Anecdote Increases Patient Willingness to Take a Biologic Medication for Psoriasis.

Patients often are apprehensive about starting biologic medications for their psoriasis. Typical fears include anxiety regarding possible side effects and reluctance in accepting their proven efficacy. In this study, we aimed to evaluate patients' willingness to take a biologic medication for their psoriasis if presented with clinical trial evidence, an anecdote, or both. A prospective online survey study was performed in 222 patients with psoriasis. Patients were randomized to receive clinical trial evidence of a biologic medication's efficacy and safety, an anecdote of a single patient's positive experience, or both. Responses were recorded on a 10-point Likert scale and evaluated using the Kruskal-Wallis test followed by Dunn test. Results indicated that presenting an anecdote-alone or in combination with clinical trial evidence-may be an effective way to improve patients' willingness to take a biologic medication for psoriasis.

Utility of boron in dermatology.

Introduction: Boron compounds are being investigated as therapies for dermatologic conditions. Several features of boron chemistry make this element an ideal component in dermatologic treatments. We review the published dermatologically-relevant clinical trials and case studies pertaining to boron compounds.Methods: PubMed was utilized to query terms boron, chemistry, drug, development, dermatology, atopic dermatitis, psoriasis, onychomycosis, tavaborole, AN 2690, crisaborole, and AN 2728. Clinical trials, case studies, animal studies and in vitro studies. Pertaining to atopic dermatitis, psoriasis and onychomycosis were included.Results: Crisaborole 2% topical solution reduced atopic dermatitis lesions by ∼60% when compared to pretreatment baseline. Crisaborole maintains its dose-dependent effect in treatment of psoriasis and significantly reduces psoriatic plaques when compared to controls. Adverse effects were mild, frequency of events varied between studies. Crisaborole was well tolerated when applied to sensitive skin. Topical tavaborole significantly reduced or eliminated onychomycosis with minimal side effects compared to placebo. Tavaborole was effective in treating recalcitrant onychomycosis.Discussion: Boron-based compounds form stable interactions with enzyme targets and are safe medications for the treatment of atopic dermatitis, psoriasis, and onychomycosis. The mild and rare side effects of topical boron-based compounds may make them ideal treatments for individuals with sensitive skin and pediatric populations.

Patients preferences for different corticosteroid vehicles are highly variable.

Introduction: Topical corticosteroids, available in an array of vehicles are used to control a variety of inflammatory skin diseases. Patients preferences for different vehicles may affect their willingness to use treatment. We assess corticosteroid vehicle preference and potential impact of topical characteristics on adherence and quality of life in patients with psoriasis.Methods: Subjects with psoriasis were recruited from Wake Forest University Dermatology Clinic. Subjects sampled desoximetasone 0.25% spray, betamethasone valerate 0.1% cream, triamcinolone acetonide 0.1% ointment, fluocinonide 0.05% gel, betamethasone valerate 0.1% lotion, clobetasol propionate 0.05% foam, and fluocinonide 0.05% solution in a predetermined randomized order. Subjects completed a Vehicle Preference Measure, Determinants of Adherence Measure, and a Determinants of Quality of Life Measure.Results: Patients preferences for the various products were highly variable. Regarding Determinants of Adherence, patients perception of absorption of the medication was ranked as 'quite important/extremely important' by 85% of total subjects. A majority of patients rated medication side effects as 'quite important/extremely important' when asked to consider topical characteristics effect on quality of life.Discussion: There was wide variation in patient preference for topical medication vehicles used for treating psoriasis. Several vehicle characteristics were considered important to adherence. Given the marked variation in vehicle preference, topical treatment should be individualized according to patients preferences.

Accountability in patient adherence.

BACKGROUND: The accountability inherent in the social interaction between a patient and healthcare provider affects patients' motivation to adhere to treatment. To characterize the role of accountability as a tool to improve self-efficacy and self-management and thereby promote patients' adherence to treatment, a measure of accountability is needed. AIMS: To develop and test the validity, reliability, and sensitivity of a new outcome measure designed to assess accountability. METHODS: The accountability measurement tool was developed from the literature, expert consultation, and focus groups. A focus group and three pilot studies were performed both in clinic and through an online crowdsourcing platform. Principal Component Analysis evaluated constructs, and Cronbach's alpha measured internal consistency. Validity was established using convergent and divergent correlations to other validated scales. RESULTS: A total of 292 participants took part in this study. The 12-item accountability scale demonstrated very good internal consistency (Cronbach's α=0.92). Components of the accountability measurement tool correlated with predicted validated measures, including the Treatment Self-Regulation Questionnaire. Divergent validity was established with no significant difference noted between age, sex, race, and education level. CONCLUSION: Future use of this questionnaire will allow for the assessment of the interaction between accountability and adherence to treatment and lead to the development of new interventions to promote better adherence.

Acquired disorders with hypopigmentation: A clinical approach to diagnosis and treatment.

Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphologic findings, can aid in delineating the causes of acquired hypopigmented disorders. The second article in this 2-part continuing medical education series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.

Acquired disorders with depigmentation: A systematic approach to vitiliginoid conditions.

Acquired disorders with depigmentation are commonly encountered by dermatologists and present with a wide differential diagnosis. Vitiligo, the most common disorder of acquired depigmentation, is characterized by well-defined depigmented macules and patches. Other conditions, such as chemical leukoderma, can present with similar findings, and are often easily mistaken for vitiligo. Key clinical features can help differentiate between acquired disorders of depigmentation. The first article in this continuing medical education series focuses on conditions with a vitiligo-like phenotype. Early recognition and adequate treatment of these conditions is critical in providing appropriate prognostication and treatment.

Psoriasis and Atopic Dermatitis "Resistant" to Topical Treatment Responds Rapidly to Topical Desoximetasone Spray.

