Interesante: Infliximab en HS, Lido buferizada, meds en psor y lavado de manos...

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September 1, 2020

In this monthly column, members of Dermatology World's Editorial Advisory Workgroup identify exciting news from across the specialty.  

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HARRY DAO JR., MD

Hidradenitis suppurativa (HS) ranks high on my list of tough conditions to manage. In 2015, adalimumab's new status as the sole FDA-approved biologic for HS gave me high hopes. These hopes were dashed as I accumulated patients who flared despite use of the drug, and I would often turn to infliximab out of desperation. Optimal infliximab dosing remained elusive, yet the always-pervasive fear of prescribing high doses for extended amounts of time was paralyzing. As such, I was glad to see a prospective analysis based out of Albert Einstein (doi:10.1016/j.jaad.2019.09.071).

In this study, two sets of patients were enrolled from March 2018 to February 2019. Most patients per treatment algorithm were treated concurrently with topical antibiotics, oral antibiotics, and anti-androgen therapy. The first cohort consisted of infliximab naïve patients (n=42), who received an induction dose of 7.5mg/kg at weeks 0, 2, and 6, followed by a maintenance dose of 7.5 mg/kg every four weeks. The second cohort consisted of patients who failed infliximab 7.5 mg/kg dosing prior to study inclusion (n=14), as well as those escalated from the infliximab 7.5 mg/kg cohort due to insufficient disease control (n=2). This group escalated to infliximab 10mg/kg every four weeks.

In the infliximab 7.5 mg/kg group, clinical response was seen in 20/42 (47.6%) at week four and 17/24 (70.8%) at week 12. Two-thirds of patients had complete resolution of pain within four weeks of treatment initiation. Dose escalation to infliximab 10 mg/kg allowed even more patients to improve: 6/16 (37.5%) and 6/12 (50%) patients achieved clinical response at four and 12 weeks, respectively.

Infliximab via this high-dose, high-frequency regimen, initiated at 7.5 mg/kg every four weeks with optional dose escalation to 10 mg/kg every four weeks, in the setting of inadequate disease control, can be a very helpful tool to reduce HS disease activity and pain.

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SETH MATARASSO, MD

1% lidocaine is often the anesthetic of choice to reduce pain for many procedures, but the concentration can range between 0.5% to 2.5%. Lidocaine can be used alone. However, the addition of epinephrine at 1:100,000 can be pre-mixed for its vasoconstrictive properties. Lidocaine has an acidic pH of 2.5-4.0 and the detection of acid-sensing ion channel receptors is responsible for the burning sensation during infiltration. Pain can be reduced when lidocaine (with or without epinephrine) is buffered to a neutral more physiologic solution by the addition of 8.4% sodium bicarbonate (sodium hydrogen carbonate). The consequent decreased lidocaine concentration and alteration in pH does not interfere or shorten the local anesthetic effect (numbness).

A recent double-blinded study reported that the optimal quantification of the amount of buffered solution that was required was a 3:1 ratio; 3 ml of lidocaine with epinephrine added to 1 ml of sodium bicarbonate. It was less painful during infiltration than both a 9:1 ratio as well as a placebo (0.9% sodium chloride pH 6.3). The stability and shelf life of neutralized lidocaine is limited, making storage of the compounded product a limiting factor. There are no published guidelines that document duration of compounded anesthesia and in the present trial, the authors interval between mixing the anesthetic with the sodium bicarbonate and administering the solution to one minute so that degradation would not be a factor. The authors warn that there are no rules to simplify compounding to ensure product quality and that the results of their trial cannot be extrapolated to other local anesthetics (J Am Acad Derm. 2020; 83:159-65).

There is an adage that says that "it costs seven times more to attract a new patient than to retain one." As a corollary, it can also be stated that "if you pain them, you do not retain them."

Editor's note: Effective Dec. 2016, the FDA prohibits office-use compounding, which is when traditional compounding pharmacies provide compounded medications as office stock without a patient-specific prescription. Find out whether the type of compounding you are prescribing or performing is compliant with FDA regulations.

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SYLVIA HSU, MD

Psoriasis treatments trend toward the use of biologics. Data from the 2001-2015 National Ambulatory Medical Care Survey — a representative sample of U.S. office-based physician visits — showed that biologic use for psoriasis increased from the 2001-2005 period to the 2011-2015 period, especially among dermatologists (from 4.1% to 12.0%), commercially insured patients (from 4.8% to 17.3%), patients in metropolitan areas (from 4.1% to 12.0% ), and patients with psoriatic arthritis (from 19.1% to 27.6%) (J Am Acad Derm. 2020; 83(1): 256-257). Acitretin prescriptions decreased over time (from 4.5% to 1.7%), and oral immunosuppressants and phototherapy use stayed about the same. Biologics were used at much higher rates (more than double) than oral medications and phototherapy combined. However, increasing biologic use was not offset by decreases of other treatment options.

A disturbing finding from this study was that systemic steroid use in psoriasis patients increased in metropolitan areas from 2001-2005 to 2011-2015 (from 1.7% to 5.6%). Systemic steroids are not recommended in U.S. or European psoriasis treatment guidelines, because of adverse events, such as rebound flares, erythroderma, and generalized pustular psoriasis. The increased use of systemic steroids over time in the management of psoriasis is quite concerning and is a practice trend that needs to be addressed and reversed.

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CRISTEN MOWAD, MD

A recent article in Dermatitis highlights hand hygiene challenges, particularly in the hospital setting, given the ever-present possible exposure to COVID-19 patients and the risk of in-hospital transmission (doi: 10.1097/DER.0000000000000639). Washing with soap and water and using alcohol-based rubs can help to fight against transmission. The authors also comment on the risk factors associated with hand dermatitis due to the heightened need and increased frequency of hand hygiene: atopic dermatitis, male gender, long work hours, and younger age as factors that are increasingly associated with hand dermatitis.

Reviewing certain hand hygiene practices, the authors comment that alcohol-based hand rubs increase compliance as they can be more widely distributed where a sink and soap are not present and may be better tolerated. Alcohol-based hand rubs are well tolerated but can result in irritant contact dermatitis, especially in those with pre-existing skin disease. Emollients can be used to mitigate these effects. Chlorhexidine, according to the authors, appears to have lower efficacy against SARS-CoV-2 compared to 70% ethanol, hydrogen peroxide 0.5%, or sodium hypochorite 0.1%. In addition to irritant contact dermatitis, allergic contact dermatitis is also seen with chlorhedixine.

Regular use of soap and water is effective and with increased frequency often results in skin irritation presenting as rough, dry, sometimes fissured skin that has erythema and pruritus as features. Self-reports of hand dermatitis increase with increased frequency of hand washing with soap and water. Educating patients on early treatment and increased use of hand creams can be helpful.

The authors comment that health care worker compliance with hand hygiene may be impacted by hand dermatitis. Use of alcohol-based hand rubs may prove less irritating than use of soap and water and result in better compliance. Hand hygiene is critical to preventing the further spread of SARS-CoV-2. Educating health care workers, and our patients, regarding prevention of hand dermatitis, completely rinsing soap and water, drying the hands, and recognizing hand dermatitis early in order to intervene with increased use of emollients is important to help reduce hand dermatitis.