Efficacy and Safety of a Second Adalimumab Treatment Cycle in Psoriasis Patients who Relapsed after Adalimumab Discontinuation or Dosage Reduction: A Double-Blind, Randomized, Placebo-Controlled Trial

Objective

To evaluate re-treatment with weekly adalimumab in patients with moderate to severe psoriasis who had been successfully treated with weekly adalimumab but relapsed following randomization to either dosage reduction or discontinuation.

Methods

Patients who had achieved a Psoriasis Area and Severity Index (PASI) response of 50 or greater after 12 weeks on adalimumab 40 mg weekly in a previous study (M02-538), but then fell below a PASI 50 response within 12 weeks following reduction of dosage frequency to adalimumab 40 mg every other week or treatment discontinuation, could enter study M03-596 and receive open-label re-treatment with 12 weeks of weekly adalimumab.

Results

Thirty-two patients relapsed on or before week 24 of M02-538 and entered study M03-596. Overall, 81.3% (26 of 32) again achieved a PASI 50 response after 12 weeks of re-treatment. Of the 19 M03-596 patients who had a PASI 75 response at week 12 of M02-538, 12 (63.1%) again achieved a PASI 75 response at week 12 of M03-596.

Conclusion

Most patients who had initially responded to weekly adalimumab and who relapsed after randomization to a lower dosage or discontinuation regained response upon re-treatment with weekly adalimumab.

Combination Therapy for Acne Scarring: Personal Experience and Clinical Suggestions

Acne is one of the most prevalent skin conditions seen by dermatologists. The cosmetic sequelae of severe acne, including scarring and pigmentation, have a profound psychological impact on those in icted. Topical (eg, retinoids, antibiotics, dapsone, hydroxyacids) and oral treatments (eg, antibiotics and/or spironolactone) are often bene cial to control acne or in the instance of oral isotretinoin use, rid the acne permanently; however, these treatments have very little affect on the ultimate cosmetic outcome of the acne scarring and skin texture that results. Given the variety of scar types that can form and the variability of responses seen in various skin types and textures, treatment options are vast without appropriate guidelines for pathways that dictate best timing, combinations, and options in given clinical scenarios. Current treatment options include solo or combina- tions of energy-based (eg, laser, radiofrequency), chemical-based (eg, peels, TCA cross), surgical-based options (eg, subcision, punch excision), microneedling, and llers and/or fat injections. Most recently, fractional radiofrequency-based treatments have been used to improve acne scarring with less reported downtime as compared to lasers or chemical peels and the ability to treat darker or sensitive skin types with less risk of scarring or hyperpigmentation. In severe cystic ares, scarring treatments are often postposed till the acne is under control and in many instances this can limit the dermatologists ability to affect future cosmetic treatments. Based on personal experience of various clinical scenarios in a busy laser practice that treats a signi cant number of patients with acne scarring, fractional radiofrequency is an excellent choice for treating all forms of acne scars with minimal risk to patients, even those on concurrent treatments such as isotretinoin. Additionally, fractional radiofrequency can be used in combination with all other treatment options to speed the time to clinical improvement appreciated by the patient. Here we present personal experiences of combination treatments for acne scarring, pigmentation and textural issues, and suggest that fractional radiofrequency be considered a "gold standard" treatment of acne scarring in those with dark or sensitive skin types or those on concurrent isotretinoin. <em>J Drugs Dermatol. 2016;15(11):1413-1419.</em>.

Female pattern alopecia: current perspectives

Hair loss is a commonly encountered problem in clinical practice, with men presenting with a distinctive pattern involving hairline recession and vertex balding (Norwood-Hamilton classification) and women exhibiting diffuse hair thinning over the crown (increased part width) and sparing of the frontal hairline (Ludwig classification). Female pattern hair loss has a strikingly overwhelming psychological effect; thus, successful treatments are necessary. Difficulty lies in successful treatment interventions, as only two medications - minoxidil and finasteride - are approved for the treatment of androgenetic alopecia, and these medications offer mediocre results, lack of a permanent cure, and potential complications. Hair transplantation is the only current successful permanent option, and it requires surgical procedures. Several other medical options, such as antiandrogens (eg, spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride), prostaglandin analogs (eg, bimatoprost, latanoprost), and ketoconazole are reported to be beneficial. Laser and light therapies have also become popular despite the lack of a profound benefit. Management of expectations is crucial, and the aim of therapy, given the current therapeutic options, is to slow or stop disease progression with contentment despite patient expectations of permanent hair regrowth. This article reviews current perspectives on therapeutic options for female pattern hair loss.

