Home- vs Office-Based Narrowband UV-B Phototherapy for Patients With Psoriasis: The LITE Randomized Clinical Trial.

Importance: Office-based phototherapy is cost-effective for psoriasis but difficult to access. Home-based phototherapy is patient preferred but has limited clinical data, particularly in patients with darker skin. Objective: To compare the effectiveness of home- vs office-based narrowband UV-B phototherapy for psoriasis. Design, Setting, and Participants: The Light Treatment Effectiveness study was an investigator-initiated, pragmatic, open-label, parallel-group, multicenter, noninferiority randomized clinical trial embedded in routine care at 42 academic and private clinical dermatology practices in the US. Enrollment occurred from March 1, 2019, to December 4, 2023, with follow-up through June 2024. Participants were 12 years and older with plaque or guttate psoriasis who were candidates for home- and office-based phototherapy. Interventions: Participants were randomized to receive a home narrowband UV-B machine with guided mode dosimetry or routine care with office-based narrowband UV-B for 12 weeks, followed by an additional 12-week observation period. Main Outcomes and Measures: The coprimary effectiveness outcomes were Physician Global Assessment (PGA) dichotomized as clear/almost clear skin (score of ≤1) at the end of the intervention period and Dermatology Life Quality Index (DLQI) score of 5 or lower (no to small effect on quality of life) at week 12. Results: Of 783 patients enrolled (mean [SD] age, 48.0 [15.5] years; 376 [48.0%] female), 393 received home-based phototherapy and 390 received office-based phototherapy, with 350 (44.7%) having skin phototype (SPT) I/II, 350 (44.7%) having SPT III/IV, and 83 (10.6%) having SPT V/VI. A total of 93 patients (11.9%) were receiving systemic treatment. At baseline, mean (SD) PGA was 2.7 (0.8) and DLQI was 12.2 (7.2). At week 12, 129 patients (32.8%) receiving home-based phototherapy and 100 patients (25.6%) receiving office-based phototherapy achieved clear/almost clear skin, and 206 (52.4%) and 131 (33.6%) achieved DLQI of 5 or lower, respectively. Home-based phototherapy was noninferior to office-based phototherapy for PGA and DLQI in the overall population and across all SPTs. Home-based phototherapy, compared to office-based phototherapy, was associated with better treatment adherence (202 patients [51.4%] vs 62 patients [15.9%]; P < .001), lower burden of indirect costs to patients, and more episodes of persistent erythema (466 of 7957 treatments [5.9%] vs 46 of 3934 treatments [1.2%]; P < .001). Both treatments were well tolerated with no discontinuations due to adverse events. Conclusions and Relevance: In this randomized clinical trial, home-based phototherapy was as effective as office-based phototherapy for plaque or guttate psoriasis in everyday clinical practice and had less burden to patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03726489.

Erythema elevatum diutinum in a patient with well-controlled Crohn disease.

Erythema elevatum diutinum is a rare, chronic cutaneous leukocytoclastic vasculitis, with prominent fibrosis at its later stage. In this article, we report a case of erythema elevatum diutinum in a 23-year-old woman with well-controlled Crohn disease. To our knowledge, erythema elevatum diutinum has been reported in only three other cases of Crohn disease, in which eruptions of erythema elevatum diutinum were associated with features of active Crohn. Our patient was in clinical remission at the time of erythema elevatum diutinum onset, making this report significant not only for its uncommon presentation, but more importantly, to aid readers. diagnosis and clinical management of similar cases.

Systemic Biologic Management of Atopic Dermatitis.

Dupilumab and tralokinumab are currently the only FDA-approved biologic therapies for the treatment of moderate-to-severe atopic dermatitis. Tralokinumab is approved for patients greater than 18 years old, and dupilumab is approved for patients as young as 6 months old. Both medications are effective in clinical trials at improving atopic dermatitis. With a good safety profile and low-risk adverse events, dupilumab and tralokinumab are generally excellent treatment options for patients with severe or refractory atopic dermatitis.

