Michael E. Farhangian

A Review of the Use of Tanning Beds as a Dermatological Treatment

IntroductionIn-office phototherapy is an effective treatment for many dermatologic conditions, however, many patients are unable to adhere to the rigorous travel and time commitments sometimes needed. Tanning bed facilities are nearly ubiquitous in modern society and could represent a more convenient means to obtain ultraviolet (UV) exposure when office phototherapy is not feasible. The purpose of this study was to review available evidence on the use of tanning facilities as a treatment for dermatologic conditions.MethodsPubMed was searched on February 2015 for “tanning beds” and “phototherapy”, and with some dermatologic conditions sensitive to UV light, including “psoriasis”, “mycosis fungoides”, “acne”, “atopic dermatitis” and “eczema”. From there, further articles were found using the reference sections of the initial papers. A similar methodology was used with the Google Scholar search engine. Only articles in English and prospective studies were included in this review.ResultsWe found studies validating the use of tanning facilities for psoriasis treatment. Use as a treatment option for atopic dermatitis, mycosis fungoides, acne, scleroderma, vitiligo, and pruritus, as well as other UV sensitive dermatoses, may also be beneficial. This study is limited by the lack of double-blind, placebo-controlled trials, long-term follow-up studies, and meta-analyses for tanning facility use in dermatologic phototherapy, and by the lack of standardization of both tanning facilities and exposure dosing.ConclusionUnsupervised sun exposure is a standard recommendation for some patients to obtain phototherapy. Selected use of commercial tanning beds in the treatment of dermatologic conditions may be another useful and effective treatment for those patients with an inability to access office-based or home-based phototherapy.

Immunogenicity of biologic treatments for psoriasis: therapeutic consequences and the potential value of concomitant methotrexate.

The five biologic agents approved for the treatment of psoriasis—etanercept, infliximab, adalimumab, ustekinumab, and secukinumab—have been transformative in the clinical management of severe forms of the disease. However, a significant number of patients fail to respond to these agents or experience a loss of efficacy over time, which may be attributable to the development of antidrug antibodies (ADAs). Increasing evidence, primarily in the context of rheumatoid arthritis or other chronic inflammatory diseases, suggests that concomitant administration of methotrexate may prevent or diminish the development of ADAs, thereby improving response rates. However, methotrexate is infrequently coadministered with biologic agents in patients with psoriasis, and the potential benefits of this strategy in the context of psoriasis are largely unexplored. In this review, we discuss clinical studies regarding the development and consequences of antibodies targeting biologic agents used in the treatment of psoriasis and present key findings describing the potential role of methotrexate as an inhibitor of immunogenicity. We also discuss clinical considerations pertaining to the use of methotrexate as a tool to reduce immunogenicity, and encourage further investigation into potential techniques to optimize this treatment approach in patients with psoriasis.

Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring

Most people with psoriasis have limited disease that could be treated with topicals, but topical efficacy is limited by low short‐term adherence. Psoriasis is a chronic disease, and long‐term adherence is an even bigger problem.

Psoriasis during pregnancy: characteristics and important management recommendations.

The treatment of psoriasis in pregnant women can be challenging. Psoriasis generally improves during pregnancy; however, many pregnant patients still require treatment. In treating pregnant patients, the benefits of treatment and risks to the mother and the fetus must be considered. For localized psoriasis, topical corticosteroids are the treatment of choice. Other topical agents that are approved for the treatment of psoriasis, such as topical tar products and topical tazarotene, should be avoided during pregnancy because of unclear risks of teratogenicity. For moderate-to-severe psoriasis, ultraviolet B phototherapy is preferred. Despite limited safety data, biologics are favored over other systemic medications when needed. While there are new treatment options for psoriasis, there is limited information on the safety of medications during pregnancy.

Adherence to Oral and Topical Medications in Cutaneous Lupus Erythematosus is not Well Characterized

IntroductionTreatment adherence plays a large role in chronic dermatologic diseases and may play an important role in the outcomes of patients with cutaneous lupus erythematosus (CLE). We sought to gauge what is currently known about adherence to topical and oral medications in patients with CLE.MethodsA review of MEDLINE was performed using a combination of the phrases “adherence”, “compliance”, “lupus”, and “cutaneous”. Studies were hand searched and prospective and cross-sectional studies evaluating medication adherence in patients with CLE and systemic lupus erythematosus (SLE) were included.ResultsOnly two articles explored adherence in patients with CLE, while 17 articles discussed treatment adherence in patients with SLE. Depression was consistently cited as detrimental to adherence. The impact that race, ethnicity, and education has on adherence is unclear. Three studies noted a clear connection between adherence and disease activity, while two others did not. Few studies investigated methods that have improved adherence to treatment which have showed promise.ConclusionMuch of what we know about adherence to medication in patients with lupus is limited to SLE. Although cutaneous symptoms are among the most common manifestations of SLE, cutaneous disease is often managed at least in part with topical agents, and adherence to topical treatment was not assessed in any of the articles, though one study investigated sunscreen usage in patients with CLE. Understanding adherence in patients with CLE may help contribute to better CLE treatment outcomes.

