Cindy J. Chambers

Psoriasis and hypertension severity: Results from a case-control study

Background Epidemiologic studies have provided new insights into the association between psoriasis and cardiovascular diseases. Previous population studies have examined hypertension frequency in psoriasis patients. However, the relationship between severity of hypertension and psoriasis has not been characterized. Objective We sought to investigate whether patients with psoriasis have more difficult-to-manage hypertension compared to non-psoriatic hypertensive patients. Approach We performed a case-control study using the University of California Davis electronic medical records. The cases were defined as patients diagnosed with both psoriasis and hypertension, and controls were defined as patients with hypertension and without psoriasis. In this identified population, 835 cases were matched on age, sex, and body mass index (BMI) to 2418 control patients. Key Results Treatment with multiple anti-hypertensives was significantly associated with the presence of psoriasis using univariate (p<0.0001) and multivariable analysis, after adjusting for diabetes, hyperlipidemia, and race (p<0.0001). Compared to hypertensive patients without psoriasis, psoriasis patients with hypertension were 5 times more likely to be on a monotherapy antihypertensive regimen (95% CI 3.607.05), 9.5 times more likely to be on dual antihypertensive therapy (95% CI 6.68–13.65), 16.5 times more likely to be on triple antihypertensive regimen (95% CI 11.01–24.84), and 19.9 times more likely to be on quadruple therapy or centrally-acting agent (95% CI 10.58–37.33) in multivariable analysis after adjusting for traditional cardiac risk factors. Conclusions Psoriasis patients appear to have more difficult-to-control hypertension compared to non-psoriatic, hypertensive patients.

Cost-effectiveness analysis of a patient-centered care model for management of psoriasis

INTRODUCTION Cost-effectiveness analyses help policymakers make informed decisions regarding funding allocation of health care resources. Cost-effectiveness analysis of technology-enabled models of health care delivery is necessary to assess sustainability of novel online, patient-centered health care models. OBJECTIVE We sought to compare cost-effectiveness of conventional in-office care with a patient-centered, online model for follow-up treatment of patients with psoriasis. METHODS Cost-effectiveness analysis was performed from a societal perspective on a randomized controlled trial comparing a patient-centered online model with in-office visits for treatment of patients with psoriasis during a 24-week period. Quality-adjusted life expectancy was calculated using the life table method. Costs were generated from the original study parameters and national averages for salaries and services. RESULTS No significant difference existed in the mean change in Dermatology Life Quality Index scores between the two groups (online: 3.51 ± 4.48 and in-office: 3.88 ± 6.65, P value = .79). Mean improvement in quality-adjusted life expectancy was not significantly different between the groups (P value = .93), with a gain of 0.447 ± 0.48 quality-adjusted life years for the online group and a gain of 0.463 ± 0.815 quality-adjusted life years for the in-office group. The cost of follow-up psoriasis care with online visits was 1.7 times less than the cost of in-person visits (

Impact of live interactive teledermatology on diagnosis, disease management, and clinical outcomes

315 vs

Fungal infections of the skin and nail: new treatment options

576). LIMITATIONS Variations in travel time existed among patients depending on their distance from the dermatologists office. CONCLUSION From a societal perspective, the patient-centered online care model appears to be cost saving, while maintaining similar effectiveness to standard in-office care.

Primary cutaneous mucormycosis at sites of insulin injection

OBJECTIVE To assess the impact of live interactive teledermatology consultations on changes in diagnosis, disease management, and clinical outcomes. DESIGN We conducted a retrospective analysis of 1500 patients evaluated via live interactive teledermatology between 2003 and 2005 at the University of California, Davis. We compared diagnoses and treatment plans between the referring physicians and the teledermatologists. Patients with 2 or more teledermatology visits within a 1-year period were assessed for changes in clinical outcomes. SETTING Academic medical center with an established teledermatology program since 1996. PARTICIPANTS Medical records were evaluated for 1500 patients who underwent live interactive teledermatology consultation. Patients seen for more than 1 teledermatology visit were included in the clinical outcome assessment. INTERVENTION Live interactive teledermatology consultation. MAIN OUTCOME MEASURES Changes in diagnosis, disease management, and clinical outcome. RESULTS Compared with diagnoses and treatment plans from referring physicians, the 1500 live interactive teledermatology consultations resulted in changes in diagnosis in 69.9% of patients and changes in disease management in 97.7% of patients. Among 313 patients with at least 2 teledermatology visits within 1 year, clinical improvement was observed in 68.7% of patients. Multivariate analysis showed that changes in diagnosis (P = .01), changes in disease management (P < .001), and the number of teledermatology visits (P < .001) were significantly associated with improved clinical outcomes. CONCLUSIONS Live interactive teledermatology consultations result in changes in diagnosis and disease management in most consultations. The numbers of live interactive teledermatology visits and changes in diagnosis and disease management are significantly associated with improved clinical outcomes.

