Treatment With Selumetinib for Café-au-Lait Macules and Plexiform Neurofibroma in Pediatric Patients With Neurofibromatosis Type 1

This case report describes 4 patients with a rare autosomal dominant multisystem disorder resulting from NF1 variants that leads to café-au-lait macules and neurofibromas.

A comprehensive review of nondermatophyte mould onychomycosis: Epidemiology, diagnosis and management

Nondermatophyte moulds (NDMs) are widely distributed and can be detected in association with mycotic nails; however, sometimes it can be challenging to establish the role of NDMs in the pathogenesis of onychomycosis (i.e. causative vs. contaminant). In studies where the ongoing invasive presence of NDMs is confirmed through repeat cultures, the global prevalence of NDMs in onychomycosis patients is estimated at 6.9% with the 3 most common genus being: Aspergillus, Scopulariopsis and Fusarium. NDM onychomycosis can, in many cases, appear clinically indistinguishable from dermatophyte onychomycosis. Clinical features suggestive of NDMs include proximal subungual onychomycosis with paronychia associated with Aspergillus spp., Fusarium spp. and Scopulariopsis brevicaulis, as well as superficial white onychomycosis in a deep and diffused pattern associated with Aspergillus and Fusarium. Longitudinal streaks seen in patients with distal and lateral onychomycosis may serve as an additional indicator. For diagnosis, light microscopic examination should demonstrate fungal filaments consistent with an NDM with at least two independent isolations in the absence of a dermatophyte; the advent of molecular testing combined with histological assessment may serve as an alternative with improved sensitivity and turnover time. In most instances, antifungal susceptibility testing has limited value. Information on effective treatments for NDM onychomycosis is relatively scarce, unlike the situation in the study of dermatophyte onychomycosis. Terbinafine and itraconazole therapy (continuous and pulsed) appear effective to varying extents for treating onychomycosis caused by Aspergillus, Fusarium or Scopulariopsis. There is scant literature on oral treatments for Neoscytalidium.

Derivation and Internal Validation of a Disease-Specific Cardiovascular Risk Prediction Model for Patients With Psoriatic Arthritis and Psoriasis

OBJECTIVE

To address suboptimal cardiovascular risk prediction in patients with psoriatic disease (PsD), we developed and internally validated a five-year disease-specific cardiovascular risk prediction model.

METHODS

We analyzed data from a prospective cohort of participants with PsD without a history of cardiovascular events. Traditional cardiovascular risk factors and PsD-related measures of disease activity were considered as potential predictors. The study outcome included nonfatal and fatal cardiovascular events. A base prediction model included 10 traditional cardiovascular risk factors. Eight PsD-related factors were assessed by adding them to the base model to create expanded models, which were controlled for PsD therapies. Variable selection was performed using Least Absolute Shrinkage and Selection Operator (LASSO) penalized regression with 10-fold cross-validation. Model performance was assessed using measures of discrimination and calibration and measures of sensitivity and specificity.

RESULTS

Between 1992 and 2020, 85 of 1,336 participants developed cardiovascular events. Discrimination of the base model (with traditional cardiovascular risk factors alone) was excellent, with an area under the receiver operator characteristic curve (AUC) of 85.5 (95% confidence interval [CI] 81.9-89.1). Optimal models did not select any of the tested disease-specific factors. In a sensitivity analysis, which excluded lipid lowering and antihypertensive treatments, the number of damaged joints was selected in the expanded model. However, this model did not improve risk discrimination compared to the base model (AUC 85.5, 95% CI 82.0-89.1).

CONCLUSION

Traditional cardiovascular risk factors alone are effective in predicting cardiovascular risk in patients with PsD. A risk score based on these factors performed well, indicating excellent discrimination and calibration.

Detection of Squalene Epoxidase Mutations in United States Patients with Onychomycosis: Implications for Management

Resistance to oral terbinafine, the most commonly used antifungal to treat dermatophytosis and onychomycosis worldwide, is being increasingly reported. In this study, we aimed to investigate the species distribution and prevalence of squalene epoxidase mutations among toenail dermatophyte isolates. Samples from 15,683 patients suspected of onychomycosis visiting the offices of dermatologists and podiatrists in the United States were analyzed. Clinical information was reviewed, and dermatophyte species with or without squalene epoxidase mutations were detected using multiplex real-time PCRs. The frequency of dermatophytes was 37.6%; of isolates belonging to the Trichophyton genus, 88.3% were the T. rubrum complex, and 11.2% were the T. mentagrophytes complex. Individuals aged >70 years exhibited higher infection rates for the T. mentagrophytes complex. The overall mutation rate among Trichophyton spp. was 3.7%, with a higher mutation rate detected in the T. mentagrophytes complex (4.3 vs. 3.6%). Commonly detected mutations were T1189C/Phe397Leu (34.5%), T1306C/Phe415Ser (16.0%), and C1191A/Phe397Leu (11.0%). Squalene epoxidase gene mutations associated with decreased terbinafine susceptibility have been identified in United States patients with toenail onychomycosis. Physicians should be aware of the risk factors for resistance development and engage in antifungal stewardship practices such as directed diagnosis and treatment of dermatophytosis and onychomycosis.

The relative efficacy of monotherapy with Janus kinase inhibitors, dupilumab and apremilast in adults with alopecia areata: Network meta-analyses of clinical trials

BACKGROUND

Janus kinase (JAK) inhibitors, biologics, and phosphodiesterase-4 (PDE-4) inhibitors are recent therapies for alopecia areata (AA)-albeit, knowledge gaps exist for these agents' relative efficacy.

