Sowmya Varada

Treatment of coexistent psoriasis and lupus erythematosus

BACKGROUND The coexistence of psoriasis and lupus erythematosus (LE) is rare. Anecdotal evidence suggests that anti-tumor necrosis factor alfa (TNF-α) agents may be efficacious in LE, although their use is commonly avoided in this disease because of concern for lupus flare. OBJECTIVE We sought to describe the epidemiology, serologic findings, and therapeutic choices in patients with coexistent psoriasis/psoriatic arthritis and LE and to determine the risk of lupus flares with TNF-α inhibitors. METHODS We performed a retrospective multicenter study of patients given the diagnoses of psoriasis (or psoriatic arthritis) and lupus erythematosus (systemic LE or cutaneous LE, including either subacute cutaneous LE or discoid LE) at 2 academic tertiary-care centers. RESULTS A total of 96 patients with a mean age of 56 years was included. We report higher-than-expected rates of white race and psoriatic arthritis. One clinical lupus flare was observed in a patient receiving a TNF-α inhibitor, resulting in an incidence of 0.92% lupus flares per patient-year of TNF-α inhibitor use. LIMITATIONS Retrospective chart review, small sample size, and limited documentation. CONCLUSION Anti-TNF-α agents, ustekinumab, and abatacept may be valid treatment options for patients with concomitant LE and psoriasis. Clinical lupus flares in LE patients treated with TNF-α inhibitors were infrequent.

Apremilast for the treatment of psoriatic arthritis

Psoriatic arthritis occurs in about one-third of patients with psoriasis, and is a severely disabling, progressive inflammatory spondyloarthropathy typically treated with non-steroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, TNF-α inhibitors and ustekinumab. These medications moderately improve the arthritis, dactylitis, and enthesitis that characterize psoriatic arthritis, however, they are associated with serious long-term adverse effects, issues with safety and tolerability, and high cost. Moreover, many patients do not respond or have resistant or recurrent manifestations to these agents. Apremilast is an orally available phosphodiesterase type 4 inhibitor that may block the pathogenic inflammatory Th17 and Th1 pathways upstream of current biologics, which target extracellular molecules of the immunological response.

Three-Dimensional Printing of the Skin

Additional Information:Drs Hardy, Glass, Sorrells, and Nicholas report beingmembers of the US Navy. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by amilitary service member or employee of the United States Government as part of that person’s official duties. No other disclosures were reported.

Management of cutaneous human papillomavirus infection in immunocompromised patients.

Individuals with inherited immunodeficiencies, autoimmune disorders, organ or bone marrow transplantation and with human immunodeficiency virus are particularly susceptible to developing severe, persistent and extensive manifestations of cutaneous human papillomavirus (HPV) disease. These complex cases require a unique and often multimodal approach to management. In this chapter, we discuss several states of immune compromise with increased susceptibility to HPV disease and review the literature on available management strategies including acitretin, cidofovir, Candida antigen, cimetidine, imiquimod, isotretinoin, fluorouracil, selenium, podophyllotoxin, photodynamic therapy, mammalian target of rapamycin inhibitors and the quadrivalent HPV vaccine.

Remission of Refractory Benign Familial Chronic Pemphigus (Hailey-Hailey Disease) with the Addition of Systemic Cyclosporine

Background Benign chronic familial pemphigus (BFCP) is an autosomal dominant dermatosis characterized by flares of painful and often debilitating blistering lesions in high friction areas of the body such as the groin, axillae, lateral neck, and intergluteal cleft. Limited knowledge of its pathophysiology has made treatment of BFCP a considerable challenge and efficacy with current first line therapies, topical corticosteroids and antibiotics, is variable. Case Report We present a case of this disease in a 52 year old woman that has responded dramatically to the addition of oral cyclosporine to her existing regimen of oral acitretin, with significant improvement of skin lesions, mobility, and quality of life. Cyclosporines mechanism of action in BFCP is poorly understood, although it possibly acts through inhibition of proinflammatory cytokines in keratinocytes or modulation of intracellular calcium. BFCP, the use of cyclosporine for its treatment, and possible mechanisms of action of cyclosporine are reviewed.

