Kourosh Beroukhim

The psychosocial impact of acne, vitiligo, and psoriasis: a review

Introduction Chronic skin conditions have been well reported to affect a patient’s quality of life on multiple dimensions, including the psychosocial domain. Psychosocial is defined as the interrelation of social factors with an individual’s thoughts and behavior. The assessment of the psychosocial impact of skin disease on a patient can help direct the dermatologists’ treatment goals. To evaluate the psychosocial impact of skin disease, we conducted a review of the literature on three skin conditions with onsets at various stages of life: acne, vitiligo, and psoriasis. Methods A PubMed search was conducted in March 2015 using the terms “psychosocial” AND “acne”, “psychosocial” AND “vitiligo”, and “psychosocial” AND “psoriasis”. The results were limited to articles published in English in the past 5 years studying patients of all ages. Results and their references were evaluated for relevance according to their discussion of psychosocial qualities in their patients and the validity of psychosocial assessments. The search for acne yielded 51 results, and eleven were found to be relevant; vitiligo yielded 30 results with ten found to be relevant; and psoriasis yielded 70 results with seven found to be relevant. Results According to the articles evaluated, 19.2% of adolescent patients with acne were affected in their personal and social lives. Social phobia was present in 45% of patients with acne compared to 18% of control subjects. Race and sex played a role in self-consciousness and social perceptions of the disease. Vitiligo negatively affected marriage potential and caused relationship problems in >50% of patients. Psoriasis negatively affected multiple domains of life, including work, relationships, and social activities. Anxiety and depression affected not only psoriasis patients but also their cohabitants; up to 88% of cohabitants had an impaired quality of life. Conclusion Though all three skin conditions resulted in an increase in anxiety and depression among their patient populations, the psychosocial focus varied slightly for each disease. Overall, acne, vitiligo, and psoriasis can have negative psychosocial impact in different stages of life development.

Emerging targeted therapies for plaque psoriasis – impact of ixekizumab

Background Recent studies into the pathogenesis of psoriasis have identified the importance of interleukin 17 (IL-17) in disease activity and have thus provided a new target for biologic therapy. Ixekizumab, the most recent US Food and Drug Administration (FDA)-approved anti-IL-17 biologic agent, appears to be a promising medication for patients suffering from moderate-to-severe plaque psoriasis. Methods We reviewed the results of phase III trials for ixekizumab in order to assess the efficacy, safety, and impact on quality of life of this agent in the treatment of plaque psoriasis. Additionally, we compared these results to phase II and phase III trials for other biologic psoriasis medications including the anti-IL-23 agents tildrakizumab and guselkumab, the combined anti-IL-12 and anti-IL-23 agent ustekinumab, and the anti-IL-17 agents brodalumab and secukinumab. Results Pooled results from individual studies demonstrate that among the most efficacious dosing regimens of these anti-interleukin therapies, ixekizumab achieves higher Psoriasis Area and Severity Index 75 rates and similar or higher static Physician Global Assessment 0-1 rates than the other anti-IL-17 and anti-IL-23 agents. The safety profile of ixekizumab is similar to these agents, with nasopharyngitis, upper respiratory infection, headache, arthralgia, and injection-site erythema as the most commonly reported adverse events. Conclusion Ixekizumab is a highly efficacious, newly FDA-approved treatment for moderate-to-severe plaque psoriasis that demonstrates a robust clinical response, significant improvement in patient quality of life, and a favorable safety profile.

Combining biologic and phototherapy treatments for psoriasis: safety, efficacy, and patient acceptability

Background The efficacy and safety of biologic and phototherapy in treating moderate-to-severe psoriasis is well known. However, some patients may not respond well to biologic agents or phototherapy on their own and may require combination therapy. Skillfully combining a biologic agent and phototherapy may provide an additive improvement without much increase in risks. Objective To summarize the current state of evidence for the efficacy and safety of combining biologics with phototherapy in the treatment of moderate-to-severe plaque psoriasis. Methods We conducted an extensive search on Pubmed database for English language literature that evaluated the use of a combination of biologic and phototherapy for the treatment of moderate-to-severe psoriasis through January 2016. The search included the following key-words: psoriasis, etanercept, adalimumab, infliximab, ustekinumab, biologics, phototherapy, and combination therapy. Results The primary literature included randomized controlled trials, a head-to-head study, open-label controlled and uncontrolled trials, case series, and case reports. Etanercept was used in over half of the reported cases, but other biologic agents used included ustekinumab, adalimumab, and infliximab. The vast majority of phototherapy was narrowband ultraviolet B (NBUVB) radiation. Most cases reported enhanced improvement with combination therapy. Serious adverse events throughout the study duration were reported in <3% of the patients. Long-term adverse events cannot be excluded. Conclusion Combination of biologic and phototherapy appears to be a viable clinical strategy in the treatment of moderate-to-severe psoriasis not responsive to monotherapy, despite limitations in the data available. NBUVB in combination with biologics appears to be especially effective. However, the long-term impact of these combinations is yet to be determined.

A prospective, interventional assessment of the impact of ustekinumab treatment on psoriasis-related work productivity and activity impairment

Abstract Background: The negative impact of psoriasis on quality of life is well documented. Psoriasis is also associated with impairments in work productivity and daily activities. Objectives: This study was conducted to prospectively measure the impact of ustekinumab treatment on work productivity and daily activity impairments due to psoriasis, using the Work Productivity and Activity Index: Psoriasis instrument. Methods: Thirty-two patients with moderate-to-severe plaque psoriasis received 36 weeks of ustekinumab and were followed every 4 weeks. During each visit, patients were evaluated using the Psoriasis Area Severity Index and Work Productivity and Activity Index: Psoriasis instrument. Results: Thirty-two patients completed the study. There was no change in unemployment rate after treatment. Twenty-two patients who were employed at both baseline and week 36 experienced a significant decrease in total work productivity impairment, presenteeism and a non-significant decrease in absenteeism. All patients demonstrated significant reduction in total activity impairment. Limitations: This study was limited by the lack of a placebo group and a small sample size. Conclusions: This study demonstrates the benefits of ustekinumab treatment in terms of reducing psoriasis-related work productivity and activity impairments among patients with moderate-to-severe psoriasis.

