Heidi Jacobe

Sertraline as a first-line treatment for cholestatic pruritus†

Pruritus is frequently the most debilitating symptom of cholestatic liver diseases. Moreover, existing therapies are often ineffective. Recent small, retrospective case series reports suggest that serotonin reuptake inhibitors can improve pruritus. This study was undertaken to establish the dose of sertraline and to evaluate its efficacy for cholestatic pruritus. Twenty one subjects with chronic pruritus due to liver disease (including primary biliary cirrhosis, primary sclerosing cholangitis, chronic hepatitis C, and postnecrotic cirrhosis) initially underwent an open‐label, dose escalation to determine the dose with optimal efficacy and tolerability. After a washout period, 12 of the subjects entered a randomized, double‐blind, placebo‐controlled trial. Participants quantified their pruritus using a 0‐10 visual analog scale, and pruritus was assessed for distribution, timing, degree of disability, and physical evidence of scratching. The optimum sertraline dose (75‐100 mg/day) was well tolerated. In the controlled portion of the study, itch scores improved in patients taking sertraline, but worsened in patients taking placebo (P = 0.009). Changes in itch distribution, duration, direction, and physical evidence of scratching paralleled changes in the visual analog pruritus score. Conclusion: Sertraline seems to be an effective, well‐tolerated treatment for pruritus due to chronic liver disease. These results suggest that serotonergic pathways are important in the perception of itch. (HEPATOLOGY 2007;45:666–674.)

Safety and efficacy of alefacept, efalizumab, etanercept and infliximab in treating moderate to severe plaque psoriasis: a meta‐analysis of randomized controlled trials

Background  The relatively recent introduction of biological agents to treat psoriasis presents clinicians with the need to objectively compare and contrast these agents to allow more effective treatment of their patients.

Distinct Autoimmune Syndromes in Morphea: A Review of 245 Adult and Pediatric Cases

OBJECTIVE To determine the prevalence of extracutaneous manifestations and autoimmunity in adult and pediatric patients with morphea. DESIGN A retrospective review of 245 patients with morphea. SETTING University of Texas Southwestern Medical Center-affiliated institutions. Patients Patients with clinical findings consistent with morphea. MAIN OUTCOME MEASURES Prevalence of concomitant autoimmune diseases, prevalence of familial autoimmune disease, prevalence of extracutaneous manifestations, and laboratory evidence of autoimmunity (antinuclear antibody positivity). Secondary outcome measures included demographic features. RESULTS In this group, adults and children were affected nearly equally, and African Americans were affected less frequently than expected. The prevalence of concomitant autoimmunity in the generalized subtype of morphea was statistically significantly greater than that found in all other subtypes combined (P = .01). Frequency of a family history of autoimmune disease showed a trend in favor of generalized and mixed subgroups. The linear subtype showed a significant association with neurologic manifestations, while general systemic manifestations were most common in the generalized subtype. Antinuclear antibody positivity was most frequent in mixed and generalized subtypes. CONCLUSIONS High prevalences of concomitant and familial autoimmune disease, systemic manifestations, and antinuclear antibody positivity in the generalized and possibly mixed subtypes suggest that these are systemic autoimmune syndromes and not skin-only phenomena. This has implications for the management and treatment of patients with morphea.

Phototherapy in the management of atopic dermatitis: a systematic review.

Background/purpose: Atopic dermatitis (AD) is a common and extremely burdensome skin disorder with limited therapeutic options. Ultraviolet (UV) phototherapy is a well tolerated, efficacious treatment for AD, but its use is limited by a lack of guidelines in the optimal choice of modality and dosing. Given this deficit, we aim to develop suggestions for the treatment of AD with phototherapy by systematically reviewing the current medical literature.

