Judith Hong

The psychosocial and occupational impact of chronic skin disease

ABSTRACT:  Chronic skin diseases, particularly psoriasis and atopic dermatitis, have a negative impact on patients’ quality of life. Patients often experience significant psychological and social distress such as increased levels of depression and fear of stigma. Skin diseases can also impact patients’ occupational lives by causing them to miss work or be less productive. Quality of life instruments provide important information for healthcare professionals, the general public, and those involved in distribution of healthcare resources, which helps prevent chronic skin disease from being overlooked amidst other medical conditions.

Management of Itch in Atopic Dermatitis

Atopic dermatitis is a common, pruritic, inflammatory skin disorder. Chronic, localized, or even generalized pruritus is the diagnostic hallmark of atopic dermatitis, and its management remains a challenge for physicians. The threshold for itch and alloknesis is markedly reduced in these patients, and infections can promote exacerbation and thereby increase the itch. Modern management consists of anti-inflammatory, occasionally antiseptic, as well as antipruritic therapies to address the epidermal barrier as well as immunomodulation or infection. Mild forms of atopic dermatitis may be controlled with topical therapies, but moderate-to-severe forms often require a combination of systemic treatments consisting of antipruritic and immunosuppressive drugs, phototherapy, and topical compounds. In addition, patient education and a therapeutic regimen to help the patient cope with the itch and eczema are important adjuvant strategies for optimized long-term management. This review highlights various topical, systemic, and complementary and alternative therapies, as well as provide a therapeutic ladder for optimized long-term control of itch in atopic dermatitis.

Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks

BACKGROUND Psoralen plus ultraviolet A (PUVA) for the treatment of psoriasis has never been evaluated using the Psoriasis Area Severity Index (PASI) in a randomized, double-blind, placebo-controlled trial. The lack of such data limits our capacity to estimate PUVAs efficacy relative to other treatment options that are available today. OBJECTIVES The purpose of this study was to evaluate the efficacy of PUVA therapy for patients with plaque-type psoriasis. METHODS This study involved 40 patients with psoriasis; 30 received PUVA and 10 received UVA with placebo. PASI scores were assessed at baseline and every 4 weeks thereafter for 12 weeks. RESULTS By nonresponder imputation, 60% (18 of 30) in the PUVA group achieved 75% or more improvement in PASI score after 12 weeks of treatment compared with 0% (0 of 10) in the UVA plus placebo group (P < .0001). Using intent to treat with last observation carried forward analysis, 63% (19 of 30) in the PUVA group achieved 75% or more improvement in PASI score compared with 0% (0 of 10) in the UVA plus placebo group (P < .0001). By per protocol analysis, 86% (18 of 21) in the PUVA group as compared with 0% (0 of 7) in the UVA plus placebo group reached 75% or more improvement in PASI score after 12 weeks (P < .0001). LIMITATIONS The study was relatively small with only 40 patients enrolled and 28 patients who completed the protocol. Further studies that involve head-to-head comparison of PUVA with other treatment modalities are needed. Nonresponder imputation, last observation carried forward with intent to treat, and per protocol analyses each have separate advantages and limitations when determining clinical significance. CONCLUSIONS This study supports the observation that PUVA is a highly efficacious treatment for chronic plaque psoriasis.

A New Technique for Acupuncture Therapy and Its Effectiveness in Treating Fibromyalgia Syndrome: A Case Report

Background: The purpose of this case report is to demonstrate a new acupuncture technique in treating fibromyalgia syndrome [FMS]. Findings: A patient with FMS had poor responses to previous treatments. She received treatment at our acupuncture clinic. The new acupuncture technique we applied was similar to Hongs technique for myofascial trigger point injection but used simultaneous needle rotation to facilitate the insertion movement of a small acupuncture needle. After five sessions, she assessed her overall pain level to be at less than 20 percent of its original level. A follow-up confirmed that she was no longer suffering any serious discomfort. Conclusion: A patient with FMS may show remarkable pain relief after this treatment. The mechanism is probably similar to hyperstimulation analgesia, but postneedling discomfort may be reduced due to the small size of acupuncture needle. It is suggested to have a well-controlled, double-blinded study on a large sample to confirm that conclusion.

