Backgroundâ€‚ The pathogenesis of hidradenitis suppurativa (HS) is not clearly understood. The nomenclature suggests an important role for the apocrine glands but recent evidence implicates the pilosebaceous unit as a more likely candidate to play a central role in the pathogenesis.
Objectivesâ€‚ Our aim was to estimate the volume of the follicular epithelium, the follicular lumen and the sebaceous glands of patients with HS and healthy controls by means of stereology.
Methodsâ€‚ Four-millimetre punch biopsies were taken from 21 patients with HS and nine healthy controls, fixed in formalin, embedded in paraffin and stained with haematoxylin and eosin prior to volume estimation using the Cavalieri principle.
Resultsâ€‚ Sebaceous gland tissue could be visualized in only 10 of 15 suitable hair follicle biopsies from patients with HS but was present in all biopsies from healthy controls (PÂ =Â 0Â·05) and the mean sebaceous gland volume per follicle was one-seventh of that of healthy controls (PÂ =Â 0Â·03). There was no significant difference between patients with HS and healthy controls with regard to follicular epithelium and follicle lumen volume.
Conclusionsâ€‚ Our results suggest that the absence or reduced volume of the sebaceous gland may play a role in the pathogenesis of HS. The presence of fibrosis suggests that sebaceous glands are obliterated early in the pathogenesis of HS.
Switching to adalimumab for psoriasis patients with a suboptimal response to etanercept, methotrexate, or phototherapy: Efficacy and safety results from an open-label study |
1 Apr 2011
Background: Strategies for transitioning patients with psoriasis from suboptimal therapy have not been delineated.Objective: We sought to determine the efficacy and safety of transitioning to adalimumab for the treatment of psoriasis in patients with suboptimal response to prior therapy with etanercept, methotrexate (MTX), or narrowband (NB)-ultraviolet (UV)B phototherapy.Methods: In this 16-week, open-label, phase IIIb trial, patients with chronic plaque psoriasis discontinued suboptimal therapy between 11 and 17 days (etanercept) or between 4 and 10 days (MTX and NB-UVB) before initiating adalimumab (80 mg at week 0, then 40 mg every other week from week 1). The primary end point was the percentage of patients achieving a Physician Global Assessment of â€śclearâ€ť or â€śminimalâ€ť at week 16.Results: At week 16, Physician Global Assessment of â€śclearâ€ť or â€śminimalâ€ť was achieved by 52% of all enrolled patients (79 of 152) and 49%, 61%, and 48% in the etanercept, MTX, and NB-UVB subgroups, respectively. Four patients (2.6%) experienced at least 125% worsening of Psoriasis Area and Severity Index score relative to screening value at any study visit. The adalimumab safety profile was consistent with results from other psoriasis clinical trials.Limitations: This study is limited by its relatively short 16-week duration, small patient enrollment, and open-label design.Conclusion: Patients who had a suboptimal response to etanercept, MTX, or NB-UVB phototherapy experienced a similar, approximately 50% likelihood of achieving a clinically relevant response to adalimumab. Immediate transition to adalimumab from prior suboptimal therapy, with no dosage tapering or overlap, had a low risk of psoriasis flare.
Lyme disease: Part I. Advances and perspectives |
1 Apr 2011
Lyme disease (LD) is an increasingly recognized multisystem, insect-borne zoonosis. Prevalent worldwide, it has a variety of presentations at different stages of infection. The characteristic rash with central clearing known as erythema chronicum migrans, or simply erythema migrans, appears in its first stage. Typical features may be absent, and important variations are evident among cases seen in different parts of the world. LD may be difficult to diagnose clinically; knowledge about its epidemiology and transmission may be of assistance when the diagnosis is unclear. Based upon our experience with LD and a comprehensive literature review, we provide an update of LD epidemiology, pathophysiology, and management. We also cover the three clinical stages of LD that parallel those of syphilis, another spirochetal disease.