OBJECTIVES

We determined the relative efficacy and safety of monotherapy with the aforementioned agents in adults with AA.

METHODS

The literature was systematically searched; we used data from randomized trials that investigated the agents' efficacy-as per Severity of Alopecia Tool (SALT) scores. Bayesian network meta-analyses were used to determine relative efficacy and safety. Effect modification was determined using a generalized linear model on aggregate data; evidence quality was evaluated.

RESULTS

Based on the surface under the cumulative ranking curve estimates obtained from multiple efficacy endpoints, regimens with the highest likelihood of achieving percent reduction in SALT scores, as well as a minimum 90%, 75% or 50% reduction in SALT scores are (in alphabetical order) baricitinib 4 mg once daily (QD), brepocitinib 60/30 mg QD, deuruxolitinib (CTP-543) 12 mg twice daily (BID), ritlecitinib 200/50 mg QD, ruxolitinib 20 mg BID and tofacitinib 5 mg BID. In contrast, dupilumab subcutaneous injections administered weekly and apremilast 30 mg BID were less likely to be effective. Discontinuation due to any adverse event was the least likely with oral JAK inhibitors, and more likely with dupilumab and apremilast.

CONCLUSIONS

Our results support the conduct of high-quality comparative trials to determine whether JAK inhibitors are more effective and safer than PDE4 inhibitors.

Combatting antifungal resistance: Paradigm shift in the diagnosis and management of onychomycosis and dermatomycosis

Antifungal resistance has become prevalent worldwide. Understanding the factors involved in spread of resistance allows the formulation of strategies to slow resistance development and likewise identify solutions for the treatment of highly recalcitrant fungal infections. To investigate the recent explosion of resistant strains, a literature review was performed focusing on four main areas: mechanisms of resistance to antifungal agents, diagnosis of superficial fungal infections, management, and stewardship. The use of traditional diagnostic tools such as culture, KOH analysis and minimum inhibitory concentration values on treatment were investigated and compared to the newer techniques such as molecular methods including whole genome sequencing, and polymerase chain reaction. The management of terbinafine-resistant strains is discussed. We have emphasized the need for antifungal stewardship including increasing surveillance for resistant infection.

Third and Fourth Vaccine Doses Broaden and Prolong Immunity to SARS-CoV-2 in Adult Patients with Immune-Mediated Inflammatory Diseases

Previous studies have reported impaired humoral responses after SARS-CoV-2 mRNA vaccination in patients with immune-mediated inflammatory diseases (IMIDs), particularly those treated with anti-TNF biologics. We previously reported that IMID patients diagnosed with inflammatory bowel disease, psoriasis, psoriatic arthritis, ankylosing spondylitis, or rheumatoid arthritis exhibited greater waning of Ab and T cell responses than healthy control subjects after SARS-CoV-2 vaccine dose 2. Fewer data are available on the effects of third and fourth doses. This observational cohort study collected plasma and PBMCs from healthy control subjects and untreated or treated patients with IMIDs prevaccination and after one to four doses of SARS-CoV-2 mRNA vaccine (BNT162b2 or mRNA-1273). SARS-CoV-2-specific Ab levels, neutralization, and T cell cytokine release were measured against wild-type and Omicron BA.1 and BA.5 variants of concern. Third vaccine doses substantially restored and prolonged Ab and T cell responses in patients with IMIDs and broadened responses against variants of concern. Fourth-dose effects were subtle but also prolonged Ab responses. However, patients with IMIDs treated with anti-TNF, especially patients with inflammatory bowel disease, exhibited lower Ab responses even after the fourth dose. Although T cell IFN-γ responses were maximal after one dose, IL-2 and IL-4 production increased with successive doses, and early production of these cytokines was predictive of neutralization responses at 3-4 mo postvaccination. Our study demonstrates that third and fourth doses of the SARS-CoV-2 mRNA vaccines sustain and broaden immune responses to SARS-CoV-2, supporting the recommendation for three- and four-dose vaccination regimens in patients with IMIDs.

Differential Diagnosis, Prevention, and Treatment of mpox (Monkeypox): A Review for Dermatologists

The current 2022 mpox (monkeypox) outbreak has been officially recognized as a public health emergency. The mpox clinical symptoms include high fever, fatigue, chills, headache, swollen lymph nodes, muscle aches, and a disseminated painful rash. However, recent cases of mpox have shown a shift in clinical symptoms, with anogenital skin lesions emerging as the predominant feature. Due to the predominant skin manifestations of mpox, dermatologists could be crucial in detecting new mpox cases and educating frontline healthcare professionals about mpox. The mpox virus is continuously evolving and has several variants. Genome sequencing has revealed that the Clade IIb variant is responsible for the 2022 mpox outbreak. Mpox spread may occur through animal-to-human and human-to-human transmission; however, unlike coronavirus disease 2019 (COVID-19), long-range airborne transmission has not been reported. Healthcare professionals are at higher risk of becoming infected since they are usually in close contact with both the patients and potentially contaminated fomites (e.g., examination table, gowns, gloves). Both public and healthcare professionals should take preventive and avoidance measures to limit the spread. Mpox is usually self-limiting and may require only symptomatic treatment; however, it may cause severe complications in special populations such as immunocompromised individuals. For severe infection, clinicians may consider antiviral drugs (off-label), tecovirimat and brincidofovir, originally approved for smallpox treatment. Two smallpox vaccines, ACAM2000^® and JYNNEOS^TM, can be used as pre-exposure prophylaxis against mpox. JYNNEOS^TM, which carries approval for mpox use, has less adverse effect potential than ACAM2000^®, and may also be used as post-exposure prophylaxis, preferably within 4 days of exposure.

