Parkinson's disease (PD) is a progressive neurodegenerative disease presenting with motor and non-motor symptoms, including skin disorders (seborrheic dermatitis, bullous pemphigoid, and rosacea), skin pathological changes (decreased nerve endings and alpha-synuclein deposition), and metabolic changes of sebum. Recently, a transcriptome method using RNA in skin surface lipids (SSL-RNAs) which can be obtained non-invasively with an oil-blotting film was reported as a novel analytic method of sebum. Here we report transcriptome analyses using SSL-RNAs and the potential of these expression profiles with machine learning as diagnostic biomarkers for PD in double cohorts (PD [n = 15, 50], controls [n = 15, 50]). Differential expression analysis between the patients with PD and healthy controls identified more than 100 differentially expressed genes in the two cohorts. In each cohort, several genes related to oxidative phosphorylation were upregulated, and gene ontology analysis using differentially expressed genes revealed functional processes associated with PD. Furthermore, machine learning using the expression information obtained from the SSL-RNAs was able to efficiently discriminate patients with PD from healthy controls, with an area under the receiver operating characteristic curve of 0.806. This non-invasive gene expression profile of SSL-RNAs may contribute to early PD diagnosis based on the neurodegeneration background.
Sent from my iPhone
Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
Clinica Victoria en San Pedro: 4000-1054 Momentum Escazu: 2101-9574
Please excuse the shortness of this message, as it has been sent from a mobile device.
Live Attenuated Zoster Vaccine Safe for Patients Receiving TNF Inhibitors No cases of varicella infection found; cumulative incidence of varicella infection or shingles was 0 percent
MONDAY, Sept. 27, 2021 (HealthDay News) -- For patients receiving tumor necrosis factor (TNF) inhibitors, the live attenuated zoster vaccine (ZVL) is safe and has reasonable short-term effectiveness, according to a study published online Sept. 28 in the Annals of Internal Medicine.
Jeffrey R. Curtis, M.D., M.P.H., from the University of Alabama at Birmingham, and colleagues examined the safety and immunogenicity of ZVL among adults aged 50 years or older receiving TNF inhibitors for any indication. A total of 617 adults were randomly assigned in a 1:1 ratio to receive ZVL or placebo (310 and 307, respectively) at 33 centers.
The most common indications for TNF inhibitor use were rheumatoid arthritis and psoriatic arthritis (57.6 and 24.1 percent, respectively). The researchers observed no cases of confirmed varicella infection through week 6; the cumulative incidence of varicella infection or shingles was 0 percent. Compared with baseline, at six weeks, the mean increases in geometric mean fold rise as measured by glycoprotein enzyme-linked immunosorbent assay and enzyme-linked immunosorbent spot were 1.33 and 1.39 percentage points, respectively.
"Although country-specific labeling requirements may continue to discourage use of a live virus vaccine in immunosuppressed patients receiving biologic therapies, use of this ZVL in TNF inhibitor-treated patients may be a reasonable option, especially in the absence of an alternative zoster vaccine," the authors write.
Wearing Occlusive Gloves Increases the Density of Staphylococcus Aureus in Patients With Hand Eczema Acta Dermato-Venereologica
TAKE-HOME MESSAGE
Patients with hand eczema (HE) wore an occlusive glove on one hand for 4 hours, with a 30-minute break after 2 hours. Bacterial swabs were collected before and after glove exposure. Out of 30 patients, 19 were colonized with Staphylococcus aureus and these patients had more severe HE. After occlusion, the S. aureus colony-forming units increased on lesional skin by a factor of 1.72. In contrast, there was no increase in S. aureus colonization after occlusion for non-lesional skin.
The use of occlusive gloves increases S. aureus colonization in patients with HE and this may influence disease severity and course.