A rare presentation of congenital syphilis: Pemphigus syphiliticus in a newborn infant with extensive desquamation of the extremities

Knowledge of the currently available antifungal agents, along with clinical, microbiologic and histopathologic methods, can help the medical professional optimally manage skin and nail fungal infections. With regards to treatment of fungal disease of the skin or nail, there are a variety of systemic antifungal agents, including several newer agents that have different formulations, tolerability, adverse effect profiles and spectrum of activity. This review will highlight the clinically important fungal infections of the skin and nail and describe the activity and role of antifungal treatment.

Amelanotic blue nevus

REFERENCES 1. Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Finelli C, Giagounidis A, et al. Efficacy of azacitidine compared with that of conventional care regimens in the treatment of higher-risk myelodysplastic syndromes: a randomised, open-label, phase III study. Lancet Oncol 2009;10:223-32. 2. Walker DC, Cohen PR. Trimethoprim-sulfamethoxazole-associated acute febrile neutrophilic dermatosis: case report and review of drug-induced Sweet’s syndrome. J Am Acad Dermatol 1996;34(5 pt 2):918-23. 3. Thompson DF, Montarella KE. Drug-induced Sweet’s syndrome. Ann Pharmacother 2007;41:802-11. 4. Clark BM, Homeyer DC, Glass KR, D’Avignon LC. Clindamycin induced Sweet’s syndrome. Pharmacotherapy 2007;27: 1343-46. 5. Cholongitas E, Pipili C, Dasenaki M, Kaklamanis L. Piperacillin/tazobactam-induced Sweet syndrome in a patient with chronic lymphocytic leukemia and autoimmune cholangitis. Am J Dermatopathol 2008;30:203-4. 6. Gheorghe L, Cotruta B, Trifu V, Cotruta C, Becheanu G, Gheorghe C. Drug-induced Sweet’s syndrome secondary to hepatitis C antiviral therapy. Int J Dermatol 2008;47:957-9. 7. Kaune KM, Baumgart M, Gesk S, Mitteldorf C, Baesecke J, Glass B. Bullous Sweet syndrome in a patient with t(9;22) (q34;q11)-positive chronic myeloid leukemia treated with the tyrosine kinase inhibitor nilotinib. Arch Dermatol 2008;144:361-4. 8. Moutaoui L, Zouhair K, Benchikhi H. Sweet syndrome induced by chloroquine. Ann Dermatol Venereol 2009;136:56-7. 9. Alper Y, Sprecher E, Bergman R, Birnbaum F. Sweet’s syndromelike neutrophilic dermatosis resulting from exposure to a radiocontrast agent. J Am Acad Dermatol 2008;58:488-9. 10. Alencar C, Abramowitz M, Parekh S, Braunshweig I, Jacobson M, Silverman L, et al. Atypical presentations of Sweet’s syndrome in patients with MDS/AML receiving combinations of hypomethylating agents with histone deacetylase inhibitors. Am J Hematol 2009;84:688-9. 11. Buck T, Gonzalez LM, Lambert WC, Schwartz RA. Sweet’s syndrome with hematologic disorders: a review and reappraisal. Int J Soc Dermatol 2008;47:775-82. 12. Cohen PR. Sweet’s syndrome—a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis 2007;2:34. 13. Delluc A, Limal N, Puechal X, Franc es C, Piette JC, Cacoub P. Efficacy of anakinra, an IL1 receptor antagonist, in refractory Sweet syndrome. Ann Rheum Dis 2008;67:278-9.

Effectiveness of Online vs In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial

Congenital syphilis is an infection transmitted from mother to fetus and can present with early but variable cutaneous manifestations. In rare situations, a bullous eruption known as pemphigus syphiliticus may develop. We present an unusual case of broad desquamation of the extremities in a newborn infant who was found to have congenital syphilis. Pemphigus syphiliticus should be considered in the differential diagnosis of neonatal bullous eruptions and erosions.

Erythema induratum of Bazin

CLINICAL PRESENTATION A 38-year-old woman presented to clinic with a solitary 6.53 4-mm sharply demarcated ivory-white papule on her left temple of unknown duration (Fig 1). The lesion had a smooth surface without scale or ulceration. Small perifollicular dells were also noted. The patient reported no symptoms but believed the lesion recently turned white. She had no other similarly appearing lesions.

Eruptive purpuric papules on the arms; a case of chemotherapy-induced inflammation of actinic keratoses and review of the literature

IMPORTANCE Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes. OBJECTIVE To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care. DESIGN, SETTING, AND PARTICIPANTS The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis. INTERVENTIONS Participants were randomized 1:1 to receive online or in-person care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The in-person group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months. MAIN OUTCOMES AND MEASURES The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score. RESULTS Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was –0.27 (95% CI, –0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was –0.05% (95% CI, –1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was –0.11 (95% CI, –0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement. CONCLUSIONS AND RELEVANCE The online, collaborative connected-health model was as effective as in-person management in improving clinical outcomes among patients with psoriasis. Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be transformative to improving patient-centered outcomes in chronic diseases. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02358135