Superantigens in dermatology |
1 Mar 2011
Superantigens (SAgs) are virulent polypeptides that are produced by a variety of infectious organisms. They are capable of causing nonspecific T cell activation by circumventing normal antigen processing in the human host. The genetic makeup of the host plays a role in conferring susceptibility or protection against SAgs. They are linked to a variety of conditions, ranging from toxic shock syndrome to recurrent toxin-mediated perineal erythema. The early recognition of signs and symptoms of SAg-mediated illnesses is important to ensure prompt medical treatment.
Propranolol for treatment of ulcerated infantile hemangiomas |
28 Feb 2011
Background: Ulcerated infantile hemangiomas (IH) are a therapeutic challenge. Propranolol, a nonselective beta-blocker, was recently introduced as a novel treatment for IH.Objective: To evaluate our experience of propranolol in the management of ulcerated IH.Methods: A national, multicenter, retrospective, observational study was conducted. Data were collected from the medical charts of patients treated from 2008 to 2009 and supplemented by information obtained from parents during targeted telephone interviews.Results: Thirty-three infants with propranolol-treated ulcerated IH were included. The average time to complete ulceration healing was 4.3 weeks in 30 of 33 patients and was significantly faster for head-and-neck locations (PÂ = .0354). The mean time to complete pain control was 14.5 days. Parents rated treatment as very effective for 27 of 31 patients and very well tolerated for 29 of 31 cases.Limitations: This was a retrospective uncontrolled study.Conclusion: Propranolol appears to be an effective and well-tolerated treatment for ulcerated IH.
Clinical differentiation of primary from secondary hyperhidrosis |
21 Feb 2011
Background: Hyperhidrosis (HH) is excessive sweating that may be primary (idiopathic) or secondary to medication or disease. Clinical features supporting primary or secondary etiology have not been well documented.Objective: To identify clinical and demographic features predictive of a diagnosis of primary versus secondary HH.Methods: A retrospective chart review was conducted over a 13-year period (1993-2005) of all patients (children and adults) seen at a university-based outpatient dermatology department with an International Classification of Diseases, 9th revision diagnosis code for HH (NÂ = 415).Results: Three hundred eighty-seven patients (93.3%) had primary HH (PHH); 28 patients (6.7%) had secondary HH (SHH). SHH patients were older (39.0Â Â± 18.6 years vs 27.3Â Â± 12.3 years) with more frequent onset at age older than 25 years (55% for SHH vs12.1% for PHH; odds ratio [OR] 8.7; 95% confidence interval [CI] 3.5-21.4; PÂ < .00001 for each). SHH was more often unilateral/asymmetric (OR: 51; 95% CI: 12.6-208), generalized (vs focal; OR: 18; 95% CI: 7.3-47.6), and present nocturnally (OR: 23.2; 95% CI: 4.3-126; PÂ < .00001 for each). Of SHH cases, endocrine disease accounted for 57% (including diabetes mellitus , hyperthyroidism , and hyperpituitarism ). Neurologic disease accounted for 32% (including peripheral nerve injury , Parkinson's disease , reflex sympathetic dystrophy , spinal injury  and Arnold-Chiari malformation ). Malignancy (pheochromocytoma), respiratory disease, and psychiatric disease were each represented once. Compared to otherÂ secondary causes, asymmetric HH favored neurologic disease (OR: 63; 95% CI: 4.9-810); PÂ =Â .0002).Limitations: Results were obtained from a single, university-based population.Conclusions: On the basis of these data, the diagnostic criteria for PHH were assessed statistically. Criteria include: excessive sweating of 6 months or more in duration, with 4 or more of the following: primarily involving eccrine-dense (axillae/palms/soles/craniofacial) sites; bilateral and symmetric; absent nocturnally; episodes at least weekly; onset at 25 years of age or younger; positive family history; and impairing daily activities. These criteria discriminate well between PHH and SHH (sensitivity: 0.99; specificity: 0.82; positive predictive value: 0.99; negative predictive value: 0.852) and may facilitate optimal clinical management.
