Rupa Pugashetti

Efalizumab discontinuation: A practical strategy

Efalizumab is a recombinant, humanized IgG1 monoclonal antibody used in the treatment of plaque psoriasis. Efalizumab specifically targets T cells, leading to the subsequent inhibition of  T-cell activation. The recent cases (three confirmed and one unconfirmed but suspected case) of the demyelinating disease progressive multifocal leukoencephalopathy (PML) have resulted in efalizumab being pulled from the market by European and Canadian regulatory agencies. Furthermore, manufacturer Genentech, Inc. has voluntarily withdrawn efalizumab from the United States market as of April 2009. In light of these events, this report is a practical guide to transitioning patients from efalizumab to alternative psoriasis therapies. The major consideration is the possibility for efalizumab-associated rebound of psoriasis. According to limited available literature and in the experience of the authors, the most effective agent for minimizing or preventing rebound is cyclosporine at the maximum dermatologic dose of 5 mg/kg per day.

Occlusive therapy in atopic dermatitis: Overview

Introduction: Occlusive therapy, including both dry and wet (‘wet-wrap therapy’) offers a treatment option in atopic dermatitis (AD) which may be underutilized in clinical practice due to concerns about burdensome regimens and potential complications. This review examines current evidence for the use of occlusion in AD. Methods: Keyword and title searches in PubMed and EMBASE were used to examine data on the use of occlusive therapy in AD from January 1966 to February 2009. Results: Eighteen studies were found examining the use of occlusive therapy in AD. Of the 14 studies examining wet-wrap therapy, five were randomized controlled trials. All wet-wrap therapy studies demonstrated efficacy in severe or acute, moderate and chronic AD. Of the four studies examining dry occlusive therapy, a single controlled study of dry occlusion does not support a benefit over conventional open therapy. Increased cutaneous bacterial counts or clinical infection were reported in all studies using dry occlusion and in four of 14 studies utilizing wet-wrapping techniques. Conclusions: Available data are encouraging, though limited by the lack of adequate study controls and standardized designs. More controlled trials are indicated.

Calcium may preferentially deposit in areas of elastic tissue damage

BACKGROUND Cutaneous calcification is an acquired disorder whereby insoluble, amorphous calcium salts deposit in the skin. Classically, cutaneous calcification is categorized as metastatic, dystrophic, idiopathic, or iatrogenic. OBJECTIVE The purpose of this study was to further elucidate the underlying pathogenic mechanism for cutaneous calcification. METHODS Three cases of cutaneous calcification, including clinical characteristics and associated histopathology, were reviewed. Previous reports of cutaneous calcification were searched for in the published literature and included. RESULTS Calcium is distributed within areas of underlying tissue damage (ie, locus minoris resistentiae), and in our cases, occurred specifically at sites of chronic actinic damage and intravenous extravasation tissue injury. LIMITATIONS A small number of clinical cases and previously published reports were reviewed. CONCLUSION We hypothesize that cutaneous calcification may preferentially occur at anatomic sites where tissue integrity has been compromised (ie, locus minoris resistentiae). We suggest one potential mechanism: that cutaneous calcification occurs within dermis that contains damaged elastic fibers. Pseudoxanthoma elasticum may serve as a possible genetic disease model for this process.

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.

Phototherapy in pediatric patients: choosing the appropriate treatment option.

Phototherapeutic modalities, including narrowband-UVB, broadband-UVB, PUVA photochemotherapy, and excimer laser therapy are valuable tools that can be used for photoresponsive dermatoses in children. As a systematically safer alternative compared with internal agents, including the prebiologic and biological therapies, phototherapy should be considered a possible treatment option for children with diseases including psoriasis, atopic dermatitis, pityriasis lichenoides chronica, and vitiligo.

Broadband UVB revisited: is the narrowband UVB fad limiting our therapeutic options?

