Failure of Biologic Therapy in Psoriasis.

OBJECTIVE: This study aims to describe the frequency of biologic therapy failure in psoriasis patients along with associated patient demographics and characteristics. METHODS: This was a retrospective medical-record review of psoriasis patients evaluated from January 1st, 2013, through May 1st, 2018, and who failed at least once to adhere to their biologic therapy. RESULTS: Seventy-seven patients with psoriasis who had discontinued biologic therapy at least once were included in this study. Hypertension (58.4%), diabetes (37.7%), dyslipidemia (27.3%), and psoriatic arthritis (23.4%) were the main comorbidities observed. Adalimumab (ADA, 80.5%), ustekinumab (UST, 70.1%), and etanercept (ETA, 14.2%) were the most frequently used biologics in our cohort. The biologic with the longest mean duration of use prior to its discontinuation was UST (17.0 months), followed by ADA (15.9 months) and ETA (13.6 months). CONCLUSION: The most common reason for discontinuing biologic therapy was that said therapy was not effective, though for ETA and UST, the fact that biologic therapies are not universally covered by insurance company was found to be associated with their discontinuation, as well. There were no statistically significant associations found between biologic therapy discontinuation and age, gender, or comorbidities, which last included obesity, class I. Larger studies are warranted to identify risk factors associated with biologic therapy failure to help guide drug selection, decrease morbidity associated with such nonadherence and improve patient outcomes.

Psoriatic Alopecia in a Patient With Crohn Disease: An Uncommon Manifestation of Tumor Necrosis Factor α Inhibitors.

Tumor necrosis factor α (TNF-α) inhibitors are used to treat multiple inflammatory diseases including rheumatoid arthritis, inflammatory bowel disease, and psoriasis, among others. This family of medications can cause various side effects, some as common as injection-site reactions and others as rare as the paradoxical induction of psoriasiform skin lesions. Alopecic plaques recently have been described as an uncommon adverse effect of the TNF-α inhibitors adalimumab and infliximab. We present the case of a 12-year-old girl treated with adalimumab for Crohn disease who developed an alopecic crusted plaque on the scalp 6 months after increasing the dose of the medication. Biopsies, special stains, and sterile cultures yielded a diagnosis of psoriatic alopecia secondary to TNF-α inhibitor. A literature review for similar cases found 24 additional patients presenting with similar findings, of which only 6 were part of the pediatric population.

Folliculocystic and Collagen Hamartoma: A Distinct Hamartoma Associated With Tuberous Sclerosis Complex.

ABSTRACT: Tuberous sclerosis complex (TSC) is a neurocutaneous disease characterized by cutaneous and extracutaneous hamartomas. Dermatologic evaluation is critical for early diagnosis because mucocutaneous manifestations account for 4 of 11 major and 3 of 6 minor diagnostic criteria. Folliculocystic and collagen hamartoma (FCCH) is a recently described entity associated with TSC. We herein describe the case of a 28-year-old woman with a history of TSC who presented with a scalp lesion present since childhood. Physical examination revealed a solitary, well-circumscribed exophytic tumor over the occipital scalp measuring 9 × 8 cm and covered with comedones and cyst-like structures. Biopsy of the lesion demonstrated thickening of the collagen bundles throughout the dermis, concentric perifollicular and perivascular fibrosis, an increased number of dilated vessels, and keratin-filled cysts lined by the infundibular epithelium. Clinicopathologic correlation was diagnostic for FCCH. The patient was referred for surgical excision. In addition, we review 11 other cases of FCCH previously reported in the literature.

Treatment of erythrodermic psoriasis with biologics: A systematic review.

BACKGROUND: Biologic medications for plaque psoriasis have been used to treat erythrodermic psoriasis (EP). Since the guidelines for management of EP were published, new biologic medications have been approved for the treatment of plaque psoriasis. OBJECTIVE: To analyze the evidence of biologic medications in the treatment of EP based on response and tolerability. METHODS: A comprehensive search was conducted with the PubMed, Cochrane Library, Embase, and Scopus databases through December 31, 2018. Studies reporting 1 or more cases of EP, defined as >75% body surface area involvement, in patients aged ≥18 years treated with biologics were included. Baseline Psoriasis Area and Severity Index score, score improvement, and adverse events were documented. Adequate response to treatment was defined as Psoriasis Area and Severity Index ≥50. RESULTS: Included were 43 articles, yielding a total of 179 patients. Most patients responded at some point during treatment, with a higher level of evidence for infliximab, ustekinumab, ixekizumab, and guselkumab. Infection was the most common adverse event (n = 35). LIMITATIONS: Data are limited to case reports, case series, and uncontrolled studies. CONCLUSION: Patients with EP treated with biologics demonstrated positive responses and treatment was well-tolerated, with a weak recommendation and limited quality of evidence in favor of infliximab, ustekinumab, ixekizumab, and guselkumab.

