Drug-induced phototoxicity: A systematic review.

BACKGROUND: Phototoxicity has been attributed to numerous oral drugs over the past 60 years. OBJECTIVE: Determine the quality of evidence supporting suspected phototoxicity from oral drugs. METHODS: The MEDLINE and EMBASE databases were searched for all studies that contain original data for drug-induced phototoxicity and were published between May 1959 and December 2016. Study quality was assessed by using a modified Grading of Recommendations, Assessment, Development and Evaluation scale. RESULTS: The review included 240 eligible studies with a total of 2466 subjects. There were 1134 cases of suspected phototoxicity associated with 129 drugs. Most associations were supported by either very low-quality or low-quality evidence (89.1% of the studies). Medications supported by stronger evidence were vemurafenib, nonsteroidal anti-inflammatory drugs, and antibiotics, specifically, fluoroquinolones and tetracyclines. The most frequently reported drugs were vemurafenib, voriconazole, doxycycline, hydrochlorothiazide, amiodarone, and chlorpromazine. Photobiologic evaluation was performed in only 56 studies (23.3%), whereas challenge-rechallenge was done in 10% of cases. LIMITATIONS: Only English-language publications were reviewed. Cases of phototoxicity that had been incorrectly categorized as photoallergy would not have been included. CONCLUSIONS: Most purported associations between oral drugs and phototoxicity are not supported by high-quality evidence. Despite the variable quality of data, clinicians should be aware of the possible consequences of long-term use of culprit drugs.

Treatment of Moderate to Severe Psoriasis With High-Dose (450-mg) Secukinumab: Case Reports of Off-Label Use.

Treatment of moderate to severe psoriasis often requires systemic therapy, including biologics. Partial response to biologics and relapses are commonly managed with dose escalation. Secukinumab is a relatively new biologic that is currently used to treat moderate to severe psoriasis. There has been no literature published on dose escalation of secukinumab. This article describes the off-label use of a higher dose of secukinumab (450 mg every 4 weeks) instead of the standard dosing (300 mg every 4 weeks) in 2 patients with moderate to severe psoriasis. The first case involves a male patient with a high body mass index (BMI) (≥30 kg/m2) and severe psoriasis who was started on secukinumab at 450 mg following a partial response to treatment with the standard 300-mg dose. His psoriasis significantly improved with the higher dose of secukinumab. The second case discusses a female patient with treatment-resistant psoriasis and a BMI of 31.6 kg/m2 who initially achieved a complete remission with standard dosing of secukinumab. Later, her psoriasis relapsed and she was dose-escalated to secukinumab 450 mg in an attempt to recapture response, but this dose escalation was unsuccessful. In both cases, there were no adverse events observed with a higher dose of secukinumab. These cases demonstrate that dose escalation of secukinumab (450 mg rather than on-label 300 mg every 4 weeks) may be considered in selected patients with incomplete clearance, particularly for those with a high BMI. However, secukinumab dose escalation may not be as beneficial in patients with loss of efficacy.

The association between question type and the outcomes of a Dermatology eConsult service.

BACKGROUND: eConsult is a web based service that facilitates communication between primary care providers (PCPs) and specialists, which can reduce the need for face-to-face consultations with specialists. One example is the Champlain BASE (Building Access to Specialist through eConsultation) service with dermatology being the largest specialty consulted. METHODS: Dermatology eConsults submitted from July 2011 to January 2015 were reviewed. Post eConsult surveys for PCPs were analyzed to determine the number of traditional consults avoided and perceived value of eConsults. The time it took the PCP to receive a reply and the amount of time reported by the specialist to answer eConsult were proactively recorded and analyzed. A subset of 154 most recent eConsults was categorized for dermatology content and question type (e.g. diagnosis or management) using a validated taxonomy. RESULTS: A total of 965 eConsults were directed to dermatology from 217 unique PCPs. The majority of eConsults (64%) took the specialist between 10 and 15 minutes to answer. The overall value of this service to the provider was rated as very good or excellent in 95% of cases. In 49%, traditional in-person assessments were avoided. In the subset of the most recent cases, diagnosis was the most common question type asked (65.2%) followed by management (29%) and drug treatment (10.6%). The top five subject areas (40%) were: Dermatitis, Infections, Neoplasm, Nevi, and Pruritus. CONCLUSION: eConsults was feasible and well received by PCPs, which improves access to dermatology care with a potential to reduce wait times for traditional consultation.