Eric S. Lee

Quality-of-Life Instruments: Evaluation of the Impact of Psoriasis on Patients

The negative impact of psoriasis on a patients quality of life (QoL) is well documented in the literature. Patients often suffer poor self-esteem, difficulties in social interactions, and significant psychological distress. It is, therefore, critically important that a clinician evaluate the extent to which the disease impacts a patients QoL. This chapter reviews several validated and reliable generic, dermatology-specific, and disease-specific QoL instruments useful in measuring the impact of psoriasis on patients QoL. These QoL instruments can be especially helpful in identifying those patients who would most benefit from systemic or biologic therapy.

Single‐center retrospective study of long‐term use of low‐dose acitretin (Soriatane®) for psoriasis

BACKGROUND: Indicated as monotherapy for severe psoriasis in adults, acitretin (Soriatane®) can be used in combination therapy or as a ‘disease‐stabilizing, maintenance’ agent. While its efficacy for psoriasis and other disorders of keratinization is well established, its safety is often a concern for many dermatologists. The possible side effects associated with short‐term treatment of oral retinoids include mucocutaneous effects, elevation in serum lipid chemistries and liver enzymes, and teratogenicity. However, the only possible long‐term, cumulative side effect is skeletal and ligamentous calcification such as hyperostosis. There is a specific syndrome of hyperostosis associated with oral retinoids called DISH (diffuse idiopathic skeletal hyperostosis). OBJECTIVE: To examine the incidence of DISH syndrome in long‐term acitretin use for psoriasis and to quantify the incidence of other side effects. METHODS: All patients seen at the UCSF Psoriasis and Skin Treatment Center who had been on acitretin for more than 1 year were identified. RESUTLS: A chart review of these patients revealed no X‐ray‐confirmed cases of DISH syndrome, minimal changes in coronary heart disease risk indicators, and extremely rare significant elevation of liver enzymes. CONCLUSION: Acitretin does not appear to cause significant long‐term side effects at low doses; the implications for thousands of patients are that use of this medication can be continued for long periods of time with routine monitoring.

How psoriasis patients perceive, obtain, and use biologic agents: Survey from an academic medical center

Abstract The availability of new biologic agents for the treatment of psoriasis provides hope for improved quality of life outcomes. However, the way patients come to use biologics, the potential barriers they encounter, and their attitudes towards using these medications are still not well studied. Here, we conducted a survey of 106 psoriasis patients at an academic medical center to discern patient attitudes towards biologics. We found that most patients learn of biologics through their physician and perform follow-up research using the Internet. Most patients did not find it difficult to make the decision to start a biologic. Difficulty in obtaining biologics was associated with age less than 55 (p = 0.01), lower income level (p = 0.007), and lack of insurance (p = 0.04). Patients were found to have high satisfaction and compliance rates on biologics. Of patients who missed a dose of their biologic, this was mainly due to logistical reasons such as not having the medication or forgetting to take it, rather than being depressed or overwhelmed. Patients with lower income levels had increased cut backs in personal expenses due to co-payments (p = 0.001). Among respondents, the mean annual out-of-pocket expense for a biologic was

Delusional infestations: clinical presentation, diagnosis and treatment

557.12 per year, with a range of

The role of tumor necrosis factor-alpha and other cytokines in depression: what dermatologists should know

0–7000.

Goeckerman therapy: a very effective, yet often forgotten treatment for severe generalized psoriasis.

Patients with delusional infestations (DI), previously named delusions of parasitosis, have a fixed, false belief that they are infested with living or non‐living pathogens. Patients have abnormal cutaneous symptoms such as itching, biting, or crawling sensations. They often demonstrate self‐destructive behavior in an effort to rid the pathogens from under their skin, leading to excoriations, ulcerations, and serious secondary infections. This review article aims to provide an overview of DI including its clinical presentation, diagnosis, and treatment. Strategies on how to establish a strong therapeutic alliance with DI patients are discussed. In addition, antipsychotic medications used in the treatment of DI are described.

The impact of emollients on phototherapy: A review

Abstract Recent studies have suggested that inflammatory responses may play an important role in the pathophysiology of depression. In fact, depressed individuals have been found to have higher levels of pro-inflammatory cytokines, especially tumor necrosis factor-alpha (TNF-α) and interleukin-6. This appears to be independent of any pre-existing chronic inflammatory disorders. In this article, various studies correlating increased levels of cytokines to depression are reviewed. As much as 60% of individuals with psoriasis also suffer from clinical depression. TNF-α antagonists, frequently used in the treatment of psoriasis, may be helpful in directly reducing depressive symptoms for patients with psoriasis and other chronic inflammatory conditions.

Occlusive Therapy in Atopic Dermatitis

Abstract As early as 1925, patients suffering from psoriasis have been effectively treated with combination crude coal tar and ultraviolet B radiation, commonly known as Goeckerman therapy. Even though the efficacy of Goeckerman therapy is as good as, if not better than, other more recently available treatment options, its use virtually disappeared after extended inpatient therapies became no longer feasible in the USA. Our clinic at the University of California San Francisco is one of the few outpatient dermatologic clinics that still offer Goeckerman therapy. We present a case report of a patient with severe generalized plaque-type psoriasis, who demonstrated dramatic improvement within 28 days of Goeckerman therapy. It is our hope that this case report serves to remind physicians that Goeckerman therapy is viable treatment option for patients with severe psoriasis, especially those with treatment-resistant psoriasis.

Ketoconazole-induced Sweet syndrome: a new association.

When treating psoriasis, various topical emollients exist that can affect the penetration of ultraviolet radiation in phototherapy. Compared with normal-appearing skin with a reflectance of 4% to 5%, psoriatic skin has higher reflectance as a result of its increased air-to-corneocyte interfaces. Studies have tested the effect of emollients on light penetration by assessing psoriatic plaque clearance, differences in minimal erythema dose, and physical properties of the emollient (eg, monochromatic protection factor and absorbance). Psoriatic plaque clearance was found to improve with serous (thin liquid)-based emollients (eg, Vaseline oil [Unilever, Blackfriars, London, UK], mineral oil, and glycerol), whereas clearance decreased with salicylic acid and viscous-based emollients (eg, petrolatum). Emollients with high ultraviolet absorbance properties increased minimal erythema dose, and those with low absorbance properties decreased minimal erythema dose. Interestingly, when a liquid emollient with a refractive index close to that of normal-appearing skin was applied, there was a net increase in light absorption, or a reduction in reflection that exceeded the emollients innate ability to absorb light.

Hydroxyurea for the Treatment of Psoriasis with an Emphasis on HIV-Infected Psoriasis Patients: A Review

Misha M. Heller1, Eric S. Lee2, Faranak Kamangar3, Wilson Liao4 and John Y. M. Koo4 1University of Southern California, Keck School of Medicine, Los Angeles, California 2University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska 3University of California Davis, School of Medicine, Sacramento, California 4University of California San Francisco, Department of Dermatology San Francisco, California USA