A systematic review of morphea treatments and therapeutic algorithm

BACKGROUND Morphea (localized scleroderma) is a skin disorder with significant morbidity. No consistent recommendations exist for therapy, impeding patient care. OBJECTIVE We sought to create an evidence-based therapeutic algorithm. METHODS We reviewed English-language literature using search engines and hand searches for therapeutic interventions in morphea. Results were summarized. RESULTS Narrowband ultraviolet B is appropriate for progressive or widespread superficial dermal lesions; broadband ultraviolet A/ultraviolet A-1 is appropriate for widespread or progressive deeper dermal lesions. Systemic treatment with methotrexate, corticosteroids, or both is indicated for deep or function-impairing lesions and rapidly progressive or widespread (severe) disease. Topical treatment with calcipotriene or tacrolimus is supported for limited, superficial, inflammatory lesions. Use of oral calcipotriol, D-penicillamine, interferon gamma, and antimalarials is not supported. LIMITATIONS Limitations are publication bias; lack of adequately powered, controlled trials; and no validated outcome measures. CONCLUSION Phototherapy, methotrexate/systemic corticosteroids, calcipotriene, and topical tacrolimus have the most evidence for efficacy in morphea. Treatment works best in inflammatory disease. Disease activity, severity, progression, and depth should play a role in therapeutic decision making.

Development of consensus treatment plans for juvenile localized scleroderma: A roadmap toward comparative effectiveness studies in juvenile localized scleroderma

Juvenile localized scleroderma (LS) is a chronic inflammatory skin disorder associated with substantial morbidity and disability. Although a wide range of therapeutic strategies has been reported in the literature, a lack of agreement on treatment specifics and accepted methods for clinical assessment has made it difficult to compare approaches and identify optimal therapy. Our objective was to develop standardized treatment plans, clinical assessments, and response criteria for active, moderate to high severity juvenile LS.

Addictive-like behaviours to ultraviolet light among frequent indoor tanners

Background.  Frequent, purposeful exposure to ultraviolet (UV) light may induce a compulsive desire to tan despite the negative consequences being known, suggesting a behavioural complex similar to addictive disorders.

UVA1 phototherapy for cutaneous diseases: an experience of 92 cases in the United States

Background: The efficacy and safety of UVA1 (340–400 nm) phototherapy were established by studies from European countries.

An evaluation of long-term outcomes in adults with pediatric-onset morphea.

The prevalence of morphea in childhood is not well established, but past reports suggest approximately 2/3 of linear morphea begins before age 18, and 20–30% of morphea overall begins in childhood.1, 2 Studies have described significant morbidity in children with morphea, but none have addressed the disease effects when they reach adulthood. From the Morphea Registry and DNA Repository at the University of Texas Southwestern Medical Center (UTSW), we identified adults with pediatric onset morphea (APOM) 18yr or older to address the impact of childhood morphea in adults.

Morphea in adults and children cohort II: Patients with morphea experience delay in diagnosis and large variation in treatment

BACKGROUND Little is known about the diagnosis, evaluation, and therapy of morphea (localized scleroderma) in the United States. Delays in diagnosis and initiation of appropriate therapy, if present, may negatively affect patient care. Further, this gap in knowledge hinders planning for clinical trials and therapeutic guidelines. The morphea in adults and children (MAC) cohort is designed to address this gap. OBJECTIVE We sought to determine the duration between morphea onset and diagnosis, specialty of the diagnosing provider, and initial evaluation and therapy in the MAC cohort. METHODS This was a cross-sectional survey of the inception cohort of the MAC study. RESULTS In all, 63% (n = 141 of 224) of patients were given the diagnosis more than 6 months after onset. Dermatologists diagnosed and treated the majority of patients (83.5%, n = 187). Rheumatologists diagnosed and treated the more severe forms of morphea (linear and generalized). The most commonly prescribed therapy was topical corticosteroids (63%). Dermatologists predominantly prescribed topical treatments or phototherapy (P < .0001, P = .0018, respectively), even to patients with linear and generalized morphea. In contrast, rheumatologists predominantly prescribed systemic immunosuppressives and physical therapy (P < .0001, P = .0021, respectively). LIMITATIONS Referral bias and recall bias may affect patterns of evaluation/therapy and ascertainment of disease duration before diagnosis. CONCLUSIONS Patients with morphea experience delay in diagnosis, which likely impacts outcome. Therapeutic decision making is largely determined by the specialty of the provider rather than disease characteristics and many treatments with little or no proven efficacy are used, whereas others with proven efficacy are underused. This underscores the need for a collaborative, multispecialty approach in designing therapeutic trials and guidelines.