points were quantified using the LPP Activity Index (LPPAI) and scores before and after treatment were assessed using a paired t test. Adverse events were monitored. RESULTS Patients who completed treatment with MMF had significantly decreased signs and symptoms of active LPP despite having failed multiple prior therapies (P < .005). Five of 12 patients were complete responders (LPPAI score decreased>85%), 5 of 12 patients were partial responders (LPPAI score decreased 25%-85%), and two of 12 patients were treatment failures (LPPAI score decreased<25%). Four patients withdrew from the trial because of adverse events. LIMITATIONS Retrospective analysis and small sample size were limitations. CONCLUSIONS MMF was effective at reducing the signs and symptoms of active LPP in 83% of patients (10 of 12) who had failed multiple prior treatments after at least 6 months of treatment.

Topical steroid risk analysis: Differentiating between physiologic and pathologic adrenal suppression

Abstract Background: Topical corticosteroids are a mainstay of therapy for inflammatory skin disorders. Hypothalamic–pituitary–adrenal (HPA) axis suppression is a potential systemic risk of topical steroid use. Our aim was to review available data on the risk of HPA axis suppression associated with long-term topical steroid use and to distinguish between pathologic and physiologic adrenal suppression. Methods: We performed a PubMed search for literature that evaluated the risk of HPA axis suppression associated with topical steroid use. Results: Fifteen of sixteen clinical trials reviewed did not report any pathologic adrenal suppression. In the single clinical trial that reported pathologic adrenal suppression, the patients used twice the maximum recommended amount of clobetasol propionate continuously for as long as 18 months. Physiologic adrenal suppression was seen as early as 1–2 weeks after treatment with class I–IV topical corticosteroids. In about half of these patients, cortisol levels spontaneously returned to normal within a few weeks, despite continuous therapy. Conclusion: Even when adrenal suppression occurs, topical corticosteroids are unlikely to be associated with clinical signs or symptoms of HPA axis suppression and are extremely safe as long as they are used within the current safety guidelines.

Cutaneous Lymphoid Hyperplasia (Pseudolymphoma) in a Tattoo After Far Infrared Light

Cutaneous tattoo reactions are relatively frequent, including granulomatous, lichenoid, sarcoidal, morpheaform, and pseudolymphomatous reactions. Red tattoo pigment, which is often a mercury containing pigment, is most often to blame. Reactions to other pigments such as cobalt salts (blue), chrome salts (green), manganese salts, and cadmium salts have also been described. These reactions can occur within months of tattoo placement or can take many years to develop.

Psoriasis responds to intralesional injections of alefacept and may predict systemic response to intramuscular alefacept: Interim results of a single-arm, open-label study

Abstract Background: Alefacept is a remittive treatment for generalized psoriasis but is rarely used due to its erratic efficacy. Objective: To determine if psoriasis plaques will respond to intralesional alefacept and if this predicts a systemic response to intramuscular (IM) alefacept. Methods: We describe a 25-week, single-center, open-label study. Patients received weekly intralesional alefacept of increasing concentrations into target plaques for 3 weeks followed by IM injections for 12 weeks and concluded with an observation period of 9 weeks. The psoriasis area and severity index (PASI) was used to assess the efficacy of IM alefacept. Results: Interim results are reported for the first seven patients enrolled. Two patients responded intralesionally to the most dilute 1:100 concentration of alefacept to sterile water and achieved a 59% and 100% improvement in PASI. Five patients did not respond intralesionally to the most dilute form of alefacept and none achieved PASI 75. Two of these five patients did not respond to any concentration and achieved a 26% and 38% improvement in PASI. Limitations to this study include a small sample size and being non-placebo-controlled. Conclusion: Alefacept is effective intralesionally and may predict a systemic response – challenging the concept that biologics must work systemically.

Intralesional injections of alefacept may predict systemic response to intramuscular alefacept: results from a pilot study.

Background: Alefacept (Amevive®) was the first biologic agent to be approved by the FDA for use in moderate to severe chronic plaque psoriasis and remains one of the safest systemic agents. However, alefacept is the least utilized of all the biologic agents due to the finding that it is only effective in a small proportion of patients and its maximal efficacy is not seen until approximately 6 weeks after treatment completion. Objective: To determine whether intralesional injections with a biologic agent can predict who will be a responder or a non-responder to the medication. Methods: This was a single-center 22-week study consisting of three phases: i) intralesional injection to a target plaque, ii) intramuscular alefacept injections for 12 weeks (standard dose) and iii) post-treatment follow-up. Results: There appears to be a perfect correlation between patients who show a response to an intralesional injection of alefacept to a small, target plaque and those who eventually respond to a full 12-week systemic course of the medication (achieve at least 70% improvement in their PASI scores from baseline) (p = 0.0003). Limitations: This study had a small sample size and was limited by the fact that it was open-label without a control arm. Conclusion: The results from this pilot study demonstrated that alefacept appears to work intralesionally and this may be usable to predict systemic response. More importantly, these results strongly suggest that a biologic agent can work locally – a novel concept that contradicts the common notion that biologic agents must work “systemically”.

A Clinical Study Comparing the Efficacy of Halobetasol Propionate 0.05% Ointment Once Daily versus Twice Daily in Combination with Ammonium Lactate Lotion in the Treatment of Stable Plaque Psoriasis

Objective The aim of this study was to compare the efficacy of halobetasol propionate 0.05% ointment administered once daily with that of the ointment administered twice daily in combination with 12% ammonium lactate lotion for treatment of plaque psoriasis. A second objective was to investigate the benefits of maintenance therapy with ammonium lactate 12% lotion. Design The study was a randomized, investigator-masked, parallel trial. In the first phase, subjects applied halobetasol 0.05% ointment either once or twice daily in combination with 12% ammonium lactate lotion twice daily for 2 weeks. In the second phase, subjects either continued ammonium lactate twice daily or discontinued all treatment for 4 weeks. Setting University of California San Francisco Psoriasis and Skin Treatment Center. Participants: The study comprised 40 patients with a target plaque of at least 1 cm2 and a Psoriasis Severity Assessment (PSA) score of at least 6. Measurements Plaque induration, scale, and erythema were recorded at weeks 0, 1, 2, 4, and 6. Paired t-tests compared improvement between the two groups; unpaired t-tests compared differences between the two arms. Results No significant difference was noted in efficacy between once- and twice-daily halobetasol application at weeks 0 and 2 for induration (respectively, P = 0.10 and P = 0.21), scale (P = 0.49 and 0.51), erythema (P = 0.42 and 0.14), and total PSA (P = 0.37 and 0.23). A significant difference was found in scale between weeks 2 and 4 (P = 0.04) and weeks 2 and 6 (P = 0.03) in favor of patients continuing ammonium lactate lotion. Conclusion Once-daily halobetasol ointment achieves results similar to those of twice-daily application when used with ammonium lactate lotion in plaque psoriasis treatment. Sequential therapy with 2-week halobetasol ointment followed by twice-daily ammonium lactate may enhance therapeutic duration.