PURPOSE:: Topical corticosteroids (TS) are a treatment for atopic dermatitis (AD) and psoriasis (Ps). We assessed whether use of a TS under conditions designed to enhance adherence would be effective in patients who "failed" TS in the outpatient setting. METHODS:: Individuals with treatment-resistant Ps or AD were recruited (AD, n = 12; Ps, n = 12). Six participants were randomized to each of 2 groups of desoximetasone 0.25% spray alone (n = 6) or desoximetasone spray plus twice-daily phone call reminders to use the medication. Disease severity was assessed. RESULTS:: In treatment-resistant Ps patients, desoximetasone spray, with reminders, resulted in statistically significant improvement in all outcome measures. In treatment-resistant AD patients, there was statistically significant improvement in some assessments. Despite the very small sample size and short evaluation time, statistically significant changes were detected in this cohort. This is evidence of the large effect size of TS for Ps and AD when the treatment is used. CONCLUSIONS:: Patients with "treatment-resistant" Ps and AD generally responded well to the use of desoximetasone spray in the trial setting. This may be due to better adherence in the study environment or patients' preference for the spray vehicle. Patient reminders contributed to improved clinical outcomes in Ps and AD patients with "treatment-resistant" disease.

Psychosocial Burden and Other Impacts of Rosacea on Patients' Quality of Life.

Rosacea is a common and chronic skin disorder with substantial impact on a patients' quality of life. Its varying phenotypic features and facial localization can adversely affect the mental health and socialization of those affected. Although there are no curative interventions, certain therapies have greater effect in improving patient quality of life. This article summarizes the associated psychosocial implications of rosacea. Several skin disease and rosacea-specific quality-of-life measures and their application in clinical care and research studies are also summarized. The recognition and management of the psychosocial impact of rosacea is critical to improving patient outcomes.

Genetic Predisposition to Rosacea.

Rosacea is a common inflammatory skin disease with a multifaceted pathophysiology, including environmental stressors and neurovascular and immune dysfunction affected by the presence of pathogens. The genetic component of this disorder is not well understood. However, a possible genetic origin in Northern European descendants, family inheritance, twin concordance, and genetic associations with autoimmune disorders attest the genetic predisposition to rosacea. Currently, one single-nucleotide polymorphism has been identified in association with rosacea and is intergenic between HLA-DRA and BTNL2. Additional associations with HLA alleles and immune-mediated disorders support the role of immune-regulating genes and innate and adaptive immunity in rosacea.

Early Congenital Syphilis: Recognising Symptoms of an Increasingly Prevalent Disease.

BACKGROUND: Congenital syphilis (CS) is an infectious disease resulting from transplacental transmission of Treponema pallidum spirochetes from an infected mother to fetus during pregnancy. While uncommon, CS has shown an increased incidence in Canada and the United States since 2001 and 2012, respectively. CASE REPORT: We present the case of a 5-week-old female infant with blistering rash on the palms and soles. The infant displayed decreased movement of the left upper extremity, clinically consistent with Parrot pseudoparalysis. Cutaneous involvement was limited to few tan crusted papules on the palms and soles. Mother reported a "false-positive" result of rapid plasma reagin (RPR) testing at 31 weeks. Cerebrospinal fluid studies of the infant resulted with positive Venereal Disease Research Laboratory (VRDL) test and positive microhemagglutination assay (MHA-TP). Histopathology of a crusted papule revealed a lichenoid infiltrate composed of lymphocytes, histiocytes, and plasma cells. Immunohistochemical staining for T pallidum was negative. The patient completed treatment with a 10-day course of intravenous penicillin. DISCUSSION: While CS is largely considered a historic entity, it has been increasing in incidence in the United States since 2012 and in Canada since the early 2000s. Diagnosis of CS can be difficult as infants may be asymptomatic or present with nonspecific signs. This case highlights the presentation of minimal cutaneous involvement as well as skeletal involvement after birth. RPR testing may result in false negatives or indeterminate results, further complicating diagnosis. Given these difficulties in screening and the increasing incidence of CS, clinicians may need to refamiliarise themselves with its clinical findings.

Interleukin-17 inhibition: role in psoriasis and inflammatory bowel disease.

INTRODUCTION: Interleukin 17 (IL-17) antagonism provides a highly effective approach for treating psoriasis. Exacerbations of inflammatory bowel disease have been reported in anti-IL-17 psoriasis trials. AIM: To characterize the relationship between IL-17 inhibition and inflammatory bowel disease. METHODS: A review of English-language articles was performed. Search terms included IL-17, psoriasis, inflammatory bowel disease, secukinumab, ixekizumab and brodalumab. RESULTS: IL-17 A inhibition, IL-17RA inhibition and IL-17 knockout led to induction or exacerbation of colitis in mouse models. The placebo groups fared better than the treatment group in controlled trials of anti-IL-17 antibody and anti-IL-17 receptor for Crohn's disease (CD). A brodalumab study (N = 1576) revealed one reported CD case. An ixekizumab study (N = 3736) evaluating moderate-to-severe psoriasis, four patients reported CD and seven reported UC while ixekizumab every 2 weeks led to a moderate exacerbation of UC in one patient and new-onset CD in one patient. A secukinumab study (N = 3430) revealed exposure adjusted incidence rates of 0.11 and 0.15 per 100 patient-years for CD and UC, respectively. DISCUSSION: Anti-IL-17 medications are associated with IBD exacerbation. Caution should be used in prescribing these medications in patients with diagnosed IBD or personal history suggestive of IBD.

Automobile injury: a common familiar risk for presenting and comparing risks in dermatology.

Highly effective treatments exist in dermatology, yet fears regarding rare potential adverse events lead to poor