Pie diabetico...

In diabetic foot ulcers, use 50% rule to gauge need for advanced therapies

By: BRUCE JANCIN, Dermatology News Digital Network

VANCOUVER – When diabetic foot ulcer healing has stalled despite 4 weeks of optimal standard therapy, it's time to seriously consider resorting to advanced therapies, according to Dr. Afsaneh Alavi of the University of Toronto.

Advanced therapy options include negative pressure wound therapy, hyperbaric oxygen, artificial skin substitutes, growth factors, collagen-based dressings, and electromagnetic therapy.

"You hear a lot about advanced therapy for diabetic foot ulcers. It's expensive. But it can be cost-effective if used properly. It's our duty to see who is the best person to receive this therapy," she said at the World Congress of Dermatology.

A useful rule of thumb, the dermatologist added, is that if a healable ulcer isn't 50% smaller at week 4 despite optimal care, it's time to consider moving on to advanced therapies. As was shown in a well-conducted, 203-patient, randomized, prospective controlled clinical trial, a wound that hasn't met that threshold is unlikely to be healed at 12 weeks (Diabetes Care. 2003 Jun;26(6):1879-82). 

Two caveats: advanced therapy is appropriate only for healable diabetic foot ulcers, meaning those in patients with adequate peripheral circulation as defined by measurements of transcutaneous oxygen pressure, toe pressure brachial index, and Doppler studies.

"Eighty percent of diabetic patients have noncompressible arteries and therefore the ankle brachial index is not an accurate test to evaluate their circulation," according to Dr. Avali.

The other caveat regarding advanced therapy is that appropriate candidates should have a wound edge that's sharp, not migrating, she continued. 

The 4-week cutoff for seeing substantial progress in wound healing with standard therapy before turning to advanced therapies is based in part upon an influential study of 2,517 patients with diabetic neuropathic foot ulcers who received one of three advanced biological therapies. On average, patients started advanced biological therapy within 28 days following their first visit to a specialized wound clinic. Prolonged time to initiation of advanced treatment was associated with significantly longer time to healing (Arch Dermatol. 2010 Aug;146(8):857-62).

While thinking about local wound care in a patient with a diabetic foot ulcer, Dr. Avali said it's also important to take a step back and make sure hypertension and other conventional cardiovascular risk factors are well controlled and also to take a close look at the HbA1c. In a study of 183 patients with diabetic wounds treated at a specialized academic wound center, for every 1.0% increase in HbA1c above the mean level of 8.0%, the wound-area healing rate was reduced by 0.028 cm² per day. The implication is that HbA1c may be a key biomarker that's useful in predicting wound-healing rate in patients with diabetic ulcers (J. Invest Dermatol. 2011 Oct;131(10):2121-7). 

She reported serving as a consultant to Acelity and Smith & Nephew.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Cuando llegue al País, tener cuidado con aplicacion del medicamento innovador para queratosis actinicas.

Actinic Keratosis Gel Poses Risks for Serious Allergic Reactions and Herpes Zoster

By Kristin J. Kelley

Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH

Ingenol mebutate (Picato), used to treat actinic keratosis, will undergo a label change to highlight risks for severe allergic reactions and herpes zoster when the gel is not applied correctly, the FDA announced late last week.

The update, which follows reports of eye injuries and serious skin reactions (e.g., anaphylaxis, rashes, shingles), will include more detailed instructions on how to correctly use the gel. The label will include the following:

• Ingenol mebutate shouldn't be used near the eyes, lips, or mouth.
• The gel should be used to treat one area of skin at a time, and the treated area should be less than 25 square centimeters.
• A new tube should be used for each treatment day.
• Hands should be washed thoroughly with soap and water right after use to avoid accidental transfer of the medication.

FDA MedWatch safety alert (Free)

Background: NEJM Journal Watch Dermatology coverage of ingenol mebutate (Free)

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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10 tratamientos para Vitiligo.

Top 10 treatments for vitiligo

En edermatologynews publican esta lista de 10 más nuevos tratamientos para vitiligo.