Biological therapy for pustular psoriasis: a systematic review.

BACKGROUND: The anecdotic evidence of the benefits from biologic agents for psoriasis is extensive. However, data on the efficacy of biologic agents for pustular psoriasis are limited. METHODS: To update the data on the efficacy and safety of biologic agents for the management of pustular psoriasis. A systematic review of published data regarding biologic therapies on PubMED database, used in the management of pustular psoriasis from 2012 was undertaken. RESULTS: A total of 209 articles were identified, and 43 articles were selected for inclusion. TNF-α inhibitors were used in 205 patients, and 86 patients received ustekinumab, secukinumab, brodalumab, ixekizumab and IL-1 inhibitors. Overall response was favorable for most modalities. No serious adverse events were reported. Inconsistent measures of treatment response and study variability limited the overall evaluation of data. CONCLUSIONS: Infliximab and ustekinumab have the most evidence of efficacy and safety for the treatment of pustular psoriasis. Recent evidence supports the use of IL-17 antagonists. Prospective controlled and comparative trials are needed to further explore the efficacy and safety of biologic agents in order to establish objective recommendations for the management of this challenging condition.

Extraocular Sebaceous Carcinoma-A Clinicopathologic Reassessment.

Sebaceous carcinoma is an aggressive adnexal neoplasm with sebaceous differentiation. Few reports have described the histopathologic characteristics of the sebaceous carcinoma occurring extraocularly. Seventy-two cases of extraocular sebaceous carcinoma were identified from the database of a Dermatopathology Laboratory from January 1, 2007 to May 31, 2013. More cases occurred in men (60%), with a mean age at diagnosis of 65.8 years (range 39-99 years). Neoplasms were histopathologically classified as well-differentiated (22%), moderately differentiated (67%), and poorly differentiated (11%). Sixty-seven percent (67%) of cases demonstrated a squamoid growth pattern and thirty-three percent (33%) demonstrated a basaloid growth pattern. A majority of the neoplasms histopathologically classified as well-differentiated (94%) and moderately differentiated (65%) demonstrated a squamoid growth pattern. Ten percent (10%) of cases exhibited cystic histopathologic changes. The histopathological features reported in this study aid in the understanding of extraocular sebaceous carcinoma and its eventual diagnosis and classification.

Refractory dissecting Cellulitis of the Scalp Successfully controlled with Adalimumab.

Dissecting cellulitis of the scalp (DCS) is an uncommon inflammatory disease that often results in scarring alopecia. Numerous therapies have either proved ineffective or only temporarily effective in the management of this condition. Recent reports show adequate responses to tumor necrosis factor (TNF) inhibitors in cases of DCS. We report a case of severe recalcitrant DCS successfully treated with adalimumab.

Focal dermal hypoplasia with unusual cutaneous features.

Focal dermal hypoplasia (Goltz syndrome) is a rare genetic condition characterized by numerous malformations in different organ systems derived from the ectoderm and mesoderm. We present an infant with focal dermal hypoplasia who, besides having a constellation of anomalies commonly encountered in patients with this syndrome, manifested additional unusual features such as an early inflammatory vesicular stage and a cleft lip and palate. We emphasize that a prompt, well-orchestrated and effective multidisciplinary intervention can help improve the quality of life in patients afflicted with this condition.

Modified curettage technique for molluscum contagiosum.

Molluscum contagiosum is a frequently occurring, virally induced cutaneous condition that affects infants, children, and adults. Although historically considered a self-limiting entity, many patients experience prolonged infections, often resistant to varied therapeutic interventions. Topical treatments achieve complete clearance in only a limited number of patients. Because of the associated pain, affected children are characteristically uncompliant to commonly used destructive modalities. We describe a modification of the traditional curettage technique to remove lesions of molluscum contagiosum, which has proven to be effective and well tolerated by a significant number of patients in our practice.

Acral syringomas presenting as a photosensitive papular eruption.

A 43-year-old woman presented with a recurrent and remitting eruption of reddish-brown papules in the sun-exposed areas of the arms and forearms that had been present for 2 years. Results of a histopathologic examination revealed syringoma. To the best of our knowledge, this is the first case report of syringomas confined to sun-exposed areas with a recurrent and remitting course over time. We also review the literature on acral syringomas.

Octyl-2-cyanoacrylate liquid bandage as a wound dressing in facial excisional surgery: results of an uncontrolled pilot study.