Brodalumab-Induced Eczematous Reactions in Psoriasis Patients: Management With Switching to Risankizumab

Biological treatments targeting IL-17 are highly efficacious with rapid onset of action in psoriasis. Cutaneous adverse events are associated with different biological treatments, including paradoxical psoriasis and eczematous reactions. Brodalumab was previously suggested as an alternative treatment option in psoriasis patients who developed dermatitis or paradoxical psoriasis while on a biologic. Here we report three psoriasis patients who developed brodalumab induced eczematous reaction with complete clearance after switching to risankizumab. Early recognition is crucial for appropriate management. We propose switching patients with psoriasis who develop severe eczematous reaction while on a biologic targeting IL-17 to an IL 23 inhibitor due to efficacy in psoriasis and rarely reported eczematous reaction.

Systematic review of newer agents for the management of alopecia areata in adults: Janus kinase inhibitors, biologics and phosphodiesterase-4 inhibitors

Management options for moderate-to-severe alopecia areata (AA) are limited owing to a lack of safe and effective treatments suitable for long-term use. However, newer agents have the potential to induce and maintain hair regrowth in patients with a better side-effects profile compared to systemic steroids or conventional systemic agents. In this article, we conducted a systematic review of newer agents, including Janus kinase (JAK) inhibitors, biologics and phosphodiesterase-4 (PDE-4) inhibitors, for the treatment of AA in adult patients evaluated in randomized controlled trials (RCTs) using the Severity of Alopecia Tool score. A literature search was performed on PubMed and ClinicalTrials.gov, which identified 106 items with 12 RCTs eligible for review. Information regarding the treatment regimen, duration, endpoints, efficacy and adverse events were extracted; product monograph information was also summarized for approved agents with or without indications for AA. Overall, current data suggest the oral JAK inhibitors (baricitinib, ritlecitinib, deuruxolitinib, brepocitinib) as a promising new class of agents that can induce significant hair regrowth, with mild to moderate adverse effects. Baricitinib recently received US FDA approval for the treatment of severe AA, while ritlecitinib and deuruxolitinib have received the breakthrough therapy designation for AA. In contrast, PDE-4 inhibitors (apremilast) and the biologics (dupilumab, secukinumab and aldesleukin) appear to have limited efficacy thus far. Results from ongoing and future long-term studies could shed light on the utility of the newer agents in altering the progression of AA.

A85 ASSESSING THE IMPACT OF A DEDICATED RAPID INTERDISCIPLINARY IBD CLINIC ON PATIENT WAIT TIMES, REPORTED OUTCOMES, AND SATISFACTION OF CARE

Background

Inflammatory bowel disease (IBD) is a chronic fluctuating condition where patients can experience periods of active disease and remission. Timely access to care has been shown to be impactful on important disease outcomes. In January 2020, we implemented a rapid assessment IBD program consisting of expedited access to interdisciplinary care and close monitoring of patients.

Purpose

To assess the impact of the rapid assessment program on access to care, disease activity, and patient satisfaction.

Method

Once informed consent was obtained, patients were enrolled into the RAPID IBD program. This program consisted of four close monitoring time points at baseline, 1, 2, and 3 months, as well as two follow up time points at 6 and 12 months. At each timepoint patients completed questionnaires that evaluated disease activity, using the Modified Harvey Bradshaw Index (mHBI) for Crohn’s disease (CD), partial Mayo (pMayo) score and Simple Clinical Colitis Activity Index (SCCAI) for ulcerative colitis patients. At baseline, 3, 6, and 12 months, patients were also assessed on mental health, using the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7), and satisfaction of care, using the CACHE questionnaire.

Result(s)

Between January 2020 – August 2021, 216 patients were referred to the RAPID IBD program. The mean time from referral to clinical assessment was 8.1 days. Of those referred, 143 (71 CD, 62 UC, 6 IBDU, and 4 Query IBD) patients consented to and completed the 12-month RAPID IBD study. 34.9% of patients who had active disease at baseline achieved remission by 3 months (Table 1). At baseline 44.8% and 28.4% of patients experienced moderate to severe depression and anxiety, respectively. The greatest improvement in mental health was seen at 2 months where the proportion of patients experiencing moderate to severe depression and anxiety decreased to 27.5% and 18.3%, respectively (Table 2). Patient satisfaction, specific to clinical care, improved from a baseline score of 69.1% to 74.1% at 3 months (Table 3).

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Conclusion(s)

Implementation of a dedicated RAPID IBD clinic program reveals shorter wait times to be seen in clinic. By three months of enrollment, patients demonstrate improvements in clinical response, mental health, and satisfaction of care.

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Disclosure of Interest

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Top Ten Research Priorities for Psoriasis, Atopic Dermatitis and Hidradenitis Suppurativa: The SkIN Canada Priority Setting Initiative

Background

The Skin Investigation Network of Canada (SkIN Canada) is a new national skin research network. To shape the research landscape and ensure its value to patient care, research priorities that are important to patients, caregivers, and health care providers must be identified.

Objectives

To identify the Top Ten research priorities for 9 key skin conditions.