Meta-analysis of randomized, controlled trials comparing griseofulvin and terbinafine in the treatment of tinea capitis |
21 Feb 2011
Background: Griseofulvin has been the standard treatment for tinea capitis but newer antifungal agents, particularly terbinafine, are increasingly being used because of their shorter duration of treatment and more consistent absorption rates.Objective: We sought to compare the efficacy of oral griseofulvin and oral terbinafine in the treatment of tinea capitis.Methods: A search of MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials, and the Cochrane Skin Group Ongoing Skin Trials Register was performed up to January 2010 for randomized controlled trials comparing griseofulvin and terbinafine in the treatment of tinea capitis in immunocompetent patients. The primary outcome measure was the complete cure rate. The mycological and clinical cure rates and adverse effects were secondary outcome measures. Pooling of treatment effect was accomplished using a random effects model and the I2 test was used to check for heterogeneity among the studies.Results: Seven studies involving 2163 subjects were included. There was no significant difference in efficacy between griseofulvin (mean duration of treatment 8 weeks, range 6-12 weeks) and terbinafine (mean duration of treatment 4 weeks, range 2-6 weeks); odds ratioÂ = 1.22 favoring terbinafine (95% confidence interval [CI]Â = 0.785-1.919; PÂ = .37). In the pooled analysis of 5 studies in which Trichophyton species were the predominant (â‰Ą65%) pathogenic dermatophyte, terbinafine showed a trend toward greater efficacy (odds ratio 1.49; 95% CIÂ = 0.975-2.277; PÂ = .065). Subgroup analysis revealed that terbinafine was more efficacious than griseofulvin in treating Trichophyton species (1.616; 95% CIÂ = 1.274-2.051; PÂ < .001) and griseofulvin was more efficacious than terbinafine in treating Microsporum species (0.408; 95% CIÂ = 0.254-0.656; PÂ < .001). Both griseofulvin and terbinafine demonstrated good safety profiles in the studies.Limitations: Data on efficacy of griseofulvin and terbinafine for separate groups of Trichophyton and Microsporum species were not available from every study. In the subgroup analysis of Microsporum species, data from only 3 studies were available.Conclusion: This meta-analysis suggests that terbinafine is more efficacious than griseofulvin in treating tinea capitis caused by Trichophyton species, whereas griseofulvin is more efficacious than terbinafine in treating tinea capitis caused by Microsporum species.
Online video improves clinical outcomes in adults with atopic dermatitis: AÂ randomized controlled trial |
14 Jan 2011
Background: Atopic dermatitis (AD) is a chronic inflammatory skin disorder characterized by intense pruritus that causes significant disease and psychosocial burden in patients. Patient education has the potential to improve clinical outcomes and patient knowledge of this condition.Objectives: We sought to assess the effectiveness of online video education at improving AD knowledge and disease severity compared with a written pamphlet, and to determine the usefulness and appeal of the two educational delivery vehicles.Methods: In a randomized controlled trial, 80 participants were randomized to receive either online video-based patient education or written pamphlet education about AD and its management. We assessed AD disease severity using the patient-oriented eczema measure (POEM) scale. AD knowledge was assessed with standardized questionnaires at baseline and after the 12-week intervention.Results: All participants had similar baseline knowledge and AD severity at the beginning of the study. On study completion, improvements in AD knowledge assessed by questionnaire were significantly greater in the video group than the pamphlet group (3.05 vs 1.85, PÂ = .011). Online video-based education resulted in greater improvement in clinical outcome, as measured by POEM, compared with pamphlet-based education (POEM score reduction of 3.30 vs 1.03, PÂ = .0043). Finally, although the usefulness of both interventions was rated equally (PÂ = .77), the online video was significantly more appealing than the pamphlet (PÂ = .0086).Limitations: This study is limited to AD in adults.Conclusion: Online video for patient education is an effective and appealing tool for improving clinical outcomes in adult patients with AD.
Dermatology information on the Internet: An appraisal by dermatologists and dermatology residents |
1 Dec 2010
To the Editor: Patients increasingly seek health information on the World Wide Web both for personal knowledge and to facilitate patientâ€“physician discussion at the time of medical consultation. In January 2008, approximately 44% of all health-related Web site traffic was on pages found via search engines, an increase of 3% in health-related traffic share from the previous year. Google.com received the greatest portion of this Internet traffic. The Internet provides an easily accessible forum through which health information, with varying accuracy, can be spread. This holds especially true with the development of Web 2.0, which is comprised of Web sites that are geared toward the facilitation of communication between Internet users (Wikipedia, blogs, etc).