An open label pilot study of supraerythemogenic excimer laser in combination with clobetasol spray and calcitriol ointment for the treatment of generalized plaque psoriasis.

Abstract A common therapeutic modality for psoriasis includes the combination of phototherapy with topical treatments. The recent development of targeted phototherapy with the excimer laser and spray formulations for topical treatments has increased the efficacy and convenience of these combinational therapies. Herein, we aim to assess the efficacy of a novel combination of therapies using the 308 nm excimer laser, clobetasol propionate spray and calcitriol ointment for the treatment of moderate to severe generalized psoriasis. In this 12-week study, patients with moderate to severe psoriasis received twice weekly treatments with a 308-nm excimer laser combined with clobetasol proprionate twice daily for a month followed by calcitriol ointment twice daily for the next month. Of the 30 patients enrolled, 83% of patients (25/30) achieved PASI-75 [65–94%, 95% confidence interval (CI)] at week 12. For PGA, there was an estimated decrease of 3.6 points (3.1–4.1, 95% CI, p < 0.0005) by week 12. In conclusion, the combination of excimer laser with alternating clobetasol and calcitriol application has shown to be a promising combination of therapies for the treatment of moderate to severe generalized psoriasis. Further evaluation may be conducted with a larger study inclusive of control groups and head-to-head comparisons against topical steroid and UVB therapy as monotherapies.

Dermal Mucinosis in Chronic Sclerodermoid Graft-Versus-Host Disease.

Abstract:Dermal mucinosis is characterized by the deposition of glycosaminoglycans (mucin), either focally or diffusely within the dermis. This may occur as a primary idiopathic disorder or secondary to several dermatoses, most notably lupus erythematous, scleroderma, and dermatomyositis. The authors present an unusual finding of dermal mucinosis in association with chronic sclerodermoid graft-versus-host disease.

A cross-sectional survey study to evaluate phototherapy training in dermatology residency.

Department of Dermatology, University of California, San Francisco, CA, USA. Department of Medicine, University of Arizona, Tucson, AZ, USA. Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, USA. David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. Irvine School of Medicine, University of California, Irvine, CA, USA. Department of Dermatology, University of California, Davis, CA, USA.

Dietary modifications in atopic dermatitis: patient-reported outcomes

Abstract Background: Patients with atopic dermatitis (AD) commonly turn to dietary modifications to manage their skin condition. Objectives: To investigate patient-reported outcomes and perceptions regarding the role of diet in AD. Methods: One hundred and sixty nine AD patients were surveyed in this cross-sectional study. The 61-question survey asked about dietary modifications, perceptions and outcomes. Results: Eighty seven percent of participants reported a trial of dietary exclusion. The most common were junk foods (68%), dairy (49.7%) and gluten (49%). The best improvement in skin was reported when removing white flour products (37 of 69, 53.6%), gluten (37 of 72, 51.4%) and nightshades (18 of 35, 51.4%). 79.9% of participants reported adding items to their diet. The most common were vegetables (62.2%), fish oil (59.3%) and fruits (57.8%). The best improvement in skin was noted when adding vegetables (40 of 84, 47.6%), organic foods (17 of 43, 39.5%) and fish oil (28 of 80, 35%). Although 93.5% of patients believed it was important that physicians discuss with them the role of diet in managing skin disease, only 32.5% had consulted their dermatologist. Conclusions: Since dietary modifications are extremely common, the role of diet in AD and potential nutritional benefits and risks need to be properly discussed with patients.

Vascularized Composite Tissue Transplant Pathology

Throughout the past few decades, vascularized composite tissue allotransplantation (CTA) has been introduced as an option for limb replacement and reconstruction of tissue defects. The first successful hand transplant was performed in Lyon, France, in September of 1998. Subsequently, over 90 upper extremity transplants have been performed, making these grafts the most common form of CTA. These tissue grafts are complex in that they consist of a heterogeneous mixture of tissues, including skin, fat, muscle, nerves, lymph nodes, bone, cartilage, ligaments, and bone marrow. In addition, they are unique because the skin provides a visual assessment of how the graft is functioning and aids in the diagnosis of rejection. The aforementioned phenomenon is secondary to the fact that the skin demonstrates the highest immunological activity in the context of acute rejection and is the first tissue to display signs of rejection. Clinically, early cutaneous presentation allows immediate detection of acute rejection and is particularly essential given the absence of reliable serological or cellular markers indicative of composite tissue rejection.

Article Commentary: Clinical Severity Measures for Psoriasis: A Case for the PASI

The Psoriasis Area and Severity Index (PASI) and Physician Global Assessment (PGA) are the most commonly used tools for the evaluation of psoriasis disease severity in clinical trials. Based on U.S. Food and Drug Administration requirements, many recent trials concerning measurement of psoriasis disease severity have included the PGA as a primary endpoint alongside the PASI. In this commentary, we review the advantages and disadvantages of the PASI and PGA scales, and discuss an example of a psoriasis patient in whom PGA fails to capture clinically significant disease improvement. We argue that despite its limitations, the PASI is a more accurate and descriptive instrument than the PGA for the assessment of psoriasis severity.