Methods

We first surveyed health care providers and researchers to select the top skin conditions for future research within the categories of inflammatory skin disease, skin cancers (other than melanoma), and wound healing. For those selected skin conditions, we conducted scoping reviews to identify previous priority setting exercises. We combined the results of those scoping reviews with a survey of patients, health care providers, and researchers to generate lists of knowledge gaps for each condition. We then surveyed patients and health care providers to create preliminary rankings to prioritize those knowledge gaps. Finally, we conducted workshops of patients and health care providers to create the final Top Ten lists of research priorities for each condition.

Results

Overall, 538 patients, health care providers, and researchers participated in at least one survey or workshop. Psoriasis, atopic dermatitis and hidradenitis suppurativa (inflammatory skin disease); chronic wounds, burns and scars (wound healing); and basal cell, squamous cell and Merkel cell carcinoma (skin cancer) were selected as priority skin conditions. Top Ten lists of knowledge gaps for inflammatory skin conditions encompassed a range of issues relevant to patient care, including questions on pathogenesis, prevention, non-pharmacologic and pharmacologic management.

Conclusions

Research priorities derived from patients and health care providers should be used to guide multidisciplinary research networks, funders, and policymakers in Canada and internationally.

Efficacy of guselkumab, a selective IL-23 inhibitor, in Preventing Arthritis in a Multicentre Psoriasis At-Risk cohort (PAMPA): protocol of a randomised, double-blind, placebo controlled multicentre trial

INTRODUCTION

Psoriatic arthritis (PsA) is a complex, immune-mediated disease associated with skin psoriasis that, if left untreated, can lead to joint destruction. Up to 30% of patients with psoriasis progress to PsA. In most cases, psoriasis precedes synovio-entheseal inflammation by an average of 5-7 years, providing a unique opportunity for early and potentially preventive intervention in a susceptible and identifiable population. Guselkumab is an effective IL-23p19 inhibitor Food and Drug Administration (FDA-approved for treatment of moderate-to-severe psoriasis and PsA. The Preventing Arthritis in a Multicentre Psoriasis At-Risk cohort (PAMPA) study aims to evaluate the efficacy of guselkumab in preventing PsA and decreasing musculoskeletal power Doppler ultrasound (PDUS) abnormalities in a population of patients with psoriasis who are at-increased risk for PsA progression.

METHODS AND ANALYSIS

The PAMPA study is a multicentre, randomised, double-blind, placebo-controlled, interventional, preventive trial comparing PDUS involvement and conversion to PsA in patients with psoriasis at-increased risk for progression treated with guselkumab compared with non-biological standard of care. The study includes a screening period, a double-blind treatment period (24 weeks) and an open-label follow-up period (72 weeks). At baseline, 200 subjects will be randomised (1:1) to receive either guselkumab 100 mg (arm 1) or placebo switching to guselkumab 100 mg starting at week 24 (arm 2). Arm 3 will follow 150 at-risk psoriasis patients who decline biological therapy and randomisation. Changes from baseline in the PDUS score at week 24 and the difference in proportion of patients transitioning to PsA at 96 weeks will be examined as the coprimary endpoints.

ETHICS AND DISSEMINATION

Ethics approval for this study was granted by the coordinating centre's (NYU School of Medicine) Institutional Review Board (IRB). Each participating site received approval through their own IRBs. The findings will be shared in peer-reviewed articles and scientific conference presentations.

TRIAL REGISTRATION NUMBER

NCT05004727.

Prevalence and Characteristics of Dupilumab-Induced Ocular Surface Disease in Adults With Atopic Dermatitis

PURPOSE

Dupilumab-induced ocular surface disease (DIOSD) is a common reaction among patients treated for atopic dermatitis. This study aimed to identify the clinical characteristics, associated risk factors, treatment strategies, and long-term outcomes of DIOSD.

METHODS

We conducted a multicenter retrospective cohort study of consecutive adult outpatients treated with dupilumab for moderate-to-severe atopic dermatitis from 2017 through 2021 at 2 tertiary care centers. We used stepwise multivariable logistic regression to assess the association between patient characteristics and development of DIOSD.

RESULTS

Among 210 patients treated with dupilumab, 37% (n = 78) developed DIOSD over the 52-week follow-up period. Vision-threatening complications including corneal scarring and cicatricial ectropion were noted in 1% (n = 3) of patients. Clinical features were blepharoconjunctivitis (68%, n = 53), burning/stinging/dryness (14%, n = 29), epiphora (13%, n = 10), pruritus (13%, n = 10), blurred vision (3%, n = 2), and photophobia (1%, n = 1). DIOSD was associated with a history of asthma (odds ratio: 2.94, 95% confidence interval: 1.26-6.87, P = 0.01) and a family history of atopic dermatitis (odds ratio: 2.58, 95% confidence interval: 1.08-6.17, P = 0.03). Interventions were initiated for 63% of patients with DIOSD, with artificial tears (56%) and corticosteroid drops (29%) most commonly used. Dupilumab was discontinued because of DIOSD in 4% of patients.

CONCLUSIONS

DIOSD is a common adverse event that is usually mild but may lead to treatment interruption and vision-threatening complications. A personal history of asthma and family history of atopic dermatitis may be associated with a higher risk of developing DIOSD.

