Is Exploration of Alternate Immune Pathways Needed in Hidradenitis Suppurativa? A Case of Atopic Dermatitis and Concurrent Hidradenitis Suppurativa Responding to Dupilumab.

Hidradenitis suppurativa (HS) is an inflammatory dermatosis associated with overactive T helper 1/T helper 17 (Th1/Th17) cells. HS has been effectively treated with biologic medications; however, many such biologics lack large randomized controlled trials. Only one such biologic, adalimumab, has been approved by the US Food and Drug Administration (FDA) for the treatment of HS. Other such biologics currently being studied for HS downregulate Th1/Th17 inflammatory pathways. We describe a patient with atopic dermatitis (AD) and comorbid HS, both of which improved several months into treatment with dupilumab. Interestingly enough, dupilumab targets Th2-mediated inflammatory skin conditions through the inhibition of IL-4/IL-13 cytokines. While dupilumab is known for its success in treating Th2-mediated inflammation, this presents a paradox as HS is a Th1/Th17 inflammatory condition. This case highlights how the inflammatory process of HS is not fully understood and how biologic pharmacologic interventions need to be further studied to determine their efficacy in treating HS.

Treatment of Pain in Keloids Using Only a Long-Pulsed 1064 nm Nd:YAG Laser.

BACKGROUND AND OBJECTIVE: Keloids are benign lesions arising from overproduction of the extracellular matrix and abnormal collagen deposition by dermal fibroblasts. This altered wound healing typically occurs in response to dermal trauma. Keloid treatment poses a challenge due to the variable nature of treatment response, which can be affected by the size, appearance, and associated symptoms of erythema, pruritus, and pain. Recently, successful treatment of keloids has been reported using the Nd:YAG laser in conjunction with 5-fluorouracil and intralesional corticosteroids. We present a series of patients with symptomatic keloids, who we treated with only a 1064 nm Nd:YAG laser. STUDY DESIGN/MATERIALS AND METHODS: Eight patients of Fitzpatrick skin types I-VI presented for treatment of keloids with associated symptoms of pain. The keloids were most commonly located on the trunk, and seven patients had intralesional steroid injections prior to presentation with persistence of symptoms. Patient treatment consisted of two passes under a long-pulsed 1064 nm Nd:YAG laser with a 10 mm spot size, a fluence of 18-19 J/cm2 , and 60 ms pulse duration every 3-8 weeks. Patient-reported pain scores were collected before and after treatment. RESULTS: Following treatment, transient erythema and mild edema were noted at the treatment site. All patients reported improvement in the symptoms of pain, with an average of a 5-point reduction using a 10-point scale (R: 2-10). Five out of eight patients had total resolution of their pain. An average of 3.25 treatments (R:1-5) were needed for patients to first notice an improvement in the pain. A Wilcoxon signed-rank test showed that treatment with a 1064 nm laser elicited a statistically significant improvement in pain in individuals with keloids (Z = 2.46, P = 0.01). No patients in our study suffered any scarring or pigment changes as a result of these treatments. CONCLUSION: Keloids are a common condition with variable rates of treatment satisfaction. Lasers have been used in an attempt to improve clinical appearance and associated symptoms. We report a significant reduction in pain for patients treated exclusively with a 1064 nm Nd:YAG laser. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Sustained Benefit After Treatment of Acne Vulgaris Using Only a Novel Combination of Long-Pulsed and Q-Switched 1064-nm Nd: YAG Lasers.

BACKGROUND: Acne vulgaris remains a challenging disease to treat in many patients. Traditional therapies may have limited successes with potential side effects. Laser and light energy devices may offer a desirable alternative. OBJECTIVE: To evaluate the effectiveness and safety in using a combination laser approach with both long-pulsed (LP) and Q-switched (QS) Nd:YAG lasers in the treatment of active acne. METHODS: Twenty patients with moderate to severe inflammatory acne were treated with LP YAG laser followed immediately with QS YAG laser. Patients received at least 8 treatments. Follow-up evaluation occurred at a minimum of 12 months. Pre- and post-treatment photographs were graded by blinded physicians. All topical acne medications and oral antibiotics were discontinued throughout the therapy and follow-up period. RESULTS: There was a 81% reduction in acne lesions, with 60% of patients having 90% or greater reduction. Overall appearance was graded at 84% improvement at follow-up. Follow-up occurred at a mean of 22.7 months after completion of therapy. Aside from transient erythema, there were no other adverse effects. CONCLUSION: Active acne can be treated successfully with a combination of LP and QS YAG lasers with patients remaining off acne medications throughout laser therapy and the follow-up period.