No. 10: Ultraviolet A1 (UVA1) phototherapy

Dr. Harvey Lui at the University of British Columbia in Vancouver is leading a phase II trial to evaluate the potential for UVA1 to induce repigmentation within vitiligo patches and to assess the side effect profile of the treatment. "I think it might work," said Dr. Leachman, professor and chair of dermatology at Oregon Health & Science University (OHSU), Portland.

No. 9: Ginkgo biloba

The use of ginko biloba 40-60 mg 2-3 times per day, 10 minutes before a meal, was mentioned in a Cochrane Review of vitiligo treatments published on Feb. 24, 2015. "I think I'm going to give this a try in people who have failed other treatments and see if I can get some response," Dr. Leachman said. 

No. 8: Red light

Dr. Lui is leading a randomized phase II trial of low-intensity and high-intensity red light versus no treatment for vitiligo patches. Treatments will be given twice weekly for 10 weeks, with follow-up assessments at 4, 8, and 12 weeks post treatment.

No. 7: Micrografting

A novel suction blister device known as the CelluTomeepidermal harvesting system uses heat and slight vacuum pressure to harvest healthy epidermal skin tissue without damaging the donor site. Dr. Leachman characterized the technology as "semiautomating the process of suction graft transplantation."

No. 6: The ReCell device

Manufactured by Avita Medical, this investigational autologous cell harvesting device is used after CO2 abrasion and enables clinicians to create regenerative epithelial suspension with a small sample of the patient's skin. A phase IV trial in the Netherlands is underway to assess the efficacy and safety of autologous epidermal cell suspension grafting with the ReCell device after CO₂ laser abrasion, compared with CO₂ laser abrasion alone and no treatment, in patients with piebaldism and stable vitiligo.

No. 5: Topical Photocil

In a pilot study sponsored by Applied Biology, researchers are enrolling patients with vitiligo to assess the safety and efficacy of Photocil. The primary outcome measure is the Vitiligo Area Severity Index (VASI). "When this cream is activated by sunlight, it degrades into narrow-band and UVB light, so you can put a topical cream on that will administer narrow-band UVB only in that spot," said Dr. Leachman, who is also director of OHSU's Knight Melanoma Research Program. "That's amazing to me."

No. 4: Afamelanotide

This is an analogue of a melanocyte-stimulating hormone. A randomized study conducted at two academic medical centers found that the combination of afamelanotide implant and narrow-band UVB phototherapy resulted in statistically superior and faster repigmentation, compared with narrow-band UVB monotherapy (JAMA Dermatol. 2015 Jan;151(1):42-50).

No. 3: Abatacept (Orencia) 

This is a soluble fusion protein consisting of human cytotoxic T-lymphocyte–associated antigen 4 (CTLA4), which prevents T-cell activation. A phase I trial is underway at Brigham and Women's Hospital in Boston to determine if weekly self-injections of the agent lead to clinical improvements of vitiligo lesions. The primary outcome measure is change in repigmentation with abatacept therapy based on the VASI score.

No. 2. Simvastatin

The notion of its use is based on STAT1 inhibition reducing interferon-gamma–dependent activation of CD8-positive T cells, according to Dr. Leachman. The concept has been successful in a mouse model, and a study in humans was recently completed by Dr. John Harris at the University of Massachusetts, Worcester. "What we have is the ability to apply an existing drug (Simvastatin) to the process and see if it works," she said. "Wouldn't it be cool if we could give a statin and improve vitiligo?"

No 1: Tofacitinib

This is a Janus kinase inhibitor commonly used for rheumatoid arthritis. According to Dr. Leachman, Janus kinase inhibition prevents STAT activation, "which prevents [interferon]-gamma production, which reduces activation of CD8-positive T cells via CXCL10 binding to CXCR3," she said. A case reportdemonstrating its efficacy in a 53-year-old patient was recently published in JAMA Dermatology by Dr. Brett A. King and Dr. Brittany Craiglow, dermatologists at Yale School of Medicine, New Haven, Conn. "I'm hopeful that this [agent] will be made into a topical cream because these drugs do have substantial side effects," Dr. Leachman said.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

Please excuse the shortness of this message, as it has been sent from a mobile device.