Accelerated waning of immunity to SARS-CoV-2 mRNA vaccines in patients with immune-mediated inflammatory diseases

BACKGROUNDLimited information is available on the impact of immunosuppressants on COVID-19 vaccination in patients with immune-mediated inflammatory diseases (IMID).METHODSThis observational cohort study examined the immunogenicity of SARS-CoV-2 mRNA vaccines in adult patients with inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, or psoriatic disease, with or without maintenance immunosuppressive therapies. Ab and T cell responses to SARS-CoV-2, including neutralization against SARS-CoV-2 variants, were determined before and after 1 and 2 vaccine doses.RESULTSWe prospectively followed 150 subjects, 26 healthy controls, 9 patients with IMID on no treatment, 44 on anti-TNF, 16 on anti-TNF with methotrexate/azathioprine (MTX/AZA), 10 on anti-IL-23, 28 on anti-IL-12/23, 9 on anti-IL-17, and 8 on MTX/AZA. Ab and T cell responses to SARS-CoV-2 were detected in all participants, increasing from dose 1 to dose 2 and declining 3 months later, with greater attrition in patients with IMID compared with healthy controls. Ab levels and neutralization efficacy against variants of concern were substantially lower in anti-TNF-treated patients than in healthy controls and were undetectable against Omicron by 3 months after dose 2.CONCLUSIONSOur findings support the need for a third dose of the mRNA vaccine and for continued monitoring of immunity in these patient groups.FUNDINGFunded by a donation from Juan and Stefania Speck and by Canadian Institutes of Health (CIHR)/COVID-Immunity Task Force (CITF) grants VR-1 172711 and VS1-175545 (to THW and ACG), CIHR FDN-143250 (to THW), GA2-177716 (to VC, ACG, and THW), and GA1-177703 (to ACG) and the CIHR rapid response network to SARS-CoV-2 variants, CoVaRR-Net (to ACG).

POS1217 ANTI-TNF THERAPY FOR IMMUNE MEDIATED INFLAMMATORY DISEASES MAY BE ASSOCIATED WITH LOWER ANTIBODY LEVELS AND VIRUS NEUTRALIZATION EFFICACY FOLLOWING SARS-CoV-2 mRNA VACCINATION

Background

The impact of immunosuppressants on COVID-19 vaccination response and durability in patients with immune-mediated inflammatory diseases (IMID) is yet to be fully characterized. Humoral response may be attenuated in these patients especially those on B cell depleting therapy and higher doses of corticosteroids, but data regarding other immunosuppressants are scarce.

Objectives

We aimed to investigate antibody and T cell responses and durability to SARS-CoV-2 mRNA vaccines (BNT162b and/or mRNA 1273) in IMID patients on immunomodulatory maintenance therapy other than B-cell depleting therapy and corticosteroids.

Methods

This prospective observational cohort study examined the immunogenicity of SARS-CoV-2 mRNA vaccines in adult patients with IMIDs (psoriatic arthritis, psoriasis, inflammatory bowel disease and rheumatoid arthritis) with or without maintenance immunosuppressive therapies (anti-TNF, methotrexate/azathioprine [MTX/AZA], anti-TNF + MTX/AZA, anti IL12/23, anti-IL-17, anti-IL23) compared to healthy controls. Automated ELISA for IgGs to spike trimer, spike receptor binding domain (RBD) and the nucleocapsid (NP) and T-cell release of 9 cytokines (IFNg, IL2, IL4, IL17A, TNF) and cytotoxic molecules (sFasL, GzmA, GzmB, Perforinin) in cell culture supernatants following stimulation with spike or NP peptide arrays were conducted at 4 time points: T1=pre vaccination, T2=median 26 days after dose 1, T3=median 16 days after dose 2 and T4=median 106 days after dose 2. Neutralization assays against four SARS-CoV-2 variants (wild type, delta, beta and gamma) were conducted at T3.

Results

We followed 150 subjects: 26 healthy controls and 124 IMID patients: 9 untreated, 44 on anti-TNF, 16 on anti-TNF with MTX/AZA, 10 on anti-IL23, 28 on anti-IL12/23, 9 on anti-IL17, 8 on MTX/AZA (Table 1). Most patients mounted antibody and T cell responses with increases from dose 1 to dose 2 (100% seroconversion at T3) and some decline by T4, with variability within groups. Antibody levels and neutralization efficacy was lower in anti-TNFgroups (anti-TNF, anti-TNF + MTX/AZA) compared to controls and waned by T4 (Figure 1). T cell responses were not consistently different between groups. Pooled data showed a higher antibody response to mRNA-1273 compared to BNT162b.

Table 1.

Baseline characteristics of study participants

Controluntreated IMIDAnti- TNFAnti- TNF +MTX/AZAAnti-IL-23Anti -IL-12/23Anti -IL-17MTX/AZAn=26n=9n=44n=16n=10n=28n=9n=8p-valueIMID*N/A IBD9301002704 Psoriasis1318122 PA0732172 AS0830010 RA1100011Age median years [IQR]36 [26-46]33 [27-41]38 [30-51]53 [44-59]48 [45-61]34 [28-47]49 [46-61]42 [31-55]<0.001^Sex male (%)16 (62)5 (56)18 (41)8 (50)5 (50)13 (46)6 (67)4 (50)0.772~BMImedian kg/m2 [IQR]25 [23-28]26 [22-27]22 [24-26]26 [24-28]27 [24-35]22 [21-24]32 [26-34]26[25-33]0.001^Vaccine interval median days [IQR]74 [35-84]54 [31-64]60 [45-69]64 [50-72]74 [35-84]62 [49-69]65 [52-75]58 [21-97]0.372^

*multiple IMIDs per patient possible

Figure 1.