Hand eczema is frequently colonized with Staphylococcus aureus. Some patients with hand eczema wear occlusive gloves regularly; however, the effect of this on the density of S. aureus is unexplored. The aim of this study is to examine the effect of occlusive gloves on the density of S. aureus sampled from the hands of patients with hand eczema. In an experimental set-up, patients with moderate-to-severe hand eczema wore an occlusive glove on one hand for 4 h with a 30-min break. Bacterial swabs were collected from the most severe eczema lesion on the hand before and immediately after glove exposure. S. aureus colony-forming units were counted and log-transformations used for comparison of before- and after-values. Among 30 patients, 19 (63%) were colonized with S. aureus. After glove occlusion S. aureus colony-forming units increased by a factor of 1.72 (p < 0.01). In conclusion, the density of sampled S. aureus on eczematous skin after prolonged wearing of occlusive gloves is greatly increased.
Acta Dermato-Venereologica
Wearing Occlusive Gloves Increases the Density of Staphylococcus Aureus in Patients with Hand Eczema
Acta Derm Venereol 2021 Aug 16;[EPub Ahead of Print], LB Nørreslet, SM Edslev, EM Flachs, NE Ebbehøj, PS Andersen, T Agner
Los investigadores han identificado grupos de personas con mayor riesgo de morir o de sufrir una enfermedad grave por COVID-19 después de recibir una o dos dosis de la vacuna anti-COVID-19.[1]
El estudio, realizado por la University of Oxford, en Oxford, Reino Unido, examinó el riesgo de COVID-19 grave que conduce a la hospitalización o la muerte 14 días después de un esquema completo vacunal, cuando se espera una inmunidad sustancial.
Los investigadores utilizaron la herramienta QCovidpara analizar los resultados en adultos de 19 años o más entre el 8 de diciembre del año pasado y el 15 de junio de este año.
Utilizaron conjuntos de datos nacionales de la práctica general, la inmunización nacional y las pruebas de SARS-CoV-2, el registro de defunciones y los datos de episodios hospitalarios para analizar una muestra de más de 6,9 millones de adultos vacunados. De ellos, 74,1% había recibido dos dosis de la vacuna anti-COVID-19.
La muestra incluyó 2.031 muertes por COVID-19 y 1.929 ingresos hospitalarios relacionados con COVID-19, de los cuales 81 muertes (4%) y 71 ingresos (3,7%) ocurrieron 14 días o más después de la segunda dosis de vacuna.
La edad media de las personas de la cohorte fue de 52 años.
Nueva herramienta "ayudará a identificar factores de riesgo"
Los hazard ratios (HR) por causas específicas fueron más altos para los pacientes con:
Síndrome de Down (HR: 12,7).
Trasplante de riñón (HR: 8,1).
Anemia de células falciformes (HR: 7,7).
Quimioterapia (HR: 4,3).
Residencia en hogar de mayores (HR: 4,1).
VIH/SIDA (HR: 3,3).
Cirrosis hepática (HR: 3,0).
Afecciones neurológicas (HR: 2,6).
Trasplante reciente de médula ósea o trasplante de órgano sólido alguna vez (HR: 2,5).
Demencia (HR: 2,2).
Enfermedad de Parkinson (HR: 2,2).
El estudio, publicado en The BMJ,encontró que la incidencia de mortalidad por COVID-19 aumentaba con la edad, la privación, ser hombre y para aquellos con etnia india y pakistaní.
Los mejores datos de investigación clínica del mundo
Dra. Julia Hippisley-Cox
La Dra. Julia Hippisley-Cox, profesora de epidemiología clínica y práctica general en la University of Oxford, coautora del artículo, dijo: "Reino Unido fue el primer lugar en implementar un programa de vacunación y tiene algunos de los mejores datos de investigación clínica en el mundo. Hemos desarrollado esta nueva herramienta utilizando la base de datos QResearch, para ayudar al National Health System a identificar qué pacientes tienen mayor riesgo de resultados graves a pesar de la vacunación, para una intervención dirigida.
"Esta nueva herramienta también puede informar las discusiones entre médicos y pacientes sobre el nivel de riesgo, para ayudar a la toma de decisiones compartida".
El Dr. Aziz Sheikh, profesor de investigación y desarrollo de atención primaria en la University of Edinburgh, en Edimburgo, y coautor del artículo, dijo: "Nuestra nueva herramienta QCovid, desarrollada con la ayuda de expertos de todo el Reino Unido, ha sido diseñada para identificar aquellos en alto riesgo que pueden beneficiarse de intervenciones como dosis de refuerzo de la vacuna o nuevos tratamientos como los anticuerpos monoclonales, que pueden ayudar a reducir el riesgo de progresión de la infección por SARS-CoV-2 a desenlaces graves de la COVID-19".