No se aplican los criterios para Cirugía de Mohs como se debe...

Un estudio encontró que en un grupo grande de pacientes no se escogió mohs, cuando sí estaba indicado.

Mohs micrographic surgery (MMS) might be underused for certain nonmelanoma skin cancers (NMSC), according to a retrospective chart review of 1026 cases.

Investigators applied MMS appropriate use criteria (AUC) for an analysis of 557 basal cell and 469 squamous cell carcinomas.

Of 350 cases treated with MMS: 

• 339 were deemed appropriate; 

• 4 were categorized as uncertain; and 

• 7 were inappropriate.

Meanwhile, of the 611 cases not treated with MMS, nearly 61% would have met AUC for MMS. 

Researchers urged closer attention be paid to the AUC for MMS guidelines released in 2012 by several dermatology organizations, among them the American College of Mohs Surgery. 

An accompanying commentary pointed out that the 2012 criteria need not be the final arbiter. The final decision actually belongs to the patient and provider, in which case the 61% not treated with MMS might indicate "judicious and appropriate use" of MMS," said the commentator.

Citation: 

 

Chong T, Tristani-Firouze P, Bowen G, et al. Mohs Appropriate Use Criteria: Retrospectively Applied to Nonmelanoma Skin Cancers at a Single Academic Center. Dermatol Surg. 

2015;41(8):889-895.

Baum C. Commentary on Mohs Appropriate Use Criteria: Retrospectively Applied to Nonmelanoma Skin Cancers at a Single Academic Center. Dermatol Surg. 2015;41(8):896-

897.

Hay que preguntar por Artritis psoriática...

Se están escapando 1 de cada 10 pacientes...

Prevalence of Undiagnosed Psoriatic Arthritis Shown 

Screen all patients with psoriasis for PsA 

AUGUST 5, 2015

The importance of dermatologists screening their patients with psoriasis for psoriatic arthritis (PsA) was underscored in a recent systematic review and meta-analysis.

Researchers searched PubMed, Cochrane, and Embase for studies to review. Studies they selected did not aim to uncover prevalence of undiagnosed PsA, so investigators instead used the time medical care was sought to estimate prevalence. Seven epidemiological studies and five trials that used PsA screening questionnaires were used because they allowed the research team to identify patients with newly diagnosed PsA. 

The analysis showed:

• 15.5% prevalence of undiagnosed PsA

• 10.1% prevalence when analyzing data from just the epidemiological studies

These prevalence rates highlight the fact that dermatologists must be vigilant about screening all of their patients with psoriasis for underlying PsA.

Citation: Villani A, Rouzaud M, Servain M, et al. Prevalence of undiagnosed psoriatic arthritis among psoriasis patients: Systematic review and meta-analysis. J Am Acad Dermatol. 2015; Aug;73(2):242-8.

Tratamientos coadyuvasen en penfigo vulgar.

Reducen en un 29% el riesgo de recaída, pero no ayudan en la inducción de remisión.

Adjuvants Help Reduce Risk of Pemphigus Relapse 

Analysis of 10 trials proves what's been suspected

AUGUST 12, 2015

Adjuvant therapies for pemphigus vulgaris and pemphigus foliaceus have been thought to improve oral glucocorticoid treatment in patients with pemphigus, but it has never been proven. A recent systematic review and meta-analysis of 10 trials involving 559 participants demonstrated that this approach can help reduce the risk of relapse.

Researchers analyzed studies that used the following adjuvants: azathioprine, mycophenolate mofetil, cyclophosphamide, cyclosporine, intravenous immunoglobulin, plasma exchange, and infliximab. Not all medications were included in every analysis, meaning that different adjuvants were pooled together. The primary outcome evaluated was remission; risk of relapse was among several secondary outcomes analyzed. 

The adjuvants did not help lead to remission, but they did decrease the risk of relapse by 29%. 

Citation: Atzmony L, Hodak E, Leshem Y, et al.The role of adjuvant therapy in pemphigus: A systematic review and meta-analysis.  J Am Acad Dermatol. 2015; 73(2):264-271.