Antibody responses (A) Anti spike and anti RBD IgG levels at indicated time points. Blue line represents median ratio in convalescent patients. The red line is the seropositivity threshold: the median antibody level of those that pass both a 1% false positive rate and show ≥3SD from the log means of the negative controls. (B) Relative ratio of RBD, spike and NP across time. Black and gray lines indicate median and mean values, respectively. *p≤0.05, **p≤0.01, ***p≤0.001, ****p≤0.0001

Conclusion

Following 2 doses of mRNA vaccination there is 100% seroconversion in IMID patients on maintenance therapy. Antibody levels and neutralization efficacy in anti-TNF group are lower than controls, and wane substantially by 3 months after dose 2. These findings highlight the need for third dose in patients undergoing treatment with anti-TNF therapy and continued monitoring of immunity in these patient groups, taking into consideration newer variants and additional vaccine doses.

Acknowledgements

This work was funded by a donation from Juan and Stefania Speck and by grants VR-1 172711, VS1-175545, FDN-143250, GA1- 177703 and GA2- 177716, from Canadian Institutes of Health Research and COVID Immunity task force and by Sinai Health Foundation

Disclosure of Interests

Naomi Finkelstein: None declared, Roya M. Dayam: None declared, Jaclyn Law: None declared, Rogier Goetgebuer: None declared, Gary Chao: None declared, Kento T. Abe: None declared, Mitchell Sutton: None declared, Joanne M. Stempak: None declared, Daniel Pereira: None declared, David Croitoru: None declared, Lily Acheampong: None declared, Saima Rizwan: None declared, Klaudia Rymaszewski: None declared, Raquel Milgrom: None declared, Darshini Ganatra: None declared, Nathalia V. Batista: None declared, Melanie Girard: None declared, Irene Lau: None declared, Ryan Law: None declared, Michelle Cheung: None declared, Bhavisha Rathod: None declared, Julia Kitaygorodsky: None declared, Reuben Samson: None declared, Queenie Hu: None declared, Nigil Haroon: None declared, Robert Inman Consultant of: AbbVie, Janssen, Lilly, Novartis., Grant/research support from: AbbVie, Novartis, Vincent Piguet Consultant of: AbbVie, Almirall, Celgene, Janssen, Kyowa Kirin Co. Ltd, LEO Pharma,

Novartis, Pfizer, Sanofi, UCB, and Union Therapeutic, Grant/research support from: Unrestricted educational grants from AbbVie, Bausch Health, Celgene, Janssen, LEO Pharma, Lilly, L’Oréal, NAOS, Novartis, Pfizer, Pierre-Fabre, Sandoz, and Sanofi, Mark Silverberg Speakers bureau: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Consultant of: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Grant/research support from: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Anne-Claude Grigras: None declared, Tania H. Watts: None declared, Vinod Chandran Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Amgen, Eli-Lilly.

OP0030 ASSOCIATION OF TRADITIONAL AND DISEASE-RELATED RISK FACTORS WITH CARDIOVASCULAR EVENTS IN PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS

Background

Patients with psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), have an increased risk for cardiovascular (CV) disease.

Objectives

We aimed to identify traditional CV risk factors and PsD-related risk factors associated with CV events.

Methods

Patients from a longitudinal PsD cohort without a prior history of CV events were included. Detailed information on demographics, comorbidities including traditional cardiovascular risk factors, medications and disease activity is collected according to a standard protocol. The study outcome included any of the following CV events occurring within the first 10 years of patients’ initial clinic visit: angina, myocardial infarction, congestive heart failure, transient ischemic attack, cerebrovascular accident, revascularization procedures and CV death. A total of 10 traditional CV risk factors and 15 PsD-related risk factors were assessed. The association of each risk factor with incident CVEs were analyzed separately using Cox proportional hazards regression models with time-dependent covariates, adjusted for age and sex.

Results

A total of 1,376 patients with PsD, followed between 1978 and 2020, were analyzed (mean age 48.3 ± 12.9 years, 46.8% female). During the follow-up period, 102 (7.4%) patients developed incident CV events. In Cox regression models adjusted for age and sex, age (Hazard Ratio (HR) 1.08, 95% Confidence Interval (CI) 1.06, 1.10), diabetes (HR 1.88, 95% CI 1.17, 3.02), systolic blood pressure (HR 1.02, 95% CI 1.01, 1.03), body mass index (BMI) (HR 1.04, 95% CI 1.01, 1.08), triglycerides (HR 1.24, 95% CI 1.07, 1.43), treatment for hypertension (HR 1.70, 95% CI 1.13, 2.56), and use of lipid-lowering medications (HR 1.70, 95% CI 1.13, 2.56) were among the traditional CV risk factors associated with increased CV risk. Among the PsD-related risk factors, psoriasis area and severity index (PASI) (HR 1.05, 95% CI 1.02, 1.08), erythrocyte sedimentation rate (ESR) (HR 1.02, 95% CI 1.01, 1.02), number of tender joints (HR 1.03, 95% CI 1.01, 1.05), number of swollen joints (HR 1.06, 95% CI 1.01, 1.12), health assessment questionnaire (HAQ) score (HR 1.63, 95% CI 1.23, 2.17), and daily use of non-steroidal anti-inflammatory drugs (NSAIDs) (HR 1.72, 95% CI 1.16, 2.55) were associated with increased CV risk. Use of biologic medications (HR 0.63, 95% CI 0.40, 1.00) was not found to be significantly protective against CV events.

