Rare presentation of adult-onset cutaneous mastocytoma of the breast.

Mastocytosis is a rare condition in which mast cells accumulate throughout various organs of the body-the most common subtype being confined to the skin. We present an unusual case of cutaneous mastocytosis localized to the unilateral breast of a young woman with partial involvement of the areola. Previously diagnosed as nipple eczema, the patient failed appropriate treatment with class III and IV topical corticosteroids. Given it was adult onset, failed appropriate treatment, and had an atypical clinical appearance, a biopsy was pursued that revealed mastocytosis in skin. This is another clinical diagnosis dermatologists may consider in their differential diagnosis of nipple dermatitis.

The dermatologic intimacy scale: quantitatively measuring the impact of skin disease on intimacy.

INTRODUCTION: Patient-reported outcome measures are increasingly utilized in dermatology to assess the impact of skin disease on quality of life. Despite recognition of the influence of skin disease on intimate relationships, an instrument to assess intimacy has not been developed. The objective of this study was to create the dermatologic intimacy scale (DIS) and administer the prototype to a patient population. METHODS: A group of healthcare providers at the University of California San Francisco created the DIS prototype. A total of 1676 psoriasis patients of an online community were invited to complete a cross-sectional survey including demographic information, DIS, body surface area (BSA) and anatomical involvement. RESULTS: A total of 1109 patients completed the survey in its entirety. Patients with moderate-to-severe psoriasis (BSA ≥3%) had a higher DIS score overall and for each individual question than patients with mild disease (BSA < 3%; p < .001). Patients with genitalia, nails, face, neck and scalp involvement had higher scores compared to patients without involvement (p < .001). CONCLUSIONS: Patients with more extensive disease and specific anatomical involvement experience a greater impact on intimacy. Interpretation is limited by patient response rate, as patients with or without intimacy issues may be more or less likely to respond. Further analysis is necessary for validation and interpretation.

Treatment challenges in the management of moderate-to-severe plaque psoriasis - role of secukinumab.

Psoriasis is a chronic inflammatory skin disease that has a negative impact on psychosocial well-being and cardiometabolic health. Treatment options for moderate-to-severe psoriasis have expanded with the development of interleukin-17 (IL-17) inhibitors, the first of which is now available - secukinumab. Secukinumab is a fully human monoclonal immunoglobulin G1 κ antibody that selectively inhibits the ligand IL-17A. In head-to-head studies, it is more effective than etanercept and ustekinumab, particularly in achieving Psoriasis Area and Severity Index (PASI) 90/100 and achieving PASI 50/75 as early as week 4. No head-to-head trials are available for comparison of adalimumab to secukinumab. Significant improvement in health care-related quality of life was also observed using the dermatology quality index in clinical studies. Safety data for secukinumab is comparable to available biologics. Specific safety concerns for the use of secukinumab include its use in patients with inflammatory bowel disease, reversible transient neutropenia, in those with a latex allergy, and the occurrence of mild to moderate oral or genital candidiasis. Secukinumab is an effective and safe treatment option that achieves high clearance rates up to PASI 90 and 100 as monotherapy in cases of moderate-to-severe psoriasis. It may be particularly helpful in patients with psoriasis who have formed antidrug antibodies or failed other biologic agents and in patients with psoriatic arthritis or ankylosing spondylitis.

Psychodermatology.

Psychodermatology is an underappreciated field that studies psychocutaneous disorders, which are conditions that have both dermatologic and psychiatric characteristics. Underlying psychiatric comorbidity is estimated to occur in up to one-third of dermatologic patients, and psychiatric illness may either be the cause or the consequence of dermatologic disease. Psychodermatologic patients lack insight and often do not recognize a psychiatric etiology for their symptoms and therefore comprise some of the most challenging cases to treat. Herein, we discuss the background and clinical presentation of the most commonly encountered psychodermatologic conditions, including delusional infestation, neurotic excoriations, factitial dermatitis, trichotillomania and body dysmorphic disorder, followed by practical diagnostic and therapeutic recommendations.

Enhancing patient satisfaction in dermatology.