Pilot evaluation of supra-erythemogenic phototherapy with excimer laser in the treatment of patients with moderate to severe plaque psoriasis

Background: Phototherapy is an effective treatment for generalized plaque psoriasis, but is inconvenient and dosimetry is limited by the minimal erythema dose (MED). Objective: This pilot study evaluated the efficacy, safety, and feasibility of excimer laser utilizing a supra-erythemogenic phototherapy strategy (phototherapy well beyond the MED dose) to treat generalized psoriasis. Methods: In this 9-month study, 13 patients with psoriasis involving > 10% but < 30% body surface area received laser treatment twice weekly for 12 weeks, with 6 months of post-treatment follow-up. The primary endpoint was percentage of patients achieving Psoriasis Area and Severity Index (PASI) 75. Results: Of the 12 patients who completed the treatment phase, 54% achieved PASI 75. During the 6-month follow-up period 83% maintained PASI 50 with no treatment. Limitations: This pilot study had a small sample size. Conclusion: The laser is an effective treatment with a favorable remission rate. With enhanced power in the near future, laser is likely to become more promising for generalized psoriasis.

Compassionate care: Enhancing physician–patient communication and education in dermatology: Part I: Patient-centered communication

The motivation for developing patient-centered communication stems from a desire to enhance the quality of patient care, fulfill professional competency requirements, reduce medical errors, and improve health outcomes and patient satisfaction. Patient-centered communication skills can optimize the physician-patient relationship without significantly prolonging office visits. We propose a series of practical and generally effective techniques for verbal and nonverbal communication. We also suggest a targeted approach for specific difficult conversations that may occur frequently in the practice of dermatology.

Use of Lasers for the Treatment of Psoriasis and Vitiligo

Psoriasis and vitiligo are two chronic inflammatory skin conditions that have long been treated with phototherapy. Recently, laser theropy has become an alternative to generalized light treatment, as lesions can be targeted more directly and generally require less treatment sessions. While a variety of lasers have been tested for both the treatment of psoriasis and vitiligo, the most commonly used laser for this purpose is the excimer laser, which uses a wavelength of 308 nm. This chapter discusses the indications and use of lasers in the treatment of psoriasis and vitiligo.

Hydrogel Patch: A New Occlusive Device for the Treatment of Psoriasis—Patient Feedback from a Bilaterally Controlled Study

Occlusion is an effective therapeutic modality for treating psoriasis either by itself or by enhancing the efficacy of topical agents. However, the affordable material available, namely Saran wrap and other similar plastic sheets, make it unfeasible for widespread use. The hydrogel patch is a new medical device that is not only efficacious, but also improves upon the shortcomings of previous occlusive dressing materials. It is not yet available in the market but is expected to become available soon. This article introduces the use of the hydrogel patch and presents patient input regarding its feasibility and acceptability from a bilaterally controlled study for the treatment of psoriasis.

Relapse Rate and Duration of Therapeutic Effect of Oral Psoralen plus Ultraviolet a (PUVA) in the Treatment of Plaque-type Psoriasis: Original Data Utilizing Standardized Measures of Effect Duration

Background Treatments with long duration of therapeutic effects are ideal for the long-term treatment of psoriasis. This study evaluates psoralen plus ultraviolet light A (PUVA) therapy using standardized definitions of relapse and durability of therapeutic effect. Objectives The purpose of this study was to evaluate the relapse rate and duration of therapeutic effect for PUVA patients who achieved at least 75% reduction in the Psoriasis Area and Severity Index (PASI 75) score after 12 weeks of treatment. Methods This study involved 40 patients with psoriasis; 30 received PUVA and 10 received UVA with placebo for 12 weeks during the double-blind treatment phase. During the post-treatment follow-up, patients who achieved PASI 75 after 12 weeks of PUVA were followed for 48 weeks without treatment to evaluate for relapse (time when subjects return to ≤50% reduction in baseline PASI) and durability of therapeutic effect (time from stopping treatment until 50% of improvement in PASI from the treatment is lost). Results Using per-protocol analysis, 18 out of the 21 patients (86%) who completed the double-blind treatment phase achieved PASI 75 after 12 weeks of PUVA. None of the placebo-treated patients achieved PASI 75. Of the patients who reached PASI 75 after 12 weeks, 89% (16/18) did not relapse after 12 weeks, 69% (11/16) did not relapse after 24 weeks, and 36% (5/14) did not relapse after 48 weeks follow-up. Of the patients who relapsed during the 48-week follow-up, the median time to relapse was 32 weeks. The durability of therapeutic effect was at least 12 weeks, 24 weeks, and 48 weeks respectively in 100% (18/18), 75% (12/16) and 42% (6/14) of the patients. Limitations The study was relatively small with only 14 patients completing the total follow-up period and per-protocol analysis was used. In addition, the patients were generally younger and less severe than those evaluated in biologic studies. There was no direct head-to-head comparison with other treatment modalities to evaluate relative relapse rates. Conclusions The study results support previous reports in the literature and the general clinical impression that PUVA provides prolonged duration of response in patients with plaque-type psoriasis.