Urticaria multiforme

Urticaria multiforme is a benign cutaneous hypersensitivity reaction seen in pediatric patients that is characterized by the acute and transient onset of blanchable, annular, polycyclic, erythematous wheals with dusky, ecchymotic centers in association with acral edema. It is most commonly misdiagnosed as erythema multiforme, a serum-sickness-like reaction, or urticarial vasculitis. Since these three diagnoses represent distinct clinical entities with unique prognoses and management strategies, it is important that physicians distinguish urticaria multiforme from its clinical mimics in order to optimize patient care. By performing a thorough history and physical examination, the astute clinician can make the correct diagnosis and develop an appropriate, effective treatment plan while avoiding unnecessary biopsies and laboratory evaluations. The authors report a case of urticaria multiforme in a four-year-old girl in order to emphasize the distinctive morphological manifestations of this rare, albeit unique, disease seen in the pediatric population.

Emotional benefit of cosmetic camouflage in the treatment of facial skin conditions: personal experience and review

Background

Recent studies highlighting the psychological benefits of medical treatment for dermatological skin conditions have demonstrated a clear role for medical therapy in psychological health. Skin conditions, particularly those that are overtly visible, such as those located on the face, neck, and hands, often have a profound effect on the daily functioning of those affected. The literature documents significant emotional benefits using medical therapy in conditions such as acne, psoriasis, vitiligo, and rosacea, but there is little evidence documenting similar results with the use of cosmetic camouflage. Here we present a review highlighting the practical use of cosmetic camouflage makeup in patients with facial skin conditions and review its implications for psychological health.

Methods

A search of the Medline and Scopus databases was performed to identify articles documenting the emotional benefit of cosmetic camouflage.

Results

Cosmetic camouflage provides a significant emotional benefit for patients with facial skin conditions, and this is substantiated by a literature review and personal experience. More clinical studies are needed to assess and validate the findings reported here.

Conclusion

Patients with visible skin conditions have increased rates of depression, anxiety, and decreased self-esteem. It is prudent for us to consider therapies that can offer rapid and dramatic results, such as cosmetic camouflage.

Complications of minimally invasive cosmetic procedures: prevention and management

Over the past decade, facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular. Office-based, minimally invasive procedures can promote a youthful appearance with minimal downtime and low risk of complications. Injectable botulinum toxin (BoNT), soft-tissue fillers, and chemical peels are among the most popular non-invasive rejuvenation procedures, and each has unique applications for improving facial aesthetics. Despite the simplicity and reliability of office-based procedures, complications can occur even with an astute and experienced injector. The goal of any procedure is to perform it properly and safely; thus, early recognition of complications when they do occur is paramount in dictating prevention of long-term sequelae. The most common complications from BoNT and soft-tissue filler injection are bruising, erythema and pain. With chemical peels, it is not uncommon to have erythema, irritation and burning. Fortunately, these side effects are normally transient and have simple remedies. More serious complications include muscle paralysis from BoNT, granuloma formation from soft-tissue filler placement and scarring from chemical peels. Thankfully, these complications are rare and can be avoided with excellent procedure technique, knowledge of facial anatomy, proper patient selection, and appropriate pre- and post-skin care. This article reviews complications of office-based, minimally invasive procedures, with emphasis on prevention and management. Practitioners providing these treatments should be well versed in this subject matter in order to deliver the highest quality care.