Patient satisfaction is an important component of dermatological care that reflects patients' perspectives on the care they receive. While physicians' expertise and judgment should always remain the foundation of providing appropriate and effective care, the patient experience can also be influenced by interpersonal relationships, expectations, and a sense of agency in the treatment patients receive. Dermatology providers can use practical techniques such as sitting rather than standing, reframing the concept of cure, and engaging patients in treatment decisions to improve the patient-provider experience and thereby optimize patient satisfaction.

Supraerythemogenic excimer laser in combination with clobetasol spray and calcitriol ointment for the treatment of generalized plaque psoriasis: Interim results of an open label pilot study.

BACKGROUND: The combination of phototherapy and topical therapy is one of the most widely used treatment modalities for moderate to severe psoriasis. The development of targeted phototherapy with excimer laser and new topical spray formulations has made these therapies both more convenient and more effective. In this open label pilot study, we aim to assess the efficacy of combination therapy using 308-nm excimer laser, clobetasol propionate spray and calcitriol ointment for the treatment of moderate to severe generalized psoriasis. METHODS: In this 12-week study, patients with moderate to severe psoriasis received twice weekly treatment with XTRAC® Velocity 308-nm excimer laser combined with clobetasol propionate twice daily followed by calitriol ointment twice daily. RESULTS: To date, 21 patients have completed the protocol. By week 12, 76% of the patients had a reduction in Psoriasis Area and Severity Index by at least 75% (PASI-75) and 52% had a Physicians Global Assessment of "clear" or "almost clear". CONCLUSIONS: Excimer laser therapy combined with an optimized topical regimen that includes clobetasol spray followed by calictriol ointment appears to be an effective treatment for moderate to severe generalized psoriasis that avoids the risk of serious internal side effects associated with many systemic agents.

Anti-IL-17 phase II data for psoriasis: A review.

UNLABELLED: Abstract Background: Studies investigating the molecular basis of psoriasis have established the central roles of TNFα, interleukin (IL)-12, IL-22 and IL-23 and there is increasing evidence that IL-17 plays a critical role in the complex pathophysiology. Preclinical studies suggest that IL-17 is a desirable therapeutic target for psoriasis treatment. METHODS: We reviewed the results of the phase II clinical trials for the anti-IL-17 agents secukinumab, ixekizumab and brodalumab in order to assess the efficacy and safety profile of each agent. RESULTS: By week 12, the proportion of patients reaching Psoriasis Area and Severity Index (PASI 75) was comparable among the most efficacious dosage between the different agents (secukinumab 82%, ixekizumab 83% and brodalumab 82%; p<0.001 compared to placebo for all agents). The safety profiles of the agents were similar with the most frequently reported adverse events of nasopharyngitis, upper respiratory infections and injection site reaction. A small percentage of patients experienced low-grade neutropenia that was predominantly transient and asymptomatic. CONCLUSION: The anti-IL-17 agents demonstrated a rapid and robust clinical improvement accompanied by a favorable short-term safety profile. The results of the phase II trials support the theory that the IL-17 pathway is an essential target in psoriasis treatment.

The role of IL-17 in psoriasis.

BACKGROUND: Psoriasis is a chronic skin condition traditionally believed to involve the Th1 pathway. Recently, the IL-23/Th17/IL-17 pathway has been highlighted in the pathogenesis of psoriasis and other autoimmune inflammatory conditions. From a clinician's perspective, we sought to review the basic science data relevant to IL-17's role in psoriasis pathogenesis. METHODS: We performed a Pubmed and Web of Knowledge search for English articles starting from 1990 that discussed the Th17 pathway. Search terms such as "IL-17" and "psoriasis" were utilized. RESULTS: The IL-17 pathway is regulated by IL-23, a cytokine that is vital for the expansion and maintenance of the Th17 cell population. Th17 derived cytokines (IL-17A, IL-17F, IL-17A/F and IL-22) were elevated in both psoriasis-like murine models and human psoriatic lesional biopsies. Ixekizumab (anti-IL-17A) treatment of psoriasis was found to normalize levels of IL-17 downstream gene products. CONCLUSION: Both preclinical and clinical studies support the central role of IL-17 in the pathogenesis of psoriasis.

