Combination of methotrexate with oral disease-modifying antirheumatic drugs in psoriatic arthritis: a systematic review.

Background: Oral conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), especially methotrexate, are the cornerstone of treating psoriatic arthritis (PsA). The use of csDMARDs with biologics has increased their efficacy in psoriasis. However, the combination of two oral DMARDs in patients with PsA has not been adequately reviewed. In this study, we explore the combinational use of methotrexate with DMARDs in PsA patients. Materials & methods: A review was conducted using Medline (PubMed), Embase, Web of Science and the Cochrane Library, covering articles up to February 2023. Results & conclusion: Nine studies comprising 1993 participants were included. The evidence supporting combination therapy remains limited. Combinational therapy could be considered in patients with inadequate response to monotherapy or no access to biologics.

This study aimed to determine whether combining two different medicines could serve as an option for patients with psoriatic arthritis (PsA). Typically, doctors prescribe just one medicine, but sometimes its efficacy is limited. After reviewing nine studies with 1993 participants, it appears that using two medicines together might be an alternative option for PsA patients who do not experience sufficient relief from a single medicine. This research contributes to our understanding of using this combination approach for PsA and suggests that further larger studies could confirm its potential as a beneficial method for improving the health of these patients.

Comparative Efficacy of Pharmacological Treatments for Acne Vulgaris: A Network Meta-Analysis of 221 Randomized Controlled Trials.

PURPOSE: Acne is an extremely common skin disease with an estimated global prevalence of 9.4%. We aim to provide comprehensive comparisons of the common pharmacological treatments for acne. METHODS: Randomized controlled trials comparing the efficacy of pharmacological therapies for acne vulgaris in patients of any age and sex and with a treatment duration of >2 weeks were included. PubMed and Embase databases were searched from inception until February 2022. Our prespecified primary end points were mean percentage reduction in total, inflammatory, and noninflammatory lesions. Treatment ranking was determined by P values. RESULTS: There were 210 articles describing 221 trials and 37 interventions included in the analysis. Our primary analysis of percentage reduction in total lesion count had 65,601 patients enrolled. Across all trials, the mean age was 20.4 years. The median duration of treatment was 12 weeks. The median total, inflammatory, and noninflammatory lesion counts were 72, 27, and 44, respectively. The most effective treatment was oral isotretinoin (mean difference [MD] = 48.41; P = 1.00), followed by triple therapy containing a topical antibiotic, a topical retinoid, and benzoyl peroxide (BPO) (MD = 38.15; P = .95) and by triple therapy containing an oral antibiotic, a topical retinoid, and BPO (MD = 34.83; P = .90). For monotherapies, oral or topical antibiotics or topical retinoids have comparable efficacy for inflammatory lesions, while oral or topical antibiotics have less effect on noninflammatory lesions. CONCLUSION: The most effective treatment for acne is oral isotretinoin, followed by triple therapies containing a topical retinoid, BPO, and an antibiotic. We present detailed comparisons of each intervention to serve as a practical database.

Combination Therapy for Psoriasis with Methotrexate and Other Oral Disease-Modifying Antirheumatic Drugs: A Systematic Review.

INTRODUCTION: Although the introduction of biologics and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) has reshaped the treatment paradigm for immune-mediated inflammatory diseases (IMIDs) such as psoriasis, oral conventional synthetic DMARDs (csDMARDs) remain the cornerstone in their treatment. Combinational use of DMARDs is common in rheumatological practice, but for the treatment of many skin diseases, dermatologists typically use a single oral DMARD, with methotrexate (MTX) being the most commonly prescribed csDMARD for psoriasis. METHODS: To better understand the potential benefits of MTX combination therapy in psoriasis, a literature review was conducted using Medline (PubMed), Embase, Web of Science, and the Cochrane Library, covering articles published from inception until October 2022. Randomized controlled trials, cohort, open-label, and observational studies, and case reports with efficacy and safety results for combination therapy with MTX, csDMARDs, and tsDMARDs or comparisons between MTX monotherapy and combination therapy with other oral DMARDs in psoriasis were included. Studies involving MTX monotherapy alone or sequential treatment with MTX and other oral DMARDs were excluded, as were non-English articles. The results are presented as a systematic review, and the risk of bias was assessed by the corresponding author using the Cochrane Handbook for Systematic Reviews of Interventions, version 6.3, and confirmed by an independent assessor. RESULTS: Eleven studies comprising 494 participants were included in the review. Overall, combination treatment with MTX and other oral DMARDs exhibited good efficacy and tolerability in psoriasis. However, the included studies were primarily small scale or retrospective, and larger prospective randomized trials are needed to provide stronger evidence. CONCLUSION: This literature review suggests that combination therapy with MTX and csDMARDs may serve as an efficacious treatment for psoriasis patients with an inadequate response to oral DMARD monotherapy.