Rosacea patients seeking advice: Qualitative analysis of patients’ posts on a rosacea support forum

Abstract Background: Social media have become outlets for patients to voice opinions and ask questions. Since suffering from rosacea is an isolating experience and the disease is poorly understood, patients use social media to expand their knowledge about the condition. Objective: To understand rosacea patients’ online health information seeking habits to obtain a better insight of their educational needs. Methods: Ten percent of posts in online rosacea forum composed of 3350 members and 27 051 posts, discussing patient viewpoints and concern, selected by stratified random sampling. Three hundred and nine queries were directly categorized to patients “seeking advice” by two investigators and qualitatively analyzed. Results: Patients primarily sought advice about treatments (n = 155, 50.1%), triggers (n = 53, 17.1%), diet (n = 48, 15.5%), skin care (n = 37, 11.9%) and special presentations of the disease (n = 22, 7.1%). Questions frequently pertained to adverse effects, efficacy and target of therapy (78, 49, 30 posts, respectively). Conclusion: Proactively providing reliable resources and comprehensive explanations on treatments, triggers, diet and skin care could be helpful in reducing patients’ confusion about rosacea and enhancing rosacea patient–physician relationships.

Cutaneous cryosurgery in the United States

Abstract Background: Cryosurgery is a common treatment modality for many dermatological conditions; however, the extent to which it is used and by which medical specialties is not well characterized. Objective: To determine the rates of cryosurgery use over time, the top dermatoses treated by cryosurgery, patient demographics and the rate at which practitioners used cryosurgery. Methods: We used the National Ambulatory Medical Care Survey (NAMCS) from 1993 to 2010 in order to quantify the use of cryosurgery in outpatient offices. For visits where cryosurgery was utilized, the leading diagnoses, treating physician specialties, and patient ages were tabulated. Results: Cryosurgery was most commonly used for treating actinic keratoses (48% of visits), seborrheic keratoses (25% of visits) and verrucae (21% of visits). Dermatologists performed 82% of all cryosurgeries, followed by family/internal medicine physicians (13.6%) and pediatricians (2.8%). The use of cryosurgery for these dermatoses has increased over time (p < 0.0001), especially in patients over the age of 65 years. Physicians in offices with health maintenance organization-based practices were more likely to utilize cryosurgery. Limitations: Since NAMCS data are cross-sectional, we are unable to determine whether patients tried and failed other treatments. Conclusions: As the baby boomer generation ages, the demand for cryosurgery will likely further increase.

Internet-based adherence interventions for treatment of chronic disorders in adolescents.

Background Treatment adherence is a ubiquitous challenge in medicine, particularly in the adolescent population with chronic disorders. Web-based adherence interventions may be particularly useful in adolescents, due to their familiarity with and frequent use of the Internet. Objective To review web-based interventions used to improve adherence to medication in adolescent patients with chronic disorders. Methods A PubMed search was performed for full-text, English, clinical trials in adolescents using keywords “adherence” or “compliance”, “Internet” or “web”, and “treatment” from inception until November 2014. Articles were selected if they involved using the Internet to provide support to adolescents to help improve their adherence to treatment, excluding those focused on solely providing medical services through the Internet and articles focusing on preventative care, rather than treatment of an illness. Results Fourteen studies were found concentrating on chronic adolescent disorders. Interventions included online surveys, physician chat lines, monitoring programs, and interactive programs. All interventions experienced either greater improvement in adherence or another disease control measure or no statistically significant difference compared with the control group (in-clinic visits). Limitations Few clinical trials studying web-based interventions to improve adherence in adolescents were found. Due to not having one standard outcome measured in all of the studies, it was also difficult comparing the effectiveness of the interventions. Conclusion Web-based interventions play a role in improving adherence in adolescents with chronic disorders by being more time saving and cost effective compared with in-clinic visits. Further research focusing on adherence interventions using the Internet is necessary to determine the ideal ways of utilizing the Internet to improve adherence in adolescents with chronic disorders.

Treatment of Molluscum Contagiosum with Imiquimod in the United States: A Retrospective Cross-Sectional Study.

Since there are concerns that imiquimod is being overprescribed for children with molluscum despite its limited efficacy, we used data from two nationally representative surveys to determine the rate at which imiquimod was being prescribed for molluscum contagiosum in the United States. From 1999‐2010, there were an estimated 6.4 million visits for molluscum (95% CI: 5.5, 7.3 million), and imiquimod was prescribed at 7.0% of these visits (95% CI: 3.4, 11). Given the low frequency of patients being treated with imiquimod for molluscum, the concerns of its overuse may be unfounded.

Dupilumab for the treatment of atopic dermatitis: A clinical trial review

Introduction: Current treatment options for moderate-to-severe atopic dermatitis (AD) are limited and have potentially dangerous side effects. Dupilumab is a novel monoclonal antibody that was recently studied in adult patients with moderate-to-severe AD. Dupilumab inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling and was previously found to be effective in asthma. Considering that both AD and asthma are Th2 cell-mediated inflammatory processes, it is reasonable to suspect that dupilumab would be beneficial in AD.` Areas covered: This article is a review of the one major clinical trial that assessed the efficacy of dupilumab in patients with AD. Its goal is to provide a comparison to the current modalities for the treatment of AD and expert insight regarding future studies. Expert opinion: The results of this study are a significant therapeutic advancement. Dupilumab was shown to provide a mean percent change in Eczema Area and Severity Index score of −74% ± 3.6, in addition to, statistically and clinically significant reductions the severity, symptomatology, and morbidity associated with AD. However, the small sample size makes it difficult to assess the magnitude of this effect. As a result, dupilumab will likely be reserved for cases of severe AD unresponsive to traditional modalities.