Conclusion

In patients with PsD, we identified six PsD-related risk factors that were significantly associated with incident CV events. These risk factors may be useful for the development of a PsD-specific CV risk prediction score that uses routine clinical assessments in combination with PsD-related biomarkers.

References

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

Acknowledgements

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, and Arthritis Society (TGP-19-0446). Lihi Eder is supported by a Young Investigator Award from the Arthritis Society (YIA-16-394) and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The Psoriatic Disease Program has been supported by a grant from the Krembil Foundation.

Disclosure of Interests

None declared.

Treatment Guidelines for Atopic Dermatitis Since the Approval of Dupilumab: A Systematic Review and Quality Appraisal Using AGREE-II

Introduction

Since its approval for adults with moderate-to-severe atopic dermatitis (AD) in 2017, dupilumab has been incorporated into clinical practice guidelines (CPGs). However, recommendations differ internationally, and the quality assessment of their development is unclear.

Objective

We aimed to systematically review and appraise the quality of CPGs for adult AD reported since 2017 and map the recommendations for dupilumab initiation relative to conventional systemic therapy (CST).

Materials and Methods

A literature search was conducted in June 2020 in MEDLINE, EMBASE, SCOPUS, and CINAHL. Twelve CPGs were retrieved. Methodological quality was assessed using the validated Appraisal of Guidelines for Research & Evaluation II tool (AGREE-II). Recommendations were extracted and compared.

Results

AGREE-II median scores per domain of the CPGs were (%, r = range): scope/purpose, 78% (50-96); stakeholder involvement, 54% (28-85); rigor of development, 39% (21-63); clarity of presentation, 85% (69-100); applicability, 27% (6-51); and editorial independence, 76% (42-100). Neither met the threshold of 70% quality criteria for rigor of development nor the applicability domains. Three CPGs met the criteria for recommendation without modification. CPGs' approach to dupilumab initiation was as follows: second line, preferred over CST and nbUVB (n = 1/12 CPG); second line, equivalent to CST or nbUVB (n = 3/12 CPGs); third line, after nbUVB or CST (n = 5/12 CPGs); and fourth line after nbUVB and CST (n = 2/12). No consensus was reached for n = 1/12 CPG.

Conclusion and Relevance

Dupilumab is now incorporated into CPGs for adult AD. These CPGs exhibited good quality in scope/purpose, clarity, and editorial independence domains. However, none met AGREE-II criteria for methodological rigor/applicability. Gaps were found in mechanisms for updates, facilitators/barriers, resource implications, and stakeholder involvement. Only n = 3/12 CPGs met quality criteria for recommendation without modifications. Of these, two favored a conservative sequential approach for the initiation of dupilumab relative to CST, while one did not reach consensus. Our findings highlight divergent recommendations AD treatment, underlining a need to incorporate quality criteria into future guideline development.

From the Cochrane Library: Interventions for Hidradenitis Suppurativa

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Association of Cardiac Biomarkers With Cardiovascular Outcomes in Patients With Psoriatic Arthritis and Psoriasis: A Longitudinal Cohort Study

Objective

In patients with psoriatic disease (PsD), we determined whether cardiac troponin I (cTnI) and N‐terminal pro–brain natriuretic peptide (NT‐proBNP) were associated with carotid plaque burden and the development of cardiovascular events independent of the Framingham Risk Score (FRS).

Methods

Among 1,000 patients with PsD, carotid total plaque area (TPA) was measured in 358 participants at baseline. Cardiac troponin I and NT‐proBNP were measured using automated clinical assays. The association between cardiac biomarkers and carotid atherosclerosis was assessed by multivariable regression after adjusting for cardiovascular risk factors. Improvement in the prediction of cardiovascular events beyond the FRS was tested using measures of risk discrimination and reclassification.

Results

In univariate analyses, cTnI (β coefficient 0.52 [95% confidence interval (95% CI) 0.3, 0.74], P < 0.001) and NT‐proBNP (β coefficient 0.24 [95% CI 0.1, 0.39], P < 0.001) were associated with TPA. After adjusting for cardiovascular risk factors, the association remained statistically significant for cTnI (adjusted β coefficient 0.21 [95% CI 0, 0.41], P = 0.047) but not for NT‐proBNP (P = 0.21). Among the 1,000 patients with PsD assessed for cardiovascular risk prediction, 64 patients had incident cardiovascular events. When comparing a base model (with the FRS alone) to expanded models (with the FRS plus cardiac biomarkers), there was no improvement in predictive performance.

Conclusion

In patients with PsD, cTnI may reflect the burden of atherosclerosis, independent of traditional cardiovascular risk factors. Cardiac troponin I and NT‐proBNP are associated with incident cardiovascular events independent of the FRS, but further study of their role in cardiovascular risk stratification is warranted.

Use of thermal imaging and a dedicated wound imaging smartphone app as an adjunct to staging hidradenitis suppurativa

Hidradenitis suppurativa (HS) presents with painful nodules, draining tunnels, abscesses, ulcers, and fistula formation¹ . Grading systems, (e.g. Hurley Staging System, International Hidradenitis Suppurativa Severity Score System (IHS4), Severity Assessment of Hidradenitis Suppurativa Score (HS-PGA score), and Hidradenitis Suppurativa Area and Severity Index (HASI)) assess disease severity in terms of lesion count, extension and morphology.