Hypertrophic osteoarthropathy presenting as unilateral cellulitis with successful treatment using pamidronate disodium

Hypertrophic pulmonary osteoarthropathy is a paraneoplastic syndrome seen in patients with lung cancer. This condition is characterized by the presence of digital clubbing, periosteal thickening, synovial thickening, and severe pain of the affected joints. Other syndromes exhibiting clubbing may or may not have underlying diseases causing their manifestation. An example is primary hypertrophic osteoarthropathy, or pachydermoperiostosis. While clubbing makes up part of the clinical picture in both hypertrophic pulmonary osteoarthropathy and hypertrophic osteoarthropathy, the latter has no underlying disease associations. Rather, primary hypertrophic osteoarthropathy is familial, idiopathic, and has a chronic course often beginning during puberty in males. Secondary hypertrophic osteoarthropathy is an acquired form of clubbing that is classically associated with lung disease. However, it has also been associated with diseases of the heart, liver, and intestines. In the setting of pulmonary malignancy, secondary hypertrophic osteoarthropathy is known as hypertrophic pulmonary osteoarthropathy. Hypertrophic pulmonary osteoarthropathy has a distinct constellation of clinical findings that includes intractable pain often refractory to treatments other than resolution of the underlying disease process. The authors herein report a case of hypertrophic pulmonary osteoarthropathy masquerading as recurrent lower extremity cellulitis with chronic hand and foot pain in the setting of pulmonary malignancy that responded dramatically to intravenous pamidronate disodium (a bisphosphonate). Given the rarity of hypertrophic osteoarthropathy associated with lung cancer and the difficulty with pain management in such circumstances, the authors present the following case in which pain was mitigated by treatment with bisphosphonate therapy.

Reed's Syndrome: A Case of Multiple Cutaneous and Uterine Leiomyomas

Multiple cutaneous and uterine leiomyomatosis, also known as Reed's syndrome, is an autosomal dominant genetic condition. Affected individuals have an increased predisposition to develop benign smooth muscle tumors (leiomyomas) in the skin and uterus. Affected females frequently develop uterine leiomyomas (fibroids) that are larger and more numerous and emerge earlier than those in the general population. Subsets of these patients are at risk for renal cell cancer and have been determined to have mutations in the fumarate hydratase gene. In individuals or families without renal cell cancer, the syndrome may be referred to as multiple cutaneous leiomyomatosis or multiple cutaneous and uterine leiomyomatosis. The term hereditary leiomyomatosis and renal cell cancer refers to families with an increased prevalence of smooth muscle tumors and renal cell cancer as a result of the fumarate hydratase genetic defect. In this article, the authors introduce a case of a young woman who presented with multiple, intermittently painful, cutaneous leiomyomas and a history of large uterine fibroids previously causing anemia and requiring surgical intervention. Further investigation revealed a family history of mutations in the fumarate hydratase gene. The patient is currently being monitored by the National Institutes of Health.

A bilateral comparison study of pimecrolimus cream 1% and a topical medical device cream in the treatment of patients with atopic dermatitis

Corticosteroids are the mainstay of therapy for atopic dermatitis, but long-term use is associated with adverse effects. We sought to evaluate the clinical efficacy of two steroid-sparing creams for atopic dermatitis. Twenty patients were enrolled in an investigator-blinded, bilateral comparison study. Patients applied pimecrolimus cream twice daily to a target lesion on one side of the body and also applied a topical medical device cream three times daily on a symmetrical target lesion on the opposite side of the body for four weeks. Clinical assessments including Physician Global Assessment (PGA), Target Lesion Symptom Score (TLSS), subject self-assessment and digital photography were performed at the baseline, 2 week, and 4 week visits. Seventy-five percent of patients (pimecrolimus, 15 of 20; topical medical device, 15 of 20) were rated "clear" (0) or "almost clear" (1) by PGA for both medications after four weeks. Percent improvement of the PGA from randomization for pimecrolimus cream and the topical medical device cream were 72.50 and 71.67 respectively (P=0.9283). PGA scores decreased significantly from baseline for both treatments (P=0.004). Overall, there was no statistically significant difference between treatment groups for PGA scores throughout the study (P=0.8236). No cutaneous side effects were noted. Our study was limited by a small sample size and lack of double-blinding; however, both treatments were found to be safe and effective in treating atopic dermatitis over four weeks. Significant improvements were noted for all efficacy variables. In conclusion, a lipid-rich, non-steroidal, topical medical device cream was as effective in improving atopic dermatitis as pimecrolimus cream.