La Dra. Hippisley-Cox agregó: "El riesgo individual siempre dependerá de las elecciones individuales, así como de la prevalencia actual de la enfermedad. Sin embargo, esperamos que esta nueva herramienta ayude a la toma de decisiones compartida y una evaluación de riesgos más personalizada".
Topical Sirolimus Therapy for Nevus Sebaceus and Epidermal Nevu Journal of the American Academy of Dermatology
TAKE-HOME MESSAGE
The authors treated 3 patients with nevus sebaceus (NS) and 2 patients with epidermal nevus (EN) with topical sirolimus 1% cream twice daily. A scalp NS in 1 patient was 90% flatter after 2 months and has remained stable for 5 years after tapering application to once weekly. The other patients noted thinning of their NS and EN after 1 to 4 months of treatment. A single patient discontinued treatment due to flakiness, itchiness, and redness.
Topical sirolimus 1% cream is a safe and effective option for patients with NS or EN who decline surgical management.
Nevus sebaceus (NS) and epidermal nevus (EN) are relatively common birthmarks. Treatment can be challenging because these lesions may occur in locations where excision would likely result in disfigurement. Some patients decline surgery but still desire treatment to diminish the visibility of their birthmark.
Journal of the American Academy of Dermatology
Topical sirolimus therapy for nevus sebaceus and epidermal nevus: A case series
J Am Acad Dermatol 2021 Aug 21;[EPub Ahead of Print], AG Zhou, RJ Antaya
Sent from my iPhone
Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
Clinica Victoria en San Pedro: 4000-1054 Momentum Escazu: 2101-9574
Please excuse the shortness of this message, as it has been sent from a mobile device.
Watchful Waiting and Tumor Behavior in Patients With Basal Cell Carcinoma
TAKE-HOME MESSAGE
The authors followed 89 patients with a total of 280 basal cell carcinomas (BCCs) managed with watchful waiting (WW) for at least 3 months. Only 47% of tumors increased in size during the observation period. The estimated diameter increase in 1 year was 4.46 mm for high-risk BCCs vs 1.06 mm for low-risk BCCs. Following WW, 54 patients underwent treatment for 107 BCCs due to reasons including potential tumor burden, reasons for WW resolved, and re-evaluation of patient factors.
WW could be an appropriate management option for certain patients, including those with limited life expectancy and asymptomatic low-risk BCC subtypes. Regular follow-up is necessary to detect changes that might impact the treatment plan. Additional prospective studies are warranted.
Dermatologists have an ethical duty to treat patients while avoiding harm. Yet over 100,000 patients had surgery for BCC in their final year of life.1 Might there be a point at which aggressive surveillance and surgical intervention of relatively indolent tumors are inappropriate in certain contexts? Similar to the watchful waiting approach with low-grade prostate cancers, Linos et al argue BCCs might be "overdiagnosed" and "overtreated" at the end of life.1 There are diminishing returns on survival. Treatment is not without risk, especially in those with multimorbidities.1
Discussing watchful waiting might create anxiety for patients, caregivers, and dermatologists. A useful framework and patient educational aids for shared decision–making have been published.2,3 When I sense a frail or advanced-age patient seems hesitant about biopsying or treating suspected low-risk BCC, I ask, "What are your healthcare goals at this time?" and periodically revisit at follow-ups.
The current study is an important contribution about a challenging topic. Strengths included the prospective design and the majority of patients having histological diagnosis. I was surprised by how many patients eventually opted for treatment during the short follow-up period (median, 9 months). This raises the question of how decisions change over time. Generalizability might be limited to other patient populations and countries. We must be cautious about unintentionally creating the perception that care is being withheld, particularly in historically marginalized populations who are still at risk for BCC.4 We should also guard against ageism (holding certain assumptions and biases about older adults). Consider the whole patient—not simply chronological age.