Abstract Broadband ultraviolet B (BB-UVB) phototherapy has demonstrated efficacy in the treatment of cutaneous disorders including psoriasis, atopic dermatitis, uremic pruritus and idiopathic pruritus. In the last decade, there has been a rapidly escalating process of replacing BB-UVB phototherapy units with narrowband ultraviolet B (NB-UVB) equipment, as studies have demonstrated that NB-UVB (ranging from 311 mm to 312 nm) is more efficacious in the treatment of psoriasis. Nevertheless, it is important to recognize the efficacy of BB-UVB phototherapy in the treatment of uremic pruritus, idiopathic pruritus, eosinophilic folliculitis and other inflammatory pruritic conditions. Furthermore, as highlighted in this report, there is a small but significant proportion of psoriasis and atopic dermatitis patients who do not tolerate NB-UVB but demonstrate an excellent clinical response to BB-UVB. It is critical for dermatologists to recognize the role of BB-UVB as a complement to NB-UVB phototherapy for patients who cannot tolerate or experience an inadequate therapeutic response from NB-UVB.

Practice of Phototherapy in the Treatment of Moderate-to-Severe Psoriasis

This chapter will discuss the entire spectrum of phototherapy, including narrowband UVB photo-therapy, broadband UVB phototherapy, PUVA, targeted excimer laser phototherapy, and combination treatments. Phototherapy can range from simple treatments in a UVB phototherapy box, with or without concurrent use of various tar preparations, to more elaborate modalities in which the intensity of UVB radiation applied varies according to different anatomical regions. Combining PUVA or UVB phototherapy with topical and systemic agents can also enhance phototherapy. Certain forms of phototherapy, such as the traditional Goeckerman regimen of using black tar daily with UVB light, induce a prolonged remission. Outpatient phototherapy is usually reserved for patients whose disease is not adequately controlled with topical medications, including steroids, vitamin D analogues, tazarotene, tar, or anthralin. It is also indicated for patients with such extensive psoriasis that topical therapy is nearly impossible. Additionally, phototherapy may be an excellent option for patients with specific medical problems for whom systemic medications such as methotrexate, cyclosporine, or biological agents may not be suitable. For patients with generalized psoriasis, phototherapy is a reasonable first choice among the available options because of its superior systemic safety profile in comparison to systemic or biological agents. As with all other forms of psoriasis therapy, it is essential to consider the impact of the treatment on the patients lifestyle when selecting the treatment plan. Important points to consider when initially discussing phototherapy are the patients employment schedule, commitment, flexibility, location of the phototherapy unit, and transportation.

Treatment of acne vulgaris in pregnant patients

The management of acne vulgaris in the setting of pregnancy raises important clinical considerations regarding the efficacy and safety of acne treatments in this special patient population. Particular challenges include the absence of safety data, discrepancy in safety data between different safety rating systems, and lack of evidence‐based recommendations for the treatment of acne during pregnancy. Nonetheless, many therapeutic options exist, and the treatment of acne in pregnant women can be safely and often effectively accomplished. For mild or moderate disease, patients can be treated with topical antimicrobial agents, anti‐inflammatory agents, as well as glycolic and salicylic acid. Several topical agents, notably benzoyl peroxide, previously viewed as potentially dangerous are cited by many sources as being considered safe. When necessary, systemic therapies that can be safely added include penicillins, amoxicillin, cephalosporins, erythromycin, clindamycin, and tetracyclines or sulfonamides, depending on the stage of fetal development. Adjunct therapy may include phototherapy or laser treatments. Physicians should work with this often highly motivated, safety‐conscious patient population to tailor an individualized treatment regimen. This treatment regimen will likely shift throughout the different stages of fetal development, as distinct safety considerations are raised prior to conception as well as during each of the trimesters of pregnancy. Important considerations regarding acne management in breast‐feeding mothers is also discussed.

Dermal mucinosis as a sign of venous insufficiency

Dermal mucinoses are a heterogeneous group of disorders characterized by abnormal deposition of dermal mucin, an amorphous substance composed of hyaluronic acid and sulfated glycosaminoglycans. We describe two cases of dermal mucinosis in the setting of chronic venous insufficiency. Both patients presented with painful, edematous lower extremity plaques. Biopsies of all lesions showed striking dermal mucin deposition, a slight increase in small blood vessel density, slightly thickened vessel walls and no inflammation. Neither patient showed laboratory or clinical findings consistent with a secondary mucinosis such as thyroid dysfunction, lupus erythematosus, dermatomyositis, scleroderma, granuloma annulare, graft‐vs.‐host disease or mucin deposition post‐ultraviolet or photochemotherapy treatment. Both patients were diagnosed with localized cutaneous mucinosis secondary to venous insufficiency. The clinicopathological features of this entity are described, and a pathogenic mechanism is proposed.