Magic of the Skin

11. Fanfair RN, Heslop O, Etienne K, et al. Trichosporon asahii among intensive care unit patients at a medical center in Jamaica. Infect Control Hosp Epidemiol. 2013;34(6):638-641. 12. National Committee for Clinical Laboratory Standards/ Clinical and Laboratory Standards Institute. Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts: M27-A3. Vol 28. Wayne, PA: National Committee for Clinical Laboratory Standards/Clinical and Laboratory Standards Institute; 2008. 13. Araujo Ribeiro M, Alastruey-Izquierdo A, Gomez-Lopez A, Rodriguez-Tudela JL, Cuenca-Estrella M. Molecular identification and susceptibility testing of Trichosporon isolates from a Brazilian hospital. Rev IberoamMicol. 2008;25(4): 221-225.

IDEOM: International Dermatology Outcome Measures – Proceedings from the First Meeting

SUMMER 2014 Varada et al. | PSORIASIS FORU M, VOL. 20, NO. 2 Sowmya Varada, B.S., Tufts Medical Center; Noori Kim, M.D., Tufts Medical Center; April Abernethy, N.D., National Psoriasis Foundation; April Armstrong, M.D., M.P.H., University of California Davis; Kristina Callis-Duffin, M.D., University of Utah; Amit Garg, M.D., Boston University; Alice Gottlieb, M.D., Ph.D., Tufts Medical Center IDEOM: International Dermatology Outcome Measures – Proceedings from the First Meeting

Saving Their Skins: How Animals Protect From the Sun

Adistinctive evolutionary changeexperiencedbyour ancestors as they branched away from their fellow apes was the loss of body hair. While this may have had certain benefits, our species has also suffered drawbacks; forone,without thick furorhair toscattersunlight,ourskin ismore susceptible to burning in the sun. Indeed, sunburns have been observed in other relatively hairless members of the animal kingdom, including whales, dolphins, fish, elephants, and rhinoceroses. But just as humans have evolved physiologic and behavioral adaptations to protect from the sun, other creatures too have developed their own. Whaleshavehairless, streamlinedbodiesand frequently travel to the sea surface for air, making them particularly vulnerable to UV-induced skin damage. The spermwhale,which spends up to6 hours at a time at the surface, is known to activate genotoxic stress pathways in response to persistent UV exposure. While the fin whale possesses constitutivelyhigh levelsofmelanin, thebluewhalemodulates its skinmelanin throughout the year, becoming darker when UV levels are highest from February to May. This adaptive pigmentation has also been observed in hammerhead sharks and some fish. EquatorialAfrica,which receivesabundantdaily sunlightyear round, is home to theworld’s 3 largest pachyderms: the elephant, rhinoceros, andhippopotamus, forwhomlearnedbehaviorsareessential forsunprotection.TheAfricanelephantuses itsprehensile trunkto throwdustonto itsback, the rhinoceroswallows inandcoats itselfwithmud,and thehippopotamus submerges itself in water. The hippopotamus also possesses a curious adaptation found in no other animal—it manufactures its own sunscreen. The hippopotamus’s “blood sweat” is a thick, reddish fluid that is neither blood nor true sweat, as the animal’s skin contains no sebaceous glands. It is secreted by subdermal glands through large skinpores andcontains2pigments, hipposudoric acid andnorhipposudoric acid, whose polymerization gives the fluid a reddish orange color and whose absorption of UV light makes this substance a highly effective sunscreen. Someanimalsarewell coveredwith furbutmayneedtoprotectother body parts from the sun. A giraffe’s long tongue, frequently outstretchedtoforagethetreetopsfor leaves, iscoloredblackishpurple from thecircumvallatepapillae to the tip,believedtoprotect it fromsunburn. The meerkat’s eyes are surrounded by dark bands to reduce sun glare, and the nictitating membrane covering a polar bear’s eye filters bright sunlight reflected by the snow. Increasing UV exposure from a depleted ozone layer will certainly exert a selective pressure on animals to evolvemore sophisticated skin defenses. Studying thesecreaturesmayprovidegreater insight into skin physiology and how our own species will adapt to a changing solar environment.