Further studies are needed about dermatologists' attitudes toward watchful waiting as well as streamlining discussions, particularly at busy practices lacking multidisciplinary teams. It remains to be seen if technology (eg, telemedicine and augmented intelligence) might help.
Linos E, Berger T, Chren MM. Point: Care of potential low-risk basal cell carcinomas (BCCs) at the end of life: The key role of the dermatologist. J Am Acad Dermatol. 2015;73(1):158-61. https://www.jaad.org/article/S0190-9622(15)00124-3/fulltext
Few studies have examined watchful waiting (WW) in patients with basal cell carcinoma (BCC), although this approach might be suitable in patients who might not live long enough to benefit from treatment.
OBJECTIVE
To evaluate reasons for WW and to document the natural course of BCC in patients who chose WW and reasons to initiate later treatment.
DESIGN, SETTING, AND PARTICIPANTS
An observational cohort study was performed at a single institution between January 2018 and November 2020 studying patients with 1 or more untreated BCC for 3 months or longer.
EXPOSURES
Watchful waiting was chosen by patients and proxies regardless of this study.
MAIN OUTCOME AND MEASURES
The reasons for WW and treatment were extracted from patient files and were categorized for analyses. Linear mixed models were used to estimate tumor growth and identify covariates associated with tumor growth.
RESULTS
Watchful waiting was chosen for 280 BCCs in 89 patients (47 men [53%] and 42 women [47%]), with a median (interquartile range [IQR]) follow-up of 9 (4-15) months. The median (IQR) age of the included patients was 83 (73-88) years. Patient-related factors or preferences (ie, prioritizations of comorbidities, severe frailty, or limited life expectancy) were reasons to initiate WW in 74 (83%) patients, followed by tumor-related factors (n = 49; 55%). Treatment-related and circumstantial reasons were important for 35% and 46% of the patients, respectively. The minority of tumors increased in size (47%). Tumor growth was associated with BCC subtype (odds ratio, 3.35; 95% CI, 1.47-7.96; P = .005), but not with initial tumor size and location. The estimated tumor diameter increase was 4.46 mm (80% prediction interval, 1.42 to 7.46 mm) in 1 year for BCCs containing at least an infiltrative/micronodular component and 1.06 mm (80% prediction interval, -1.79 to 4.28 mm) for the remaining BCCs (only nodular/superficial component/clinical diagnosis). Most common reasons to initiate treatment were tumor burden or potential tumor burden, resolved reason(s) for WW, and reevaluation of patient-related factors.
CONCLUSIONS AND RELEVANCE
In this cohort study of patients with BCC, WW was an appropriate approach in several patients, especially those with asymptomatic nodular or superficial BCCs and a limited life expectancy. Patients should be followed up regularly to determine whether a WW approach is still suitable and whether patients still prefer WW and to reconsider consequences of treatment and refraining from treatment.
JAMA Dermatology
Evaluation of Watchful Waiting and Tumor Behavior in Patients With Basal Cell Carcinoma: An Observational Cohort Study of 280 Basal Cell Carcinomas in 89 Patients
JAMA Dermatol 2021 Sep 08;[EPub Ahead of Print], MEC van Winden, CRM Hetterschijt, EM Bronkhorst, PCM van de Kerkhof, EMGJ de Jong, SFK Lubeek
Sent from my iPhone
Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
Clinica Victoria en San Pedro: 4000-1054 Momentum Escazu: 2101-9574
Please excuse the shortness of this message, as it has been sent from a mobile device.
Sublingual Minoxidil for the Treatment of Male and Female Pattern Hair Loss
TAKE-HOME MESSAGE
In this randomized, phase IB trial, 40 patients with androgenetic hair loss received 0.45 mg sublingual minoxidil (SM) or placebo daily for 24 weeks with 12 patients continuing into the 24-week open-label extension study with SM 1.35 mg or 4.05 mg daily. At 24 weeks, 45% of patients receiving 0.45 mg SM had improved frontal density and 55% had vertex improvement on macrophotography. There was a mean increase in terminal hair count/cm2 of 4 for the frontal area and 9 for the vertex scalp with 0.45 mg daily, of 10 and 26, respectively, with 1.35 mg daily, and of 38 and 88, respectively, with 4.05 mg daily. No significant change in blood pressure was detected in the placebo or treatment arms.