BACKGROUND: Although cyanoacrylate tissue adhesives are frequently used in the closure of cutaneous lacerations and excisions, only a few reports comment on their usefulness as a dressing over sutured wounds. A new formulation of octyl-2-cyanoacrylate (Liquid Bandage; BAND-AID, Johnson & Johnson) is used as an occlusive protective film over minor cuts and scrapes. OBJECTIVE: An uncontrolled pilot study to assess the safety, efficacy, and cost of Liquid Bandage as an occlusive dressing over sutured facial excisions. METHODS: Patients undergoing excision of facial neoplasms were recruited. After conventional layered repair, Liquid Bandage was applied. On suture removal, the wounds were photographed and evaluated by three dermatologists, who assigned an overall outcome rating. The average cost of Liquid Bandage and routine wound care materials was calculated based on prices from three different pharmacies. RESULTS: Of the 18 wounds available at follow-up, 17 were assigned an overall outcome rating of good or excellent by at least one of the evaluators. Eleven wounds received an excellent rating from at least two of the evaluators. One case of distal flap necrosis occurred. Liquid Bandage proved to be less expensive than routine postsurgical wound care materials. CONCLUSIONS: Liquid Bandage dressing is safe and effective over sutured facial excisions.

Imiquimod: an effective alternative for the treatment of invasive cutaneous squamous cell carcinoma.

BACKGROUND: Some patients with invasive cutaneous squamous cell carcinoma are either not adequate surgical candidates or present with lesions in cosmetically sensitive areas in which a surgical procedure might result in an apparent and/or a cosmetically unacceptable scar. OBJECTIVE: To evaluate the effectiveness of imiquimod 5% cream in the treatment of an invasive squamous cell carcinoma in the nose of a young man. METHODS: Imiquimod 5% cream was applied to the lesion five times a week for 12 weeks. RESULTS: Complete clinicopathologic tumor clearance and an excellent cosmetic result were achieved after 12 weeks of imiquimod treatment. CONCLUSION: Imiquimod 5% cream may represent a reasonably effective alternative for the management of invasive squamous cell carcinoma in selected patients.

Postsurgical use of imiquimod 5% cream in the prevention of earlobe keloid recurrences: results of an open-label, pilot study.

BACKGROUND: Traditional surgical modalities for the management of earlobe keloids are often associated with high recurrence rates. A recent report suggests that imiquimod 5% cream can be effective in the prevention of keloid recurrences after surgical excision. OBJECTIVES: To establish the safety and efficacy of imiquimod 5% cream in the prevention of recurrences of excised earlobe keloids. METHODS: Patients who attended a dermatologic surgery clinic for the treatment of earlobe keloids were recruited into the study. Earlobe keloids underwent parallel shave excision. Imiquimod 5% cream was applied daily for 8 weeks followed by an observation period of 16 weeks. In patients who presented with bilateral earlobe keloids, paired comparisons of imiquimod versus intralesional steroid injections were performed. RESULTS: Eight earlobes were treated with imiquimod 5% cream after parallel keloid removal. Twenty-four weeks after surgery, six (75%) remained recurrence free. Four patients underwent bilateral paired comparisons. At the end of the observation period, two patients (50%) remained recurrence free in the imiquimod-treated areas while experiencing recurrences in the intralesional steroid-treated areas. Local irritation secondary to imiquimod application required rest periods in three cases. In all cases, patients were able to resume therapy and completed the study without further complications. CONCLUSION: Although small and uncontrolled, the results of this open-label, pilot study suggest that imiquimod 5% cream may prove to be a reasonably effective adjuvant therapeutic alternative for the prevention of recurrences in excised earlobe keloids.

Successful treatment of persistent melanoma in situ with 5% imiquimod cream.

BACKGROUND: Five percent imiquimod cream, a topically applied immune response modifier with potent antiviral and antitumor activity, has been reported to be effective in the management of lentigo maligna and cutaneous metastases from melanoma. OBJECTIVE: We report a case in which 5% imiquimod cream was effective in the management of a persistent melanoma in situ. METHODS: Five percent imiquimod cream was applied to the affected area twice to three times a week, as tolerated. RESULTS: After 4 months of treatment, repeated biopsies of the previously affected areas showed complete regression of the melanoma. CONCLUSION: Treatment of melanoma in situ of sun-damaged areas with 5% imiquimod cream certainly appears warranted in selected cases where surgical procedures have failed or are not feasible owing to factors such as size and/or localization of the lesion, advanced age, or deteriorated medical status of the patient. Rigorous posttreatment follow-up is mandatory, because long-term recurrence rates after treatment of melanoma in situ with imiquimod are yet unknown.