Martina L. Porter

Update on biologic safety for patients with psoriasis during pregnancy

Biologic agents have become more common to treat patients with psoriasis, but concerns about their effect on pregnancy and lactation often preclude this treatment during these time periods. During the past decade, we have gained a much better understanding of the course of psoriasis during pregnancy and the safety of the use of biologic agents during pregnancy and lactation. Under certain circumstances, biologic agents can be considered appropriate treatment options for patients who are pregnant or lactating.

Comorbidities of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is an inflammatory skin disorder with many associated comorbidities, including obesity, metabolic syndrome, smoking, depression, arthritis, autoinflammatory syndromes, inflammatory bowel disease, and genetic syndromes. In addition, HS patients can suffer from a variety of diseases related to the chronic inflammatory nature of their HS such as cardiovascular disease and anemia. An understanding of these comorbidities and associations is essential for the management of HS, and routine screening for these entities should be considered in all HS patients.

Understanding patient engagement in psoriasis treatment

children, but should more attention be paid to the group in between, i.e. adolescents? Methotrexate is increasingly used in children with difficultto-control eczema, psoriasis and localized scleroderma, and recommendations for monitoring are the same as for adults except for the use of serum amino terminal peptide of procollagen III. Treatment is for the shortest duration possible but invariably some overlap will occur where adolescent-specific advice becomes warranted. Methotrexate is a known teratogen and two forms of contraception are recommended where relevant. But do dermatologists ask their adolescent patients with inflammatory dermatoses if they are sexually active? A review in our department found that, until recently, this was seldom done. This was in direct contrast to those teenagers on isotretinoin for acne where a strict pregnancy-avoidance strategy was in place and documented. Differences in approach may be because of factors such as age at presentation of the patient and physician comfort with the subject matter. Patients with acne usually present as adolescents and thus this discussion is likely deemed a more acceptable conversation, whereas adolescents with inflammatory dermatoses may be known to the service from a younger age. Dermatologists’ discomfort with such discussion in the U.S.A. and possible associated legal issues of consent were recently raised by Neuhaus et al. in JAMA Dermatology in relation to combined oral contraception pill prescription in the teen population they noted both a large variation in practice and a desire for guidance. Age of consent and confidentiality in medicine in the U.K. and Ireland is accepted to be 16 years, once the patient can understand the implications of his or her actions and decisions. General Medical Council best practice recommends that the same rights can be afforded to those under 16 but where certain criteria are first met (which include that he or she understands the implications of the decision, they cannot be persuaded to tell their parents, their health is likely to suffer without it and that it is deemed in the best interest of the patient to receive advice or treatment without parental consent). Making such decisions and delivering this level of care is difficult to achieve in oversubscribed dermatology clinics combining paediatric and adult services. Adolescent-specific care requires additional time to interview teenagers alone, training in confidentiality and age-appropriate patient information leaflets and websites that are currently lacking in dermatology. The concept that ‘children’ are individuals of 18 years or less for the purpose of guidelines is flawed. Most adolescents are adults medically (>14 years), although perhaps not emotionally and they need care tailored to their level of developmental maturity. The teenage years are a time of experimentation, of challenging authority and developing autonomy, and most teenage pregnancies are unplanned. Should we now be moving to recognize the need for transitional care for adolescents, as our rheumatology colleagues have done?

Pharmacoeconomics of Systemic and Biologic Therapy in Dermatology

With rising costs of healthcare, economic cost analyses will continue to become important in the evaluation of pharmaceutical products and systemic therapies in dermatology. Understanding the basic principles of pharmacoeconomics and how they apply to dermatology is important for all dermatologists and medical trainees. In this chapter, we review the key concepts of pharmacoeconomics and give examples of these as they pertain to systemic therapy in psoriasis. Costs, including direct costs, indirect costs, opportunity costs, and intangible costs, are reviewed as are types of cost analyses and measurements of humanistic outcomes or clinical efficacy, such as utility scores, patient-reported outcomes, and number needed to treat. Finally, we present an example of a cost analysis for biologic agents in the treatment of psoriasis to emphasize the importance of pharmacoeconomic considerations in daily clinical practice for dermatologists.