SM produced a dose–dependent increase in mean terminal hair count of the frontal and vertex scalp and an improvement in hair density without affecting blood pressure.
Minoxidil is an approved medication for severe hypertension androgenetic alopecia.1 Oral minoxidil (OM) is a potent vasodilator used to treat hypertension. It is a pro-drug, activated by hepatic dehydroepiandrosterone sulfotransferase (SULT2A1) to minoxidil sulfate.2OM doses of 2.5 and 5 mg produced peak plasma concentrations of 16.8 and 37.2 ng/mL within 30 min post-dose.3 Side-effects include hypertrichosis, lower limb oedema, postural hypotension and tachycardia. Minoxidil lotion (ML) is approved for the treatment of hair loss. It is also a prodrug converted in hair bulbs by thermostable phenol sulfotransferase (SULT1A1) to minoxidil sulphate. There is a considerable inter subject variability in levels of both hepatic SULT2A1 and follicular SULT1A1. Low SULT1A1 predicts weak hair regrowth with both ML and OM.4,5 Weak hair growth due to low follicular SULT1A1 can be overcome with OM through dose escalation but cannot be overcome with ML due to low solubility and saturation absorption kinetics.6
Journal of the European Academy of Dermatology and Venereology: JEADV
Sublingual minoxidil for the treatment of male and female pattern hair loss: a randomized, double-blind, placebo-controlled, phase 1B clinical trial
J Eur Acad Dermatol Venereol 2021 Aug 22;[EPub Ahead of Print], L Bokhari, LN Jones, RD Sinclair
Sent from my iPhone
Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
Clinica Victoria en San Pedro: 4000-1054 Momentum Escazu: 2101-9574
Please excuse the shortness of this message, as it has been sent from a mobile device.
Intralesional Candida Antigen and Intralesional Bivalent HPV Vaccine Are More Effective Than Cryotherapy in the Treatment of Common Warts Journal of the American Academy of Dermatology
TAKE-HOME MESSAGE
Patients with multiple common warts were randomized to treatment with intralesional Candida antigen, intralesional bivalent HPV vaccine, cryotherapy, or intralesional saline as a control treatment. The clearance rates were 63.3% in the Candida group and 50% in the HPV group, which was significantly higher than the groups treated with cryotherapy (20%) and the control group (0%). The rate of resolution of distant, non-injected warts was 71.4% in the Candida group versus 41.2% in the HPV group. Side effects included transient edema and flu–like symptoms with Candida antigen, transient erythema and edema with the HPV vaccine, and blistering and dyspigmentation with cryotherapy.
Immunotherapy with Candida antigen or the HPV vaccine is more effective than cryotherapy in the treatment of multiple common warts.
This is a really well-written article comparing intralesional Candida skin test antigen with intralesional bivalent HPV vaccine with cryotherapy, using intralesional saline injection as a control. Patients were treated every 2 weeks for up to five treatments.
My favorite part of the article is the figure at the end. The authors compared the three active treatment arms. Each arm included 30 patients. Of these patients, 63.3% of patients treated with Candida had complete clearance and no recurrence; 50% of patients treated with the HPV vaccine had complete clearance and no recurrence; 20% of patients treated with cryotherapy had complete clearance, but there was recurrence in 1 of the 6 patients with complete response. The authors concluded (and I agree) that immunotherapy is more effective than cryotherapy in the treatment of multiple common warts. There is also improvement of untreated distant warts with immunotherapy. There are none of the disfiguring side effects of blistering or dyspigmentation with immunotherapy that occur with cryotherapy. One can, however, develop local erythema and edema from intralesional immunotherapy as well as occasional flu-like symptoms.
This article is another of the many published that support immunotherapy for the treatment of HPV infections. The main benefits in my opinion include the systemic immunity, only one wart needs to be treated, and there are no disfiguring side effects. This article is interesting in that the investigators compared intralesional Candida with intralesional HPV vaccine.