Social impact of the burden of psoriasis: effects on patients and practice.

The raised, scaly, and erythematous plaques associated with psoriasis can be cosmetically disfiguring, which may provoke disgust, fear, and aversion in others. Consequently, the social stigma of psoriasis can be devastating for patients, evoking feelings of shame and anxiety about how they are perceived. In recent years, appreciation of psoriasis as a disease that can cause social distress and impairment has increased. This review discusses the manifold social burdens of psoriasis; different and emerging therapies that may mitigate these burdens by improving outcomes associated with the underlying disease; and psoriasis management in the context of healthcare reform changes focused on assessing the quality and value of patient care. The social impact of psoriasis is substantial (eg, affecting interpersonal relationships, sexual function, intimacy, occupational success). Undertreatment of psoriasis continues, despite evidence that biologic agents may lessen the physical and social burdens and provide greater patient satisfaction than conventional therapy. Changes in healthcare place an even greater emphasis on measurable outcomes, including patient satisfaction. Increased understanding of the social burden of psoriasis may lead to provision of more comprehensive, holistic care that is in concordance with the evolving restructured reimbursement system.

How to optimally manage unhappy, anxious, and difficult patients.

Patient satisfaction has been and is of growing importance in healthcare. Recent healthcare initiatives aim to provide physicians with performance feedback reports based partially on patient completed surveys; thus, patient satisfaction will be an even more important determinant of high quality care. In the field of dermatology, patient satisfaction is particularly relevant and at times difficult to achieve, since many patients are plagued with chronic skin diseases often requiring intensive topical regimens or undesirable systemic immunosuppressants. The discussion of patient satisfaction is usually restricted to encounters with the general clinic population leaving encounters with difficult patients largely underreported; therefore, we provide examples of more common difficult patient encounters a dermatologist may face with specific recommendations on how to best optimize patient satisfaction.

Biologic fatigue in psoriasis.

BACKGROUND: Over the past 15 years, biologic medications have greatly advanced psoriasis therapy. However, these medications may lose their efficacy after long-term use, a concept known as biologic fatigue. We sought to review the available data on biologic fatigue in psoriasis and identify strategies to help clinicians optimally manage patients on biologic medications in order to minimize biologic fatigue. METHODS: We reviewed phase III clinical trials for the biologic medications used to treat psoriasis and performed a PubMed search for the literature that assessed the loss of response to biologic therapy. RESULTS: In phase III clinical trials of biologic therapies for the treatment of psoriasis, 20-32% of patients lost their PASI-75 response during 0.8-3.9 years of follow-up. A study using infliximab reported the highest percentage of patients who lost their response (32%) over the shortest time-period (0.8 years). Although not consistently reported across all studies, the presence of antidrug antibodies was associated with the loss of response to treatment with infliximab and adalimumab. CONCLUSION: Biologic fatigue may be most frequent in those patients using infliximab. Further studies are needed to identify risk factors associated with biologic fatigue and to develop meaningful antidrug antibody assays.

Successful use of the excimer laser for generalized psoriasis in an ustekinumab non-responder.

Effective treatments for moderate to severe psoriasis are phototherapy and biologics. These treatments are similar in that they both decrease cutaneous immune system hyperactivity yet do so via different mechanisms. Our patient, a 63 year old Asian male had a rapid response to treatment with the high dose excimer laser, having previously failed treatment with 28 weeks of ustekinumab therapy. A pre-treatment biopsy of a psoriatic plaque was found to contain relatively low levels of IFN-γ (Th1) and IL-17 (Th17) secreting T cells. Following treatment with the excimer laser, the patient had a quick improvement in PASI that was reflected by a 3-fold reduction in the number of live T cells found in the post-treatment biopsy. Although ustekinumab and the excimer laser both result in decreased levels of these cytokines, the excimer laser directly causes apoptosis of T cells and induces DNA damage in antigen presenting cells. Thus, the broader effects of phototherapy on immune cells compared to the targeted inhibition of IL-12 and IL-23 by ustekinumab likely account for the superior response observed.