Jacqueline Greb

High-dose ustekinumab for the treatment of severe, recalcitrant pyoderma gangrenosum.

Correspondence Jacqueline E. Greb, Department of Dermatology, Tufts Medical Center, 800 Washington Street, Box 114, Boston, MA 02111, USA. Email: jacqueline.greb@tufts.edu Conflict of Interest Dr. Gottlieb currently has consulting/advisory board agreements with the following: Amgen Inc.; Astellas, Akros, Centocor (Janssen), Inc.; Celgene Corp., Bristol Myers Squibb Co., Beiersdorf, Inc., Abbott Labs. (Abbvie), TEVA, Actelion, UCB, Novo Nordisk, Novartis, Dermipsor Ltd., Incyte, Pfizer, Canfite, Lilly, Coronado, Vertex, Karyopharm, CSL Behring Biotherapies for Life, Glaxo Smith Kline, Xenoport, Catabasis, Meiji Seika Pharma Co., Ltd., Takeda, Mitsubishi Tanabe Pharma Development America, Inc. She has research/educational grants (paid to Tufts Medical Center) with the following: Centocor (Janssen), Amgen, Abbott (Abbvie), Novartis, Celgene, Pfizer, Lilly, Coronado, Levia, Merck, Xenoport.

Psoriasis Trends and Practice Gaps

The present article addresses several high-impact practice gaps affecting psoriatic patients, current practices, the barriers that prevent the delivery of optimal care, and recommendations to improve patient outcomes. Discussions of treatment, cardiovascular risk factor screening, psoriatic arthritis screening, and biologics are included. Finally, an overview of current resident exposure to psoriatic care and recommendations for improvements in resident education are made.

Insights on methotrexate in psoriatic disease.

The folic acid analogue methotrexate is used as an anti-neoplastic agent and treatment for inflammatory disorders including psoriasis, dermatomyositis, lupus erythematous, sarcoidosis, and systemic sclerosis. Despite the introduction of newer biologic agents, methotrexate remains a first-line systemic therapy for many patients with disorders of chronic inflammation. Here we briefly describe the current clinical evidence for methotrexate use in psoriatic disease, our current understanding of methotrexates anti-inflammatory properties, and the future role of methotrexate in the treatment of immune mediated disorders.

Adalimumab for the treatment of actinic granuloma

We report a 55-year-old, caucasian man with a thirteen year history of erythematous, non-scaly, annular plaques in a photo-distributed pattern over the dorsal forearms and hands which were annually recurrent duing the spring and summer months. He had a history of chronic sun exposure with clinical evidence of solar elatosis. Previous biopsy was consistent with actinic granuloma (AG). Clinical clearance was achieved with adalimumab 40 mg every other week in the first reported use of adalimumab for the treatment of AG. AG is a noninfectious, granulomatous disorder related to granuloma anulare (GA), and affects sun-exposed skin (O’Brien, 1975). On histology both conditions feature granulomatous inflammation although elastophacocytosis and a central elastin-poor zones characteristic of AG are absent in GA (O’Brien, 1975). Another disorder, annular elastolytic giant cell granuloma, is considered an overlaping entity with AG and demonstrates a similar histologic pattern. AG typically flares annually during periods of increased sun exposure, although ultimately the disease process may remit spontaneously after a course of years. The disorder may arise from T-cell autoreactivity to degenerated elastin peptides, although its pathogenesis has not been fully elucidated (McGrae, 1986; Gutierrez-Gonzalez, Pereiro, & Toribio, 2015). Our patient previously failed to respond to months of class I topical corticosteroids and 6 months of hydroxychloroquine 200 mg PO twice daily. Temporary improvement was achieved with occasional intralesional kenalog injections over the course of years and a prednisone taper from 50 mg over a course of 2 weeks, however, neither was used as long term therapy due to the significant number of plaques and side effects, respectively. Adalimumab, dosed per standard psoriasis protocol, was approved by the patient’s insurance and started in June 2015 during an active AG flare (Figure 1). Subsequent to the first two injections, however, he developed herpes zoster over a midthoracic dermatome. After holding adalimumab and a 1 week course of valacyclovir, adalimumab was restarted without further side effects. Following two more injections of adalimumab, the number of plaques decreased; after three additional months of treatment with adalimumab clinical clearance was achieved (Figure 2). These follow-up visits occurred during the time of year the patient would have otherwise experienced active disease. Treatment of AG is challenging and no therapies have been evaluated in placebo-controlled trials. Case reports and observational studies have reported treatment with topical and intralesional corticosteroids, psoralen ultraviolet A therapy, antimalarials, cyclosporine, methotrexate, systemic retinoids, cryotherapy (Parikh et al., 2015). While antimalarials are typically effective in the treatment of photodistributed disorders, AG and AEGCG have variable responses to these agents (Parikh et al., 2015). We present the first use of adalimumab in the treatment of AG. Adalimumab is a fully human, monoclonal antiboty targeting tumor necrosis factor (TNF)-a with demonstrated treatment efficacy in GA (Min & Lebwohl, 2016; Rosmarin, LaRaia, Schlauder, & Gottlieb, 2009). TNF is essential in the formation and maintenance of granulomas through regulation of chemokine production, macrophage activation and apoptosis, and adhesion molecule expression (Roach et al., 2002; Lopez Ramirez et al., 1994; Flesch & Kaufmann, 1990; Keane, 2005). Additionally, TNF blockade has been shown to stimulate granuloma breakdown in GA (Torres, Pinto Almeida, Alves, Sanches, & Selores, 2011). We suggest that in the appopriate clinical setting, particularly in recalcitrant cases with

Article Commentary: Corrona's Application in Psoriatic Disease:

Corrona is a prospective observational registry founded in 2002 that collects data from patients and physicians about rheumatoid arthritis, psoriatic arthritis, other spondyloarthritis, and psoriasis. Here, we summarize the significant findings derived from the psoriatic arthritis Corrona database and describe future goals for Corronas application in psoriasis.

Worms: A Remarkably Reasonable Treatment Option for Psoriasis

There is a need to expand safe and effective treatment options for patients with moderate to severe psoriasis. This article hypothesizes one promising novel treatment option: Trichuris Suis. Epidemiological, experimental, and clinical evidence suggest that Trichuris Suis therapy may be both applicable and advantageous in the treatment of psoriasis. Epidemiologically, the de-worming of developed nations has been correlated with the increased prevalence of immune-mediated disease such as psoriasis. Additionally, the mechanisms of helminth immune regulation should mitigate the underlying immunopathology in psoriasis. Finally, safety and efficacy of Trichuris Suis has been demonstrated in other immune-mediated diseases such as Crohns, ulcerative colitis, and multiple sclerosis with clinical responses in as many as 80% of patients. Evidently, there is ample evidence to warrant the investigation of Trichuris Suis therapy as a novel psoriasis treatment.