Novel treatment of female-pattern androgenetic alopecia with injected bimatoprost 0.03% solution

Female-pattern androgenetic alopecia is a very common disorder that has been associated with extreme psychological morbidity. Few treatments have documented utility and many physicians are often overwhelmed with how little is pharmacologically available to treat this condition. Novel treatments that are effective, safe, less costly and simple are in high demand. We report a case of female-pattern androgenetic alopecia that failed to respond to a novel treatment with injected bimatoprost solution. Hypothetically, the treatment should have been effective and although we did not have success, this report suggests critical points to consider in the future of prostaglandin analogs, as well as other therapies being considered for the treatment of female-pattern hair loss.

A rare case of multiple segmental eccrine spiradenomas

Eccrine spiradenoma is a benign adnexal neoplasm that has been historically designated as a tumor of eccrine differentiation, although current reconsideration indicates an apocrine process. It usually presents on the trunk and extremities as a tender dermal or subcutaneous papule or nodule frequently with a pink or blue hue. The clinical picture is often not distinct and biopsy is required for diagnosis. Eccrine spiradenoma can present in a variety of ways, including as tumors arranged in zosteriform/dermatomal and/or blaschkoid distributions, often precluding a straightforward diagnosis. Proper diagnosis of eccrine spiradenoma is important due to the occurrence of potentially life-threatening malignant transformation. This article illustrates a rare presentation of eccrine spiradenoma with a concise review for the dermatologist.

A Randomized, Double-blind, Placebo-controlled Study to Evaluate the Safety and Efficacy of Ammonium Lactate Lotion 12% and Halobetasol Propionate Ointment 0.05% in the Treatment and Maintenance of Psoriasis

Consensus recommends a gradual reduction in the frequency or steroid potency of topical corticosteroids following clinical improvement in the treatment of psoriasis, although no established guidelines have been developed. The authors sought to evaluate a combination regimen in the treatment and maintenance of psoriasis. Patients with mild-to-moderate psoriasis were enrolled (n=55) in a randomized, double-blind, placebo-controlled study using ammonium lactate lotion and halobetasol ointment. Those with initial improvement of target plaques after two weeks of combination treatment twice daily were randomized to a maintenance phase (n=41). Patients applied ammonium lactate lotion twice daily everyday and either placebo ointment (n=20) or steroid ointment (n=21) twice daily on weekends only. Forty-one of 55 patients (74.6%) were rated as "clear" (0) or "almost clear" (1) after two weeks of combination treatment. In the maintenance phase, the probability of physician global assessment worsening at six weeks in the steroid group was only 10 percent while in the placebo group the probability rose to 75 percent (p<0.0001). The probability of physician global assessment worsening climbed to 100 percent by 14 weeks in the placebo group while only increasing to 29 percent in the steroid group (p<0.0001). Twelve patients at study termination still had not worsened. Worsening of the physician global assessment index was more likely (HR 7.8 [2.84, 21.43]) in the placebo group than in the steroid group (p<0.0001). No cutaneous side effects, such as steroid atrophy or irritation, were noted. Combination treatment effectively cleared plaque psoriasis initially, and ammonium lactate twice daily everyday with weekend-only applications of halobetasol ointment effectively sustained the initial improvement for a significantly longer period of time when compared with placebo without demonstrating any significant side effects, such as steroid atrophy.

