Sean D. Doherty

National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents

BACKGROUND Chronic immunosuppression is a known risk factor for allowing latent tuberculosis (TB) infection to transform into active TB. Immunosuppressive/immunomodulatory therapies, while highly efficacious in the treatment of psoriasis and psoriatic arthritis, may be associated with an increased rate of active TB in patients receiving some of these therapies. OBJECTIVE Our aim was to arrive at a consensus on screening for latent TB infection in psoriasis patient treated with systemic and biologic agents. METHODS Reports in the literature were reviewed regarding immunosuppressive therapies and risk of TB. RESULTS Screening patients for latent TB infection before commencement of treatment is of utmost importance when beginning treatment with the tumor necrosis factor-alpha inhibitors, T-cell blockers, cyclosporine, or methotrexate. The currently recommended method for screening is the tuberculin skin test. It is preferable that positively screened patients be treated with a full course of latent TB infection prophylaxis before immunosuppressive/immunomodulatory therapy is initiated. However, in the opinion of many experts, patients may be started on the immunosuppressive/immunomodulatory therapy after 1 to 2 months, if their clinical condition requires, as long as they are strictly adhering to and tolerating their prophylactic regimen. LIMITATIONS There are few evidence-based studies on screening for latent TB infection in psoriasis patients treated with systemic and biologic agents. CONCLUSIONS The biologic TNF-alpha inhibitors are very promising in the treatment of psoriasis. However, because TNF-alpha is also an important cytokine in preventing TB infection and in keeping latent TB infection from becoming active disease, the use of TNF-alpha inhibitors has been associated with an increased risk of developing active TB. A higher incidence of TB has also been reported with other immunosuppressive/immunomodulatory treatments for psoriasis. It is, therefore, of utmost importance to appropriately screen all patients for latent TB infection prior to initiating any immunologic therapy. Delaying immunologic therapy until latent TB infection prophylaxis is completed is preferable. However, if the patient is adhering to his prophylactic regimen and is appropriately tolerating the regimen, therapy may be started after 1 to 2 months if the clinical condition requires.

Actinic cheilitis: a treatment review

All other factors being equal, the presence of actinic cheilitis, a pre‐invasive malignant lesion of the lips, doubles the risk of squamous cell carcinoma developing in this anatomic area. Various forms of local ablation,immunomodulation and surgical extirpation have been proposed as therapeutic interventions. This paper critically evaluates the available medical literature to highlight the evidence‐based strength of each recommended therapy for actinic cheilitis. Vermilionectomy remains the gold standard for efficacy; trichloroacetic acid application is easy and convenient, but the least efficacious overall.

Thermotherapy in dermatologic infections

The use of local induced hyperthermia or thermotherapy for dermatologic infections has not been fully explored in the more recent medical literature. Herein, we discuss the rationale behind the use of thermotherapy and review reported clinical experience with its use in the management of cutaneous infections.

A Paradigm for Facial Skin Rejuvenation

There is a significant desire by patients to reverse the signs of aging caused by photodamage. Numerous procedures for facial skin rejuvenation have been developed in an attempt to minimize the erythema, dyspigmentation, and rhytides associated with photoaging. The initial procedures developed for facial rejuvenation involve skin resurfacing via complete ablation of layers of skin. Of these procedures, ablative laser resurfacing is the most precise technique and is considered the gold standard for facial skin rejuvenation. Although ablative procedures are quite efficacious, they carry significant patient downtime and risks of adverse effects such as scarring and dyspigmentation. Concerns regarding patient morbidity have led to the development of nonablative procedures that target dermal collagen without damaging the epidermis. Of these technologies, intense pulsed light is the most commonly used because it effectively targets both the erythema and dyspigmentation seen in photoaging. Nonablative techniques minimize side effects and patient downtime; however, they do not match the results seen in fully ablative procedures. Fractional laser technologies-first nonablative and more recently ablative-represent the most recent attempt to match the results seen in fully ablative procedures with less patient downtime. Their results are promising but require further study.