Abstract
Traditional destructive modalities, such as cryotherapy, have been applied over the years to remove tissue infected with the human papilloma virus (HPV). Because they act locally without systemic effect, every wart has to be treated, which might make these modalities inappropriate for patients with multiple lesions.1On the other hand, intralesional immunotherapeutic agents, such as Candida antigen and HPV vaccines, are associated with systemic immune responses that help eradicate HPV in both injected and noninjected warts. Therefore, they can provide an effective alternative to destructive therapy for patients with multiple warts.2,3
Journal of the American Academy of Dermatology
Comparative efficacy of intralesional Candida antigen, intralesional bivalent HPV vaccine, and cryotherapy in the treatment of common warts
J Am Acad Dermatol 2021 Aug 28;[EPub Ahead of Print], A Nassar, R Alakad, R Essam, NM Bakr, A Nofal
Sent from my iPhone
Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
Clinica Victoria en San Pedro: 4000-1054 Momentum Escazu: 2101-9574
Please excuse the shortness of this message, as it has been sent from a mobile device.
Real-World Effectiveness of Adalimumab in Patients With Moderate to Severe Hidradenitis Suppurativa
TAKE-HOME MESSAGE
In this prospective, observational, study from 23 Canadian centers, 165 adults with moderate to severe hidradenitis suppurativa (HS) were treated with adalimumab. At week 24, 68.9% of patients achieved Hidradenitis Suppurativa Clinical Response (HiSCR) and this was maintained at week 52. The proportion of responders was higher in patients with an abscess and inflammatory nodule (AN) count >5 at baseline. Male responders were 4-times more likely than female responders to achieve HiSCR at week 24. Earlier onset of HS was associated with improved response.
The effectiveness of adalimumab in the treatment of HS is maintained at 52 weeks, and patients with the highest AN count derive the greatest benefit from treatment.
Hidradenitis suppurativa (HS) is a debilitating skin disease that is typically difficult to manage. Adalimumab is currently the only FDA-approved treatment for HS. As clinical trials have stringent criteria for participation, the results may not match the experience we see in the real world, across a more diverse patient population. This real-world, 1-year, prospective, observational study with 120 adult patients from 23 centers across Canada provides insight into the efficacy of adalimumab in HS.
The HiSCR is the standard measure of efficacy in HS, representing a 50% improvement in abscess and nodule count. At week 24, about 60% of patients achieved a HiSCR, which is higher than the 50.6% from PIONEER I and II, the adalimumab phase III trials. This may be explained by the fact that this study had about 15% to 20% more patients with moderate (Hurley stage 2) disease and fewer severe patients. Males had four times the odds of responding compared with females, which was not observed in prior adalimumab trials. The odds of responding decreased by 5% for each additional year in the age at disease onset. Patients with more inflammatory nodules and abscesses at baseline were more likely to respond. The response at 24 weeks was maintained at 52 weeks.
These findings indicate that, among patients with HS treated with adalimumab, the patients who see the largest benefit are those with a high inflammatory burden and high numbers of nodules and abscesses. They also support the concept of a "window of opportunity" in controlling HS. As adalimumab aims to suppress the inflammation driving HS, it has the most benefit in patients experiencing heavy inflammation before the inflammation leads to scarring and tunnel formation. Patients who respond to adalimumab at week 24 can be counseled to expect to maintain that response long-term. A limitation of this study is the high proportion of white participants (82.6%), which limits generalizability of the results to a more diverse population.
Abstract
BACKGROUND
Long-term, real-word data are needed to help manage patients with hidradenitis suppurativa (HS) through this recurrent, painful and debilitating disease.
OBJECTIVES
To primarily measure real-world effectiveness of adalimumab in HS and to secondarily observe clinical course of HS in the light of patients' response.
METHODS
In SOLACE, adults with moderate-to-severe HS in need for change in ongoing therapy were treated with adalimumab for up to 52 weeks as per physician's medical practice. Treatment effectiveness was measured by Hidradenitis Suppurativa Clinical Response (HiSCR). Inflammatory nodules, abscesses and draining fistulas were counted, Hurley stage was assessed, and disease severity was rated using the International HS Severity Scoring System (IHS4). A post hoc analysis further explored the HiSCR response by abscess and inflammatory nodule (AN) count at baseline (low, medium and high) and gender. Spontaneously reported safety events were collected.