Case report: Development of vanishing bile duct syndrome in Stevens-Johnson syndrome complicated by hemophagocytic lymphohistiocytosis.

Background: Vanishing bile duct syndrome is a rare drug-induced disease characterized by cholestasis and ensuing ductopenia. Dermatological manifestations of drug hypersensitivity such as Stevens-Johnson syndrome and toxic epidermal necrolysis may also present in such cases. Hemophagocytic lymphohistiocytosis is a hyperimmune response caused by unchecked stimulation of macrophages, natural killer cells, and cytotoxic T lymphocytes. Case presentation: We report a severe case who presented with concurrent Stevens-Johnson syndrome and vanishing bile duct syndrome complicated by hemophagocytic lymphohistiocytosis after the ingestion of non-steroidal anti-inflammatory drugs. Despite the fact that improvements in vanishing bile duct syndrome can be assumed when combining the clinical lab data clues, as well as repeated liver biopsies showing recovering ductopenia, the patient developed hypovolemic shock combined with septic shock episodes and died on day 236. Conclusion: To our knowledge, this is the fifteenth report of vanishing bile duct syndrome associated with Stevens-Johnson disease or toxic epidermal necrolysis. Mortality rate remains high without treatment guidelines established due to the rarity and heterogenicity of the population. Further studies are needed to identify possible risk factors, prognostic indicators, and the standard of care for vanishing bile duct syndrome associated with Stevens-Johnson disease or toxic epidermal necrolysis.

Treating toxic epidermal necrolysis with systemic immunomodulating therapies: A systematic review and network meta-analysis.

BACKGROUND: Various systemic immunomodulating therapies have been used to treat toxic epidermal necrolysis (TEN), but their efficacy remains unclear. OBJECTIVE: To perform a systematic review and network meta-analysis (NMA) evaluating the effects of systemic immunomodulating therapies on mortality for Stevens-Johnson syndrome (SJS)/TEN overlap and TEN. METHODS: A literature search was performed in online databases (from inception to October 31, 2019). Outcomes were mortality rates and Score of Toxic Epidermal Necrolysis (SCORTEN)-based standardized mortality ratio (SMR). A frequentist random-effects model was adopted. RESULTS: Sixty-seven studies involving 2079 patients were included. An NMA of 10 treatments showed that none was superior to supportive care in reducing mortality rates and that thalidomide was associated with a significantly higher mortality rate (odds ratio, 11.67; 95% confidence interval [CI], 1.42-95.96). For SMR, an NMA of 11 treatment arms showed that corticosteroids and intravenous immunoglobulin combination therapy was the only treatment with significant survival benefits (SMR, 0.53; 95% CI, 0.31-0.93). LIMITATIONS: Heterogeneity and a paucity of eligible randomized controlled trials. CONCLUSIONS: Combination therapy with corticosteroids and IVIg may reduce mortality risks in patients with SJS/TEN overlap and TEN. Cyclosporine and etanercept are promising therapies, but more studies are required to provide clearer evidence.

The high prevalence of sarcopenia and its associated outcomes following hip surgery in Taiwanese geriatric patients with a hip fracture.