A Paradigm Shift in the Treatment and Management of Onychomycosis

There is an increase in the incidence of onychomycosis, especially in at-risk populations. Onychomycosis is difficult to treat, as the efficacy of most antifungal agents is relatively low. Nondermatophyte molds (NDMs) and mixed infection (dermatophyte plus NDM) onychomycosis are contributing to growing antifungal resistance, as they are often underestimated and ignored due to incorrect diagnosis. There is a need for a paradigm shift in the management of onychomycosis to a patient-centered, holistic approach with an emphasis on laboratory diagnosis prior to initiating treatment, which enables the rational choice of the antifungal agent. Additionally, in the case of resistant infections, antifungal susceptibility testing is recommended. Strategies for effective management of onychomycosis include disinfection of fungal reservoirs in shoes and socks and prophylaxis posttreatment using topical antifungal agents. These measures may reduce the recurrence of onychomycosis and improve long-term clinical success.

Cathelicidin LL-37 Ignites Primed NLRP3 Inflammasomes in Rosacea

Microbes and commensal mites contribute to the development of inflammation and neurovascular dysregulation in rosacea. Cathelicidin family proteins are epithelial antimicrobial peptides expressed in higher-order mammals. In humans, mature LL-37 is cleaved from its precursor in response to microbial infection, UV light, and injury. In their new article in the Journal of Investigative Dermatology, Yoon et al. expand on existing evidence supporting LL-37 proinflammatory activity in lipopolysaccharide (LPS)- and UV-primed models of rosacea. They show in vitro that LL-37 promotes NLRP3-mediated inflammasome activation through lysosomal destabilization in the presence of LPS and that the injection of LL-37 in vivo leads to skin inflammation that is abrogated by direct NLRP3 inhibition and homozygous knockout in a murine model.

Incidence, prevalence, and predictors of inflammatory arthritis in patients with hidradenitis suppurativa: a systematic review and meta-analysis

An increasing amount of evidence has emerged suggesting that hidradenitis suppurativa (HS) is associated with inflammatory arthritis. This study reviewed the incidence, prevalence, and predictors of inflammatory arthritis in patients with HS. A comprehensive literature search was conducted in CINAHL, Embase, and Medline from inception to February 14, 2020. Articles were included in the review if they provided data on disease epidemiology or predictors of adult or pediatric HS patients with comorbid inflammatory arthritis. There are no validated diagnostic criteria for HS, thus we considered patients as having HS if they had at least one diagnostic code in a hospital or claims database or a diagnosis of HS/inflammatory arthritis in a medical record. The same criteria were used to confirm presence of inflammatory arthritis. We identified an increased incidence of rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) in HS patients when compared with estimates in the general population. We identified a relatively high prevalence of RA, spondyloarthritis (SpA), and PsA in HS patients when compared with estimates in the general population. There was evidence to suggest that patients who are younger than 30, male, have severe HS, or are taking infliximab or adalimumab (which may also be confounded by HS disease severity) may be at greater risk for specific subtypes of inflammatory arthritis. However, further data are needed to confirm these associations. The increased incidence and prevalence of inflammatory arthritis within HS patients underscore the need for increased awareness and interdisciplinary partnership within rheumatology and dermatology.

Extracellular Adenosine Triphosphate: A Modulator of Cutaneous Candida albicans Infection

Typically found in the skin, Candida albicans can be both commensal and pathogen. In their report, Zhang et al. (2021) address the regulation of C. albicans skin infection by extracellular adenosine triphosphate-a metabolite actively released by the fungus-that potentially modulates cutaneous infection.

Three-year efficacy and safety of certolizumab pegol for the treatment of plaque psoriasis: results from the randomized phase 3 CIMPACT trial

Background

Certolizumab pegol (CZP) is an Fc‐free, PEGylated anti‐tumor necrosis factor biologic.

Objectives

To report 3‐year outcomes from the CIMPACT (NCT02346240) phase 3, CZP in moderate to severe plaque psoriasis, randomized controlled trial.

Methods

Adults were randomized 3:3:3:1 to CZP 200 mg every other week (Q2W), CZP 400 mg Q2W, etanercept biweekly or placebo. At Week 16, CZP‐ and etanercept‐treated PASI 75 responders were re‐randomized to CZP 200 mg Q2W, CZP 400 mg Q4W, CZP 400 mg Q2W or placebo for maintenance treatment; PASI 75 non‐responders entered an open‐label escape CZP 400 mg Q2W arm. Patients entering the open‐label extension (OLE; Weeks 48–144) from blinded treatment received CZP 200 mg Q2W.

Results

Double‐blinded results have been reported previously. 261 patients received 200 mg Q2W upon OLE entry. PASI 75 response was maintained in patients continuing 200 mg Q2W treatment through Weeks 16–144 (Week 144: 96.2%). In patients dosed down at Week 48 (double‐blinded 400 mg to 200 mg Q2W), PASI 75 decreased (Week 48: 98.7%; Week 144: 85.9%). In patients who received placebo through Weeks 16–48, PASI 75 response decreased (Week 48: 60.4%), then increased following Week 48 switch to 200 mg Q2W (Week 144: 95.1%). 48 and 36 patients initially randomized to 200 and 400 mg Q2W, respectively, were Week 16 PASI 75 non‐responders and entered the escape arm; at Week 144, 71.8% and 78.2% achieved PASI 75. No new safety signals were identified.

Conclusions

Response to CZP was durable over three years; no new safety signals were identified.