RESULTS
From 23 Canadian centres, 69% of the 138 patients achieved HiSCR at week 24, which increased to 82% and 75% at week 52 in patients with medium and high AN counts, respectively. Gender (4 times the odds for female) and age at HS onset (5% decrease with each additional year) had an effect on achieving HiSCR. Treatment with adalimumab led to an important decrease in number of lesions in responders, with most gains observed in inflammatory nodules, more frequently in the lower body area of patients in the high AN count group. The IHS4 scores of responders were substantially lowered, with a larger decrease in patients of the high AN count group. No new safety signal was detected.
CONCLUSIONS
The effectiveness of adalimumab was maintained during this 1-year period, and an optimal gain was documented for patients with medium and high AN counts. These real-world data support a prompt treatment of HS patients and the use of IHS4 to monitor treatment.
Journal of the European Academy of Dermatology and Venereology: JEADV
Real-world effectiveness of adalimumab in patients with moderate-to-severe hidradenitis suppurativa: the 1-year SOLACE study
J Eur Acad Dermatol Venereol 2021 Aug 11;[EPub Ahead of Print], W Gulliver, A Alavi, MC Wiseman, MJ Gooderham, J Rao, MS Alam, KA Papp, O Desjardins, C Jean
Sent from my iPhone
Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
Clinica Victoria en San Pedro: 4000-1054 Momentum Escazu: 2101-9574
Please excuse the shortness of this message, as it has been sent from a mobile device.
Dupilumab is highly effective in treating atopic dermatitis (AD). However, some patients experience difficulties with dupilumab therapy, such as inadequate clinical response, failure to achieve long-term disease control, or adverse events (AEs). Our objective is to assess inadequate response and AEs occurring in children on dupilumab therapy for AD.
Methods
This is a retrospective cohort study of children on dupilumab for AD. Collected variables included patient demographics, medical histories, and dupilumab therapy characteristics. Response analysis was conducted in those with ≥3 months of dupilumab therapy: primary poor responders were defined as those whose EASI scores did not decrease by >50%, and secondary poor responders were those who initially responded but had significant AD flares while on therapy.
Results
We included 200 patients on dupilumab for AD in our cohort; 192 received ≥3 months of therapy and were included in our response analysis. Twelve children experienced inadequate primary response, and 4 were secondary poor responders. Four of these 16 children discontinued therapy due to inadequate response.
The most common dupilumab-associated AEs were facial erythema (n = 24, 12.0%) and injection-site reactions (n = 24, 12.0%). Female sex was significantly associated with experiencing injection-site reactions, and prior hospitalization was significantly associated with HSV infection on dupilumab. Eight patients discontinued therapy due to an AE.
Conclusion
A small but significant number of patients experienced treatment difficulties while on dupilumab. The risk of inadequate response to dupilumab and dupilumab-associated AEs should be discussed thoroughly with patients and their families prior to initiation.
Efficacy and Safety of 0.5 mg/kg/day Starting Dose of Oral Corticosteroids to Treat Bullous Pemphigoid The British Journal of Dermatology
TAKE-HOME MESSAGE
In this study of 190 patients with bullous pemphigoid, the initial dose of prednisone prescribed was 0.5 mg/kg/day. By day 21, disease control was attained in 75% of patients with mild disease, 68.8% of patients with moderate disease, and 46.4% of patients with severe disease. The 1-year survival rate was 90.9%, 83.0%, and 80.0% for mild, moderate, and severe disease, respectively.
While the majority of patients with mild and moderate disease responded to a medium dose of prednisone by day 21, less than half of those with severe disease had reached disease control in the same time period at this dose.
European guidelines propose a 0·5 mg kg-1 per day dose of oral prednisone as initial treatment for bullous pemphigoid (BP). We assessed the safety and efficacy of this regimen depending on BP extent and general condition of the patients.