Light-based devices in the treatment of cutaneous vascular lesions: An updated review.

BACKGROUND: Light-based devices have been used to treat cutaneous vascular lesions almost since the original development of the laser. After the introduction of the initial continuous wave and pulsed laser systems, the pulsed lasers became the gold standard device. Since then, new devices and methods to treat patients have been introduced. OBJECTIVE: To review and summarize the current literature specific to treatment of cutaneous vascular lesions with light-based devices. METHODS: A review of the current literature of light-based devices used for the treatment of vascular lesions. RESULTS AND CONCLUSIONS: New systems continue to be developed to treat vascular lesions with advantages and disadvantages compared to older devices. Nonlaser sources such as intense pulsed light and radiofrequency devices can also be used in the treatment of these patients. Newer approaches may lead to even better results.

Risk of rash associated with lenalidomide in cancer patients: a systematic review of the literature and meta-analysis.

BACKGROUND: Lenalidomide is indicated for treatment of multiple myeloma in combination with dexamethasone and as a single agent in myelodysplastic syndromes. The incidence and risk of rash has been inconsistently reported. MATERIALS AND METHODS: We conducted a systematic review and metaanalysis of the literature to determine the incidence and risk of developing rash. Relevant studies were identified from PubMed and abstracts presented at American Society of Clinical Oncology annual meetings. Incidence, relative risk, and 95% confidence intervals were calculated. RESULTS: Ten trials were available for analysis, and the overall incidence of all-grade and high-grade rash was 27.2% and 3.6%, respectively. Lenalidomide was associated with increased risk of all-grade rash (P < .001). CONCLUSION: Further studies for prevention and treatment of this toxicity are needed to minimize effect on quality of life and dose intensity.

Cetirizine-associated delusions and depression in an 18-year-old woman.

INTRODUCTION: Cetirizine is a second-generation H1 histamine receptor antagonist that is commonly used for symptomatic relief of hay fever and other allergies and can be combined with pseudoephedrine hydrochloride, a decongestant. The most common adverse effects include headache, nausea, nasopharyngitis, vomiting, and coughing. OBJECTIVE: To report on an adolescent 18-year-old woman who developed delusional thinking and depression after starting treatment with cetirizine. CASE REPORT: We report on an adolescent 18-year-old woman who developed delusional thinking and depression after starting treatment with cetirizine. Once cetirizine was discontinued, the patient returned to her clinical baseline. CONCLUSIONS: Physicians need to be aware of the potential psychiatric adverse effects associated with cetirizine.

The risk of rash associated with ipilimumab in patients with cancer: a systematic review of the literature and meta-analysis.

BACKGROUND: Ipilimumab is a human antibody that inhibits cytotoxic T-lymphocyte-associated antigen 4, leading to increases in T-cell activation and interleukin 2 secretion and has been approved for the treatment of advanced melanoma. Dermatologic adverse events such as rash, pruritus, and vitiligo have been reported in trials, with varying incidences. The overall incidence and risk of rash to ipilimumab is unknown. OBJECTIVE: We conducted a systematic review of the literature and performed a meta-analysis to ascertain the incidence and risk of developing rash among patients receiving ipilimumab. METHODS: Databases from PubMed and Web of Science from January 1998 until July 2011 and abstracts presented at the American Society of Clinical Oncology meetings from 2004 through 2011 were searched to identify relevant studies. The incidence and relative risk of rash were calculated using random effects or fixed effects model depending on the heterogeneity of included studies. RESULTS: A total of 1208 patients from clinical trials were included in this analysis. The overall incidence of all-grade rash was 24.3% (95% confidence interval [CI] 21.4%-27.6%), with a relative risk of 4.00 (95% CI 2.63-6.08, P < .001). The overall incidence of high-grade rash was 2.4% (95% CI 1.1%-5.1%), with a relative risk of 3.31 (95% CI 0.70-15.76, P = .13). LIMITATIONS: The ability to detect rash may vary among institutions. CONCLUSION: There is a significant risk of developing rash in patients with cancer receiving ipilimumab. There was no statistically significant difference in the risk of rash based on dose or underlying tumor. Adequate monitoring and early intervention are recommended to prevent decreased quality of life and inconsistent dosing.