BACKGROUND: Sarcopenia, which is a common risk factor for falls and fractures, affects the functional outcome and mortality in geriatric populations. However, the prevalence of sarcopenia among geriatric Taiwanese patients with a hip fracture is unknown, nor is the effect of sarcopenia on the outcome of hip surgery. METHODS: From December 2017 to February 2019, geriatric patients who underwent surgery for a hip fracture were prospectively enrolled. Basic demographic data, responses to questionnaires for dementia screening and quality of life (QoL) and daily living activities (ADL) before the injury were analyzed to identify any association with sarcopenia. The QoL and ADL were monitored at six months after the operation to determine the difference between hip fracture patients with or without sarcopenia. RESULTS: Of 139 hip fracture patients, 70 (50.36%) were diagnosed with sarcopenia. Accounting for all confounding factors in the multivariate logistic regression, lower body mass index (BMI), male gender and a weaker handgrip are the risk factors that are most strongly associated with a diagnosis of sarcopenia in geriatric patients with a hip fracture. Hip fracture patients with sarcopenia also have poor ADL and a lower QoL than patients without sarcopenia before the injury and six months after the operation. CONCLUSION: A high prevalence of sarcopenia among geriatric hip fracture patients is associated with a poor mid-term outcome following hip surgery. Clinicians must recognize the risk of sarcopenia, especially for male hip fracture patients with a lower BMI and a weaker handgrip.

A Meta-analysis of the Evidence for Assisted Therapy with Platelet-Rich Plasma for Atrophic Acne Scars.

BACKGROUND: A number of studies have investigated the role of platelet-rich plasma (PRP) as an assisted therapy for atrophic acne scars. However, the results are diverse, and no up-to-date meta-analysis was found that exclusively examined atrophic acne scar treatment. OBJECTIVES: To perform a meta-analysis to assess improvements in the side effects of PRP and the effect of assisted therapy for atrophic acne scars. METHODS: This study followed PRISMA guidelines. A comprehensive search of the literature was carried out in September 2018 using the electronic databases of PubMed, EMBASE, MEDLINE, and the Cochrane Library. RESULTS: Seven articles were included in this review. All of the studies published utilized PRP as additive therapy. The major therapies included fractional carbon laser therapy and microneedling. Five studies (249 participants) reported four degrees of improvement on an improvement scale (degrees 3 and 4 were considered improvement in this analysis). Four studies (200 participants) reported mean improvement scores. A significantly higher degree of improvement was shown in the PRP group compared to the control group (OR = 8.19; 95% CI 4.32-15.52; p < 0.00001), as well as better mean improvement score (WMD = 23.73; 95% CI 18.60-28.87; p < 0.00001). Substantial heterogeneity was seen in the degree of improvement (I2 = 54% p = 0.07) and the mean improvement score (I2 = 75%; p = 0.008). There were overall fewer monitored side effects, including erythema and edema (in days), in the PRP groups; however, no significance was found. CONCLUSIONS: This review shows that PRP is a useful assisted therapy for atrophic acne scars, which can achieve better improvement. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Ultrasound-detected lateral band snapping syndrome in proximal interphalangeal joint of small finger-A rare case report.

BACKGROUND: Snapping fingers resulting from flexor tendon tenosynovitis at the metacarpophalangeal (MCP) joint, is common. However lateral band snapping syndrome (LPSS) in the proximal interphalangeal joint (PIPJ) are extremely rare. CASE PRESENTATION: A 43-year-old female was diagnosed with LPSS in the PIPJ of fifth finger which was confirmed by dynamic evaluation upon ultrasound. Repair of retinacular ligament of the extensor tendon was performed. At the six-month follow up, the patient had regained full ROM with no discomfort, without evidence of recurrence. DISCUSSION: The diagnosis of LPSS at the PIPJ is challenging. Dynamic evaluation of the extensor tendon over PIPJ is necessary to diagnose LBSS. Ultrasound was used to assess the movement of the lateral band of the extensor tendon when the fingers flexed and to demonstrate dynamically the snapping and subluxation of the lateral band, so as to facilitate confirming the diagnosis of LBSS. CONCLUSION: Given clinical suspicion of LBSS, we recommend ultrasonography as a feasible tool to confirm the diagnosis. Patients with LBSS may thus benefit from prompt repair of the retinacular ligament without sequela.