Differentiation of vascular tumors from vascular malformations by expression of Wilms tumor 1 gene: Evaluation of 126 cases |
1 Dec 2010
Background: Vascular tumors and malformations can be challenging to diagnose. Although they may initially appear very similar, they have distinct clinical courses and management. Wilms tumor 1 (WT1) gene expression has been reported in many different tumors including hematologic malignancies and some solid tumors.Objective: We sought to evaluate the expression of WT1 in 126 vascular lesions (64 vascular tumors, one Masson tumor, and 61 vascular malformations).Methods: Based on the International Society for the Study of Vascular Anomalies classification of vascular anomalies, we studied the expression of WT1 in vascular tumors composed of infantile hemangioma, congenital hemangiomas (non-involuting, rapidly involuting, and not otherwise specified), pyogenic granuloma, tufted angioma, cherry angioma, Kaposi sarcoma, and angiosarcoma. We also studied WT1 expression in vascular malformations composed of angiokeratoma/verrucous hemangioma, combined vascular malformations, venous malformations, glomuvenous malformations, lymphatic malformations/lymphangioma, telangiectasia, and targetoid hemosiderotic hemangioma.Results: All vascular tumors and proliferations had positive WT1 cytoplasmic endothelial immunostaining whereas only 3 vascular malformations were WT1 positive. Moreover the positivity of WT1 in these vascular malformations was focal and involved only re-endothelialized neovessels within thrombi.Limitations: The low number of malignant vascular tumors is a limitation.Conclusions: Immunohistochemical detection of WT1 could be a useful tool to routine evaluation of vascular anomalies allowing the distinction of vascular tumors and proliferations from vascular malformations. Staining for WT1 may guide the clinician in difficult cases, as positive results would suggest a proliferative vascular lesion whereas negative results might point to a vascular malformation.
Delayed treatment and continued growth of nonmelanoma skin cancer |
9 Nov 2010
Background: Patients may delay treatment for skin cancer for various reasons. Prior research on treatment delay has focused on melanoma rather than nonmelanoma skin cancer (NMSC), which is much more common.Objective: We sought to clarify the reasons for delay in the presentation for diagnosis and treatment of NMSC.Methods: This was a prospective cohort study in a Mohs micrographic surgery private practice in an urban setting. Eligible subjects were 982 consecutive patients presenting for Mohs micrographic surgery for NMSC between March and December 2005. No enrolled subjects were withdrawn for adverse effects. The survey was a 4-page written self-administered questionnaire, eliciting patient medical history, skin cancer history, demographic information, initial and subsequent lesion size, and reasons for delay in presentation for evaluation and management. Outcome analyses addressed the: (1) frequency of specific reasons for delayed presentation, as provided by self-report; (2) association between reasons for delay with demographic or other patient-specific factors; and (3) change in lesion diameter from the time of detection by the patient to the time of presentation to the doctor.Results: Among the reasons for waiting, denial (including: thought it would go away, thought it wasn't important, too busy, thought they could self-treat, afraid it might be something dangerous) was the most frequent, accounting for 71% of cases; difficulty scheduling was associated with 10% of the instances of delay. Older patients (age >64 years) were more likely to wait to seek care than younger patients (odd ratio [OR]Â = 0.5; 95% confidence interval [CI] 0.4-0.7). Patients with a prior skin cancer were more likely to wait (ORÂ = 1.4; 95% CI 1.1-2.0), as were patients with major life problems (ORÂ = 2.6; 95% CI 1.6-4.3) and patients with a history of any cancer (ORÂ = 1.8; 95% CI 1.3-2.4). Weighted kappa analysis comparing tumor size at the two time points yielded a kappa of 0.72 (SEÂ = .02; 95% CI 0.68-0.77). When the data were separated into two groups, one including those tumors that had decreased in size or remained the same (698 patients), and those that had increased in size (120 patients), the median delay-to-presentation intervals associated with these two groups (2.5 vs 6.0 months, respectively) were found to be significantly different (PÂ < .0001).Limitations: This study may have limited generalizability to the extent that it reflects the characteristics only of the subpopulation of patients with skin cancer who eventually received treatment at a referral-based, urban, dermatology private practice. Overall, these patients may have been better insured and be more affluent than the general population.Conclusions: Denial is the most common patient-specific factor accounting for delayed presentation for NMSC diagnosis and treatment. Patients younger than 65 years, with a skin cancer history, with major life problems, and with a history of any cancer were most likely to wait to see a doctor. There was a significant increase in tumor size from the time when tumors were noticed by patients to the time when patients presented to a physician. Increased delay was associated with increased tumor growth.