A practical approach to monitoring patients on biological agents for the treatment of psoriasis

Psoriasis is a chronic, systemic, inflammatory skin condition that manifests predominantly as well-demarcated, erythematous, scaly plaques on the elbows, knees, and scalp. While mild cases (minimal body surface) often respond to various topical treatments and light therapy, patients with extensive disease (larger body surface and possibly joint involvement) may require systemic medications for remission. The development of biological agents provides dermatologists valuable ways to help treat psoriatic disease quite efficiently, but literature regarding the monitoring of patients on biological treatments is sparse. Clinical practice varies widely since there is modest strong evidence to recommend or refute most tests currently recommended by the United States Food and Drug Administration. The purpose of this article is to present a practical approach to monitoring patients on biological therapy based on the most up-to-date literature.

Rituximab: a review of dermatological applications

The treatment of many dermatological disorders, such as autoimmune and immune-mediated diseases, consists of the use of systemic corticosteroids alone or in combination with other steroid-sparing immunosuppressants. Often, these treatment regimens are sufficient to control disease activity with relatively few side effects if monitored by a diligent physician. Some patients, however, may be refractory to treatment or develop intolerable side effects from therapy. For these patients, alternative treatment modalities with less toxicity and greater efficacy are required. Rituximab is a genetically engineered, chimeric monoclonal antibody directed against the B-cell lineage specific CD20 antigen. Originally developed for the treatment of B-cell non-Hodgkin"s lymphoma, rituximab has increasingly been used to treat a variety of autoimmune and immune-mediated disorders, such as rheumatoid arthritis, pemphigus diseases, systemic lupus erythematosus, dermatomyositis, and idiopathic thrombocytopenic purpura to name a few. Since very few randomized, controlled, clinical trials exist regarding the use of rituximab in the treatment of dermatological disorders, guidelines for the off-label use of this medication come from anecdotal case reports and cohort studies. Further clinical studies are needed to validate the safety and efficacy of rituximab therapy in dermatological disorders. Until then, we present a literature review of the emerging use of this B-cell depletion therapy. (J Clin Aesthetic Dermatol. 2009;2(5):29-37.).

Is There a Potential Role for Anti-tumor Necrosis Factor Therapy in Patients with Human Immunodeficiency Virus?

Anti-tumor necrosis factor therapy has shown remarkable safety and efficacy in the treatment of many autoimmune and inflammatory disorders, although limited published data exists regarding these treatments in patients with concomitant human immunodeficiency virus and/or acquired immune deficiency syndrome. The use of tumor necrosis factor inhibition is associated with an increased risk of severe infections, including tuberculosis and risk of worsening hepatitis B virus, but its effect on viral infections is conflicting. Currently, package inserts for the three anti-tumor necrosis factor medications (infliximab, etanercept, and adalimumab) affirm that caution should be exercised when considering their use in patients with chronic infection or a history of recurrent infection, as clinical trials for these medications have historically excluded patients with chronic viral infections. With the increasing prevalence of chronic viral infections in patients who are candidates for anti-tumor necrosis factor therapy, there is reason for additional research to assess the safety, efficacy, and potential role of tumor necrosis factor inhibition in this population. This article is an up-to-date review of the emerging use of biologic therapies in patients infected with the human immunodeficiency virus and concurrent psoriatic or rheumatological disease.

Primary cutaneous blastomycosis as a cause of acute respiratory distress syndrom: case report and literature review

Blastomycosis is a fungal infection caused by Blastomyces dermatitidis. Exposure in endemic regions frequently occurs when spores in soil are disturbed and subsequently inhaled. Less commonly, primary cutaneous blastomycosis may follow after traumatic inoculation of the fungus into the skin. Most patients infected with blastomycosis are asymptomatic, but an unfortunate small number present with fulminant disease. Rarely, the infection can affect organs, such as the skin, bone, or genitourinary system. In a small percentage of cases, blastomycosis may cause acute respiratory distress syndrome, which is associated with a very high mortality rate. Increased survival rates have been shown when the clinician has a high index of suspicion and facilitates rapid evaluation and initiation of the appropriate therapy. We present a rare case of a patient presenting with primary cutaneous blastomycosis that progressed to disseminated disease causing acute respiratory distress syndrome. High clinical suspicion, prompt diagnostic testing, and therapy with amphotericin B, confirmed the diagnosis and resulted in a swift recovery.