Differentiating hidradenitis suppurativa flare from infection in the emergency department and recommendations for transitioning care to the outpatient setting.

Hidradenitis suppurativa is a painful and often progressive inflammatory skin condition that presents with papules, nodules, abscesses, and tunnels in the axillary, inframammary and anogenital regions. HS can be difficult to differentiate from a skin infection, such as a bacterial abscess. However, differentiation between the two is important as management of hidradenitis suppurativa often requires long-term follow-up and specialist care. Emergency physicians should be aware of how to differentiate acute hidradenitis suppurativa flares from similarly presenting conditions, particularly skin and soft tissue infection, when encountered in the emergency department and what steps should be taken to adequately bridge care to the outpatient setting.

Myelodysplasia cutis masquerading as granulomatous dermatitis.

Myelodysplastic syndromes (MDS) are a group of clonal hematopoietic neoplasms resulting from mutations in stem cells. They carry a risk of transformation to acute myeloid leukemia. Cutaneous manifestations of MDS, including myelodysplasia cutis or infiltration by MDS tumor cells, are rare, but significantly associated with increased risk of progression to high-grade myeloid tumors. The clinical and histopathologic differential diagnosis for myelodysplasia cutis includes interstitial granulomatous dermatitis (IGD), a reactive granulomatous dermatitis (RGD) associated with systemic diseases including rheumatologic diseases, and hematologic malignancy like MDS. We report a patient with MDS who presented with myelodysplasia cutis masquerading as IGD both in a clinical and histopathological manner.

Alpha-gal syndrome: A review for the dermatologist.

Alpha-gal syndrome (AGS) is an allergy to "red meat" and other mammalian products due to immunoglobulin E (IgE) antibodies against the sugar moiety galactose-alpha-1,3-galactose (alpha-gal), which is acquired following tick bites. Clinically, AGS presents with urticaria, abdominal pain, nausea, and occasionally anaphylaxis, and has wide inter- and intra-personal variability. Because symptom onset is generally delayed by 2 to 6 hours after meat consumption, AGS can be easily confused with other causes of urticaria and anaphylaxis, such as chronic spontaneous urticaria (CSU) and mast cell activation syndrome (MCAS). Diagnosis relies on a combination of clinical history, positive alpha-gal IgE blood testing and improvement on a mammalian-restricted diet. Management of the syndrome centers primarily on avoidance of mammalian meats (and occasionally dairy and other products) as well as acute management of allergic symptoms. Counseling about tick avoidance measures is also important as AGS will wane over time in many patients.

Methotrexate Monitoring in Dermatology- A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: There are currently no evidence-based recommendations to guide lab monitoring in the first 90 days of methotrexate treatment. The purpose of this study was to determine whether certain monitoring practices or baseline patient characteristics were associated with increased risk of developing clinically meaningful lab abnormalities during the course of methotrexate treatment. PATIENTS AND METHODS: This retrospective cohort study analyzed 243 dermatologically managed patients taking methotrexate at the University of Virginia Health System. Odds ratios were used to analyze the risk of these patients developing lab abnormalities that result in a change in clinical management, referred to as clinically relevant events. Chi-square analysis was used to determine the optimal timing of methotrexate lab monitoring. RESULTS: A diagnosis of congestive heart failure (P=0.03), chronic kidney disease (P=0.03), and an initial low platelet count (P=0.008) increased the odds of developing a clinically relevant event at some point during methotrexate therapy. In the first 15 days following methotrexate initiation, only 1/114 (0.9%) lab draws resulted in discontinuation of the medicine, 1/114 (0.9%) resulted in maintenance of a stable dose, and 2/114 (1.8%) resulted in repeat laboratory testing. CONCLUSION: In the absence of concerning baseline patient characteristics, dermatologists may consider postponing initial lab monitoring until 15 days post methotrexate initiation.J Drugs Dermatol. 2021;20(3):320-325. doi:10.36849/JDD.5790.