Grading dermatologic adverse events of cancer treatments: the Common Terminology Criteria for Adverse Events Version 4.0.

Dermatologic adverse events to cancer therapies have become more prevalent and may to lead to dose modifications or discontinuation of life-saving or prolonging treatments. This has resulted in a new collaboration between oncologists and dermatologists, which requires accurate cataloging and grading of side effects. The Common Terminology Criteria for Adverse Events Version 4.0 is a descriptive terminology and grading system that can be used for uniform reporting of adverse events. A proper understanding of this standardized classification system is essential for dermatologists to properly communicate with all physicians caring for patients with cancer.

The risk of skin rash and stomatitis with the mammalian target of rapamycin inhibitor temsirolimus: a systematic review of the literature and meta-analysis.

OBJECTIVE: We conducted a systematic review of the literature and performed a meta-analysis to determine the risk of developing skin rash and stomatitis among patients receiving temsirolimus. METHODS: Databases from PubMed and Web of Science from January, 1998 until June, 2011 and abstracts presented at the American Society of Clinical Oncology annual meetings from 2004 through 2011 were searched to identify relevant studies. The incidence and relative risk (RR) of skin rash and stomatitis were calculated using random-effects or fixed-effects model depending on the heterogeneity of included studies. RESULTS: A total of 779 patients from 10 clinical trials were included in this analysis. The overall incidence of all-grade rash was 45.8% (95% confidence interval (CI): 35.6-56.3%), with a RR of 7.6 (95%CI: 4.4-13.3; p<0.001). The overall incidence of high-grade rash was 3.3% (95%CI: 1.9-5.6%), with a RR of 13.70 (95%CI: 0.82-227.50, p=0.07). The overall incidence of all-grade stomatitis was 44.3% (CI: 32.1-57.1%), with a RR of 11.10, 95%CI: 5.60-22.00; p<0.001). The overall incidence of high-grade stomatitis was 3.2% (95%CI: 1.9-5.4%), with a RR of 13.2 (95%CI: 0.80-218.50, p=0.07). CONCLUSION: There is a significant risk of developing skin rash and stomatitis in cancer patients receiving temsirolimus. The risk is independent of underlying tumour. Adequate monitoring and early intervention are recommended to prevent debilitating toxicity and suboptimal dosing.

The risk of nail changes with epidermal growth factor receptor inhibitors: a systematic review of the literature and meta-analysis.

BACKGROUND: The overall incidence and risk of nail changes associated with the use of epidermal growth factor receptor inhibitors (EGFRIs) varies widely across the literature. OBJECTIVE: We conducted a systematic review of the literature and performed a meta-analysis to determine the risk of developing nail toxicity among patients receiving EGFRIs. METHODS: Databases from Pubmed and Web of Science from January 1998 until July 2011 and abstracts presented at the American Society of Clinical Oncology annual meetings from 2004 through July 2011 were searched to identify relevant studies. The incidence and relative risk (RR) of nail toxicity were calculated using random-effects or fixed-effects model depending on the heterogeneity of the included studies. RESULTS: A total of 2107 patients from 22 clinical trials were included in this analysis. The overall incidence of all-grade nail toxicity was 17.2% (95% confidence interval [CI]: 13.8%-21.3%), with an RR of 76.94 (95% CI: 40.76-145.22, P < .001). The overall incidence of high-grade nail toxicity was 1.4% (95% CI: 0.9%-2.1%), with an RR of 13.11 (95% CI: 3.73-46.03, P < .001). LIMITATIONS: The ability to detect and grade nail changes may vary among institutions. CONCLUSION: There is a significant risk of developing nail toxicity in cancer patients receiving EGFRIs. The risk is independent of the underlying agent. Adequate monitoring and early intervention are recommended to prevent debilitating toxicity and suboptimal dosing of EGFRI.