Shilpa Gattu

Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks

BACKGROUND Psoralen plus ultraviolet A (PUVA) for the treatment of psoriasis has never been evaluated using the Psoriasis Area Severity Index (PASI) in a randomized, double-blind, placebo-controlled trial. The lack of such data limits our capacity to estimate PUVAs efficacy relative to other treatment options that are available today. OBJECTIVES The purpose of this study was to evaluate the efficacy of PUVA therapy for patients with plaque-type psoriasis. METHODS This study involved 40 patients with psoriasis; 30 received PUVA and 10 received UVA with placebo. PASI scores were assessed at baseline and every 4 weeks thereafter for 12 weeks. RESULTS By nonresponder imputation, 60% (18 of 30) in the PUVA group achieved 75% or more improvement in PASI score after 12 weeks of treatment compared with 0% (0 of 10) in the UVA plus placebo group (P < .0001). Using intent to treat with last observation carried forward analysis, 63% (19 of 30) in the PUVA group achieved 75% or more improvement in PASI score compared with 0% (0 of 10) in the UVA plus placebo group (P < .0001). By per protocol analysis, 86% (18 of 21) in the PUVA group as compared with 0% (0 of 7) in the UVA plus placebo group reached 75% or more improvement in PASI score after 12 weeks (P < .0001). LIMITATIONS The study was relatively small with only 40 patients enrolled and 28 patients who completed the protocol. Further studies that involve head-to-head comparison of PUVA with other treatment modalities are needed. Nonresponder imputation, last observation carried forward with intent to treat, and per protocol analyses each have separate advantages and limitations when determining clinical significance. CONCLUSIONS This study supports the observation that PUVA is a highly efficacious treatment for chronic plaque psoriasis.

Anthropometric and aesthetic analysis of the Indian American woman's face☆

BACKGROUND This is the first study defining the facial anthropometric and aesthetic measurements in Indian American women (IAW). METHODS This is a prospective cohort study involving evaluation of facial photographs. Frontal, lateral and basal photographs were taken of IAW (n=102), and 30 anthropometric measurements were determined. Proportions were compared with published North American white women (NAWW) norms. Judges (n=6) evaluated the photographs for aesthetics using a visual analogue scale. Attractive IAW (top 15%) were compared with average IAW (remaining 85%) and average NAWW. All completed a facial self-esteem survey. RESULTS There were significant differences between IAW and NAWW in 25 of 30 facial measurements. Six measurements correlated with aesthetic scores: intercanthal distance, mouth width, nasolabial angle, midface height 2, ear length and nasal height. Attractive IAW had nine measurements approximating NAWW features, 15 measurements similar to average IAW values and two measurements distinct from both average IAW and average NAWW. Attractive IAW had higher facial self-esteem scores than average IAW. CONCLUSIONS Facial measurements in IAW are much different from NAWW, and these results will assist in preoperative planning. Several features are correlated with attractiveness in IAW: larger and wider-set eyes, a smaller midface, a smaller nose with greater tip rotation, smaller ears and a larger mouth. Attractive IAW display many measurements typical of average IAW and several measurements that reflect average NAWW values. These results contribute to concepts of transcultural aesthetics--for a minority ethnic group, facial beauty appears to be an assimilation of deep-rooted ethnic features with prevailing cultural traits and aesthetic standards.

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.

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.

Parental artistic drawings of the fetus before and after 3-/4-dimensional ultrasonography.

The purpose of this study was to assess the impact of 3‐/4‐dimensional ultrasonography (3D/4DUS) on parental impressions of their fetus using preexamination and postexamination parental drawings.

Psoriasis responds to intralesional injections of alefacept and may predict systemic response to intramuscular alefacept: Interim results of a single-arm, open-label study

Abstract Background: Alefacept is a remittive treatment for generalized psoriasis but is rarely used due to its erratic efficacy. Objective: To determine if psoriasis plaques will respond to intralesional alefacept and if this predicts a systemic response to intramuscular (IM) alefacept. Methods: We describe a 25-week, single-center, open-label study. Patients received weekly intralesional alefacept of increasing concentrations into target plaques for 3 weeks followed by IM injections for 12 weeks and concluded with an observation period of 9 weeks. The psoriasis area and severity index (PASI) was used to assess the efficacy of IM alefacept. Results: Interim results are reported for the first seven patients enrolled. Two patients responded intralesionally to the most dilute 1:100 concentration of alefacept to sterile water and achieved a 59% and 100% improvement in PASI. Five patients did not respond intralesionally to the most dilute form of alefacept and none achieved PASI 75. Two of these five patients did not respond to any concentration and achieved a 26% and 38% improvement in PASI. Limitations to this study include a small sample size and being non-placebo-controlled. Conclusion: Alefacept is effective intralesionally and may predict a systemic response – challenging the concept that biologics must work systemically.

Intralesional injections of alefacept may predict systemic response to intramuscular alefacept: results from a pilot study.

Background: Alefacept (Amevive®) was the first biologic agent to be approved by the FDA for use in moderate to severe chronic plaque psoriasis and remains one of the safest systemic agents. However, alefacept is the least utilized of all the biologic agents due to the finding that it is only effective in a small proportion of patients and its maximal efficacy is not seen until approximately 6 weeks after treatment completion. Objective: To determine whether intralesional injections with a biologic agent can predict who will be a responder or a non-responder to the medication. Methods: This was a single-center 22-week study consisting of three phases: i) intralesional injection to a target plaque, ii) intramuscular alefacept injections for 12 weeks (standard dose) and iii) post-treatment follow-up. Results: There appears to be a perfect correlation between patients who show a response to an intralesional injection of alefacept to a small, target plaque and those who eventually respond to a full 12-week systemic course of the medication (achieve at least 70% improvement in their PASI scores from baseline) (p = 0.0003). Limitations: This study had a small sample size and was limited by the fact that it was open-label without a control arm. Conclusion: The results from this pilot study demonstrated that alefacept appears to work intralesionally and this may be usable to predict systemic response. More importantly, these results strongly suggest that a biologic agent can work locally – a novel concept that contradicts the common notion that biologic agents must work “systemically”.