METHODS
In a prospective international study, we consecutively included all patients diagnosed with BP. Patients received a 0·5 mg kg-1 per day dose of prednisone, which was then gradually tapered 15 days after disease control, with the aim of stopping prednisone or maintaining minimal treatment (0·1 mg kg-1 per day) within 6 months after the start of treatment. The two coprimary endpoints were control of disease activity at day 21 and 1-year overall survival. Disease severity was assessed according to the Bullous Pemphigoid Disease Area Index (BPDAI) score.
RESULTS
In total, 198 patients were included between 2015 and 2017. The final analysis comprised 190 patients with a mean age of 80·9 (SD 9·1) years. Control of disease activity was achieved at day 21 in 119 patients [62·6%, 95% confidence interval (CI) 55·3-69.5]; 18 of 24 patients (75%, 95% CI 53·3-90·2), 75 of 110 patients (68·8%, 95% CI 59·2-77·3) and 26 of 56 patients (46.4%, 95% CI 33·0-60·3) had mild, moderate and severe BP, respectively (P = 0·0218). A total of 30 patients died during the study. The overall Kaplan-Meier 1-year survival was 82·6% (95% CI 76·3-87·4) corresponding to 90·9%, 83·0% and 80·0% rates in patients with mild, moderate and severe BP, respectively (P = 0·5). Thresholds of 49 points for BPDAI score and 70 points for Karnofsky score yielded maximal Youden index values with respect to disease control at day 21 and 1-year survival, respectively.
CONCLUSIONS
A 0·5 mg kg-1 per day dose of prednisone is a valuable therapeutic option in patients with mild or moderate BP whose general condition allows them to be autonomous.
The British Journal of Dermatology
International multicentre observational study to assess the efficacy and safety of a 0·5 mg kg-1 per day starting dose of oral corticosteroids to treat bullous pemphigoid
Br J Dermatol 2021 Jun 25;[EPub Ahead of Print], V Hébert, S Bastos, K Drenovska, J Meijer, S Ingen-Housz-Oro, C Bedane, L Lunardon, S Debarbieux, H Jedlickova, F Caux, G Chaby, M D'Incan, C Feliciani, C Boulard, N Schumacher, E Schmidt, A Roussel, MA Richard, J Gottlieb, V Ferranti, O Guérin, J Bénichou, P Joly
Sent from my iPhone
Benjamin Hidalgo-Matlock Skin Care Physicians of Costa Rica
Clinica Victoria en San Pedro: 4000-1054 Momentum Escazu: 2101-9574
Please excuse the shortness of this message, as it has been sent from a mobile device.
Dermatologists have an ethical duty to treat patients while avoiding harm. Yet over 100,000 patients had surgery for BCC in their final year of life.1 Might there be a point at which aggressive surveillance and surgical intervention of relatively indolent tumors are inappropriate in certain contexts? Similar to the watchful waiting approach with low-grade prostate cancers, Linos et al argue BCCs might be "overdiagnosed" and "overtreated" at the end of life.1 There are diminishing returns on survival. Treatment is not without risk, especially in those with multimorbidities.1
Discussing watchful waiting might create anxiety for patients, caregivers, and dermatologists. A useful framework and patient educational aids for shared decision–making have been published.2,3 When I sense a frail or advanced-age patient seems hesitant about biopsying or treating suspected low-risk BCC, I ask, "What are your healthcare goals at this time?" and periodically revisit at follow-ups.
The current study is an important contribution about a challenging topic. Strengths included the prospective design and the majority of patients having histological diagnosis. I was surprised by how many patients eventually opted for treatment during the short follow-up period (median, 9 months). This raises the question of how decisions change over time. Generalizability might be limited to other patient populations and countries. We must be cautious about unintentionally creating the perception that care is being withheld, particularly in historically marginalized populations who are still at risk for BCC.4 We should also guard against ageism (holding certain assumptions and biases about older adults). Consider the whole patient—not simply chronological age.
Further studies are needed about dermatologists' attitudes toward watchful waiting as well as streamlining discussions, particularly at busy practices lacking multidisciplinary teams. It remains to be seen if technology (eg, telemedicine and augmented intelligence) might help.
References