Benefit-risk analysis of adalimumab versus methotrexate and placebo in the treatment of moderate to severe psoriasis: Comparison of adverse eventâ€“free response days in the CHAMPION trial |
8 Oct 2010
Background: The Comparative Study of Humira versus Methotrexate (MTX) versus Placebo in Psoriasis Patients (CHAMPION) demonstrated superior efficacy of biologic over conventional systemic immunosuppressant therapy in psoriasis.Objective: We sought to compare the risk-benefit profile of adalimumab (ADA), MTX, and placebo using data from CHAMPION.Methods: Patients randomized to ADA (nÂ = 107), MTX (nÂ = 110), or placebo (nÂ = 53) were followed up for 16 weeks. Response (â‰Ą75% improvement in Psoriasis Area and Severity Index), days free of adverse events (AEs), moderate to severe AEs, infection-related AEs, and study drugâ€“related AEs were analyzed.Results: ADA treatment was associated with substantially more days (SD) of AE-free response compared with MTX or placebo treatment, respectively: 36.9 (31.1) versus 8.3 (15.9) or 6.7 (18.1) days of response free of any AEs, 43.8 (31.9) versus 11.1 (19.9) or 7.9 (19.9) days of response free of moderate to severe AEs, 48.5 (29.2) versus 12.4 (21.7) or 9.2 (21.8) days of response free of infection-related AEs, and 44.6 (31.4) versus 11.8 (21.1) or 10.0 (24.0) days free of study drugâ€“related AEs (all PÂ < .0001 for ADA vs MTX or placebo).Limitations: This clinical trialâ€“based analysis may not have captured the full spectrum of AEs in the actual clinical setting. The short (16-week) duration of the trial limited the ability to capture some important but uncommon AEs associated with long-term ADA or MTX use.Conclusion: With 4 times as many AE-free response days, ADA demonstrated a superior benefit-risk profile.
IgM in lesional skin of adults with Henoch-SchĂ¶nlein purpura is an indication of renal involvement |
8 Oct 2010
Background: Henoch-SchĂ¶nlein purpura (HSP) is a multisystem disease believed to be a consequence of the entrapment of circulating IgA-containing immune complexes in blood vessel walls throughout the skin, kidneys, and gastrointestinal tract. The skin manifestations are characterized by nonthrombocytopenic palpable purpura over the lower extremities.Objective: We assessed adult patients with HSP who had nonthrombocytopenic palpable purpura on the extensor surfaces of their lower limbs, and had no associated connective tissue disease. Patient medical records, including clinical presentation, laboratory data, and direct immunofluorescence (DIF) reports, were reviewed retrospectively.Methods: We reviewed the records of 25 adult patients with HSP who presented at our department, between 2006 and 2008, with an initial cutaneous manifestation of palpable purpura on their lower extremities. Adult HSP was defined in all cases as documented leukocytoclastic vasculitis according to a skin biopsy specimen, with histopathologic evidence of IgA deposition by DIF. Statistical analyses were performed using a Ď‡2 test to compare prevalence among each clinical manifestation.Results: There was a significant correlation between IgM deposition by DIF and renal involvement (Ď‡2Â =Â 5.23, PÂ = .022). IgM deposition and complement 3 deposition by DIF showed a close relationship (Ď‡2Â = 5.11, PÂ = .024). There was a significant positive correlation between serum IgA and C-reactive protein levels (Spearman's rank correlation coefficientÂ = 0.35, PÂ = .044).Limitations: These findings should be validated in larger studies. Renal biopsies were not done to confirm the presence of nephritis.Conclusions: This study suggests that IgM deposition in palpable purpura based on DIF provides an indicator of nephritis in adult patients with HSP. We believe that IgM deposition could be related to theÂ pathogenic factors that trigger the development of renal involvement.