Online communications amongst hidradenitis suppurativa patients on Facebook

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Antiandrogen therapy with spironolactone for the treatment of hidradenitis suppurativa

Background: Hormonal therapy is a potential treatment for hidradenitis suppurativa (HS). However, few data exist describing the efficacy of spironolactone in treatment of HS. Objective: To assess whether spironolactone treatment improves HS disease severity and patient‐reported pain. Methods: We performed a single‐center chart review of female patients with HS who were treated with spironolactone between 2000 and 2017. Primary outcome measurements included the HS Physicians Global Assessment (HS‐PGA), Hurley staging, inflammatory lesion count, fistula count, and a numeric rating scale for pain. Results: On average, subjects were exposed to 75 mg of spironolactone daily over a 7.1‐month follow‐up period. Patients achieved significant disease improvement with regard to pain (&Dgr;‐1.5 [P = .01]), inflammatory lesions (&Dgr;‐1.3 [P = .02]), and HS‐PGA score (&Dgr;‐0.6 [P < .001]). As expected, no change was found for Hurley stage (&Dgr;0 [P = .32]) or fistulas (&Dgr;0 [P = .73]). There was no difference in improvement between subjects who received less than 75 mg of spironolactone daily (n = 25; average dose, 45 mg/d) and those who received more than 100 mg daily (n = 21; average dose, 112 mg/d). Limitations: Retrospective nature, limited sample size, and variations in severity measures documented were limiting factors. Conclusions: Management of HS with spironolactone reduces lesion count, HS‐PGA score, and pain. Lower doses appear to be effective and may be an appropriate option for patients with tolerability concerns.

Response to: Remission of hidradenitis suppurativa after bariatric surgery

To the Editor: We recently read with interest the article Remission of hidradenitis suppurativa after bariatric surgery by Gallagher et al. Obesity is an established risk factor for hidradenitis suppurativa (HS), and we appreciate the authors’ work on this relevant piece. Weight loss is thought to improve HS symptoms by decreasing friction, microbial colonization, and inflammation associated with obesity. Patients often inquire about the association between HS and obesity and the possibility of disease abatement with weight loss. Bariatric surgery is effective in reducing body mass index, but negative consequences of bariatric surgery for HS also should be considered. HS patients avidly use online forums to share disease experiences. In a previously published abstract from 2013, we investigated whether online users described HS improvement after bariatric surgery. A Google query of ‘‘hidradenitis1weight loss/gastric bypass/bariatric surgery’’ found 2 Yahoo! groups: a 3839-member HS group and a 77-member group specific for weight loss in HS, as well as postings in other skin and obesity forums. Of 35 posts from patients who wrote about HS disease severity after bariatric surgery, 69% described worsening symptoms caused by an increase in skin folds after weight loss, 26% reported improvement after excess skin removal, and 37% discussed obstacles related to insurance coverage for removal of excess skin. Additionally, a retrospective chart review of HS patients undergoing gastric bypass at our institution yielded 2 cases comparing HS severity before and after surgery. Both patients had stable or worsening disease after surgery. Currently, there are 52 HS support groups on Facebook, the largest of which has 12,217 members. Adding to previously collected data, we searched all posts related to ‘‘gastric bypass’’ or ‘‘weight loss’’ on this group and found 39 discussions. Of these, 25 were relevant and included 56 comments specific to the effects of bariatric surgery on HS severity. Only 29% of posters reported improvement or remission. Many patients (39%) conveyed neither improvement nor worsening of HS symptoms but were satisfied

Assessment of treatment-seeking behaviour in patients with psoriasis

While recent advances in psoriasis treatment have improved achievable efficacy levels, with regimens achieving PASI 90 response, 9-30% of severe psoriasis patients and almost 50% of mild patients do not receive treatment. The Health Belief Model (HBM), designed in 1952, uses patient perspectives to predict preventive health behavior and has been used to help elucidate patient engagement in health promoting behaviour, including treatment seeking and barriers to psoriasis care. This article is protected by copyright. All rights reserved.

Longstanding alopecia and nail dystrophy are associated with more severe overall chronic graft-versus-host disease in adults

Chronic graft-versus-host disease (cGVHD) causes significant morbidity and mortality for recipients of allogeneic hematopoietic stem cell transplants (HSCT) [1, 2]. The multisystem disease is prevalent in an estimated 80% of patients who receive HSCT and most commonly affects the skin, ranging from nonsclerotic epidermal involvement to deep sclerotic disease [3, 4]. The NIH Global Severity of cGVHD uses clinical assessment, laboratory findings, and patient reported symptoms to calculate the overall cGVHD severity score (mild, moderate, or severe). Although “skin” is one of eight organ systems included, grading of hair and nail involvement is not specifically required [4]. Although cGVHD-related alopecia and nail dystrophy have been documented in limited case reports, their overall prevalence in adults has not been well described [5]. Cutaneous involvement is thought to predict a poorer overall cGVHD prognosis [3], and patients with adnexal involvement have been shown to be less responsive to standard treatments [6]. The hair follicle and nail bed are immune privileged sites with lower-MHC class II expression of antigen presenting cells [7, 8]. Such mechanisms suppress T-cell activation and antigen recognition and should presumably reduce the probability of cGVHD in these areas [3, 7, 9]. Therefore, it may be reasoned that the presence of adnexal involvement in cGVHD may be associated with more severe overall cGVHD, as was shown in the pediatric population [6]. A retrospective, case–controlled study of adult HSCT recipients with skin cGVHD seen at MGH between January 2005 and October 2016 was performed to determine the prevalence of hair and nail changes in adult patients with skin cGVHD, and to investigate whether adnexal involvement in adult patients with cutaneous cGVHD is predictive of more extensive and severe overall cGVHD. IRB approval via Partners Human Research Committee was obtained. A search was performed for patients who had been coded for an ICD 9 or 10 associated with cGVHD at least once. Inclusions criteria include patients who were >18 years of age, with only one allogeneic HSCT and confirmed skin cGVHD. Subjects were excluded if they were under 18 years old, received more than one HSCT, and did not have confirmed cutaneous cGVHD. Charts of eligible patients were reviewed to determine the presence of skin cGVHD and adnexal findings. Search terms included “hair”, “alopecia”, and “nail(s)”, which helped to extract data on these findings. Additional data were collected including demographics, reason for HSCT, donor gender, GVHD severity, and other affected GVHD organs. Between January 2005 and October 2016, 474 patients with an ICD code for GVHD were seen. Of these, 193 were found to have cutaneous GVHD, with 163 meeting criteria for chronic skin GVHD. After thorough chart review, patients were assigned to one of four groups. Group 1 consisted of patients with hair and nail changes confirmed to be associated with cGVHD. The adnexal findings were substantiated by multiple, detailed references in the chart. Group 2 consisted of patients with minimal mention of hair and nail changes and unclear association with cGVHD. These charts lacked detailed clinical Co first authors: Jason S. Naftulin, Lauren R. Penzi

Clinical Presentation of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease whose identification hinges upon characteristic lesion morphology, anatomic location, and a recurrent, chronic clinical course. The meaning of ‘hidradenitis suppurativa’ gives multiple clues to its clinical presentation. ‘Hidraden-’ refers to sweat glands, and although the disease is no longer thought to be a disease of apocrine glands, the disease distribution mimics that of apocrine gland bearing skin; ‘-itis’, referring to inflammation; and ‘suppurativa’, or pus, another key clinical sign of this disease.