Photosensitivity testing in children |
4 Oct 2010
Background: Phototesting is an important diagnostic tool to objectify light-related symptoms. Data on phototesting procedures in children are scarce.Objective: The aim of this study was to evaluate phototest results in photosensitivity disorders in children.Methods: The phototest procedures are described. All children phototested in our department between 1995 and 2007 were included in this retrospective study. Children given the diagnosis of polymorphic light eruption (PLE) were selected for follow-up.Results: A total of 92 children (39 boys and 53 girls, age range 4-16 years) were successfully phototested. AÂ photosensitivity disorder was confirmed in 56 children (61%, 24 boys and 32 girls). PLE was diagnosed in 39%, photosensitivity associated with atopic dermatitis in 23%, and erythropoietic protoporphyria in 23%. Other diagnoses were less common. Ten children with PLE were followed up for at least 5 years. Seven reported their photosensitivity had not changed over time, in two cases it had diminished, and in one patient the photosensitivity had disappeared.Limitations: Retrospective study design is a limitation.Conclusion: Phototesting in children is feasible when performed in a case- and child-dependent manner. PLE was the most prevalent diagnosis in our series followed by photosensitivity in atopic dermatitis.
A prospective, randomized, split-face, controlled trial of salicylic acid peels in the treatment of melasma in Latin American women |
4 Oct 2010
Background: Melasma, a common disorder of hyperpigmentation, is often resistant to therapy. Although salicylic acid peels have been reported to be useful for patients with recalcitrant melasma, controlled trials are lacking.Objective: We sought to determine the efficacy of salicylic acid peels when added to hydroquinone in the treatment of melasma.Methods: Twenty Latin American women with moderate to severe bilateral melasma were treated with a series of 20% to 30% salicylic acid peels every 2 weeks for a total of 4 peels on one side of the face along with 4% hydroquinone cream to both sides of the face twice daily. The primary efficacy variable was reduction in pigmentation of the peeled side compared with the unpeeled side using narrowband reflectance spectrophotometry.Results: Eighteen patients completed the study. Although both sides had significant reduction in pigment intensity, there was no difference between the peeled and unpeeled side with all outcome measures.Limitations: Patients were limited to Latin American women and only 4 peels were performed.Conclusion: A series of four 20% to 30% salicylic acid peels are not effective in the treatment of melasma when added to twice-daily 4% hydroquinone cream.
Commentary: Iron deficiency and hair loss: Problems with measurement of iron |
1 Oct 2010
Iron is involved in many critical physiologic processes within the hair follicle, suggesting that iron deficiency could disrupt hair synthesis. However, studies of iron as a cause of hair loss have produced conflicting results. Some of the discrepancies may relate to limitations of assays for iron deficiency. This commentary discusses the sensitivity and specificity of available tests for iron deficiency and presents practical guidelines for testing and supplementation.
Iron deficiency and diffuse nonscarring scalp alopecia in women: More pieces to the puzzle |
1 Oct 2010
The relationship between nonscarring scalp alopecia in women and iron deficiency continues to be a subject of debate. We review the literature regarding the relationship between iron deficiency and nonscarring scalp alopecia and describe iron-dependent genes in the hair follicle bulge region that may be affected by iron deficiency. We conclude with a description of our approach to the diagnosis and treatment of nonscarring alopecia in women with low iron stores. Limitations include published studies with small numbers of patients, different study designs, and absence of randomized, controlled treatment protocols. Additional research regarding the potential role of iron during the normal hair cycle is needed, as is a well-designed clinical trial evaluating the effect of iron supplementation in iron-deficient women with nonscarring alopecia.
Early treatment of cold sores with topical ME-609 decreases the frequency of ulcerative lesions: AÂ randomized, double-blind, placebo-controlled, patient-initiated clinical trial |
20 Sep 2010
Background: Prior pilot studies support the use of antiviral medications with topical corticosteroids for herpes simplex labialis (HSL). ME-609 (Xerese, Xerclear) is a combination of 5% acyclovir and 1% hydrocortisone developed for the topical treatment of HSL.Objectives: The primary study end point was the prevention of ulcerative HSL lesions.Methods: In all, 2437 patients with a history of HSL were randomized to self-initiate treatment with ME-609, 5% acyclovir in ME-609 vehicle, or ME-609 vehicle (placebo) at the earliest sign of a cold sore recurrence. Cream was applied 5 times/d for 5 days. AÂ total of 1443 patients experienced a recurrence and initiated treatment with ME-609 (nÂ = 601), acyclovir (nÂ = 610), or placebo (nÂ = 232).Results: Of patients receiving ME-609, 42% did not develop an ulcerative lesion compared with 35% of patients receiving acyclovir in ME-609 vehicle (PÂ = .014) and 26% of patients receiving placebo (PÂ < .0001). In patients with ulcerative lesions, healing times were reduced in the ME-609 and acyclovir groups compared with placebo (PÂ < .01 for both). The cumulative lesion area for all lesions was reduced 50% in patients receiving ME-609 compared with the placebo group (PÂ < .0001). There were no differences among groups in the number of patients with positive herpes simplex virus cultures. The side-effect profile was similar among treatments.Limitations: The study did not contain a group treated with a topical corticosteroid alone.Conclusions: ME-609 prevented progression of cold sores to ulcerative lesions and significantly reduced the cumulative lesion area compared with acyclovir and placebo. ME-609 treatment offers additional therapeutic benefit compared with therapy with topical acyclovir alone.
Obesity and psoriasis: From the Medical Board of the National Psoriasis Foundation |
9 Aug 2010
An association between obesity and psoriasis has been reported. For a variety of reasons, obese persons with psoriasis are often more difficult to treat. We sought to review the literature on obesity and psoriasis and to discuss efficacy and safety data that could be utilized by clinicians who are making treatment decisions for obese persons with psoriasis. We performed a literature review using the terms â€śobesity and psoriasisâ€ť and â€śmetabolic syndrome and psoriasis.â€ť Evidence from relevant literature was evaluated and categorized according to the criteria of Shekelle et al (published 1999). Numerous reports cite an association between obesity and psoriasis. When compared with non-obese patients with psoriasis, obese patients with psoriasis are more likely to experience certain adverse effects to medications and are less likely to respond favorably to systemic therapies. The amount of category I evidence for objectively determining the best treatment choices for obese patients with psoriasis was scarce and thus did not allow for the development of a treatment algorithm that could be generally applied for all psoriasis patients who are obese. Efficacy and safety concerns affected by obesity are important considerations for clinicians who are making decisions on proper treatment of psoriasis.
Therapeutic ladder for pemphigus vulgaris: Emphasis on achieving complete remission |
15 Jul 2010
Background: Pemphigus vulgaris (PV) is a blistering autoimmune bullous disease that is usually fatal without proper treatment. There are no clear treatment guidelines for PV at this time.Purpose: We suggest a standard treatment regimen for patients with PV based on the success of our treatment.Methods: A retrospective chart review of 18 patients with PV was conducted to assess response to a similar approach using mycophenolate mofetil (MMF) and prednisone. Diagnosis was confirmed through routine histology, direct immunofluorescence, and indirect immunofluorescence, and patients were followed up for a total average of 35.2 months.Results: We achieved complete disease control in 89% of patients using our treatment algorithm. Fourteen of 18 patients achieved complete disease control on therapy with prednisone and MMF. Three of the 4 patients who did not achieve control on MMF and prednisone went on to receive rituximab therapy, and two of those patients achieved disease control on rituximab. The average length of time from initiating therapy to 75% clearance of lesions was 4.5 months. Three of 18 patients were able to discontinue therapy after an average of 3 years and have remained in complete remission for more than 1 year.Limitations: This was a retrospective chart review with a small patient sample size.Conclusions: The combination therapy of MMF and prednisone is an effective treatment regimen to achieve rapid and complete control of PV. For those patients who fail treatment with MMF and prednisone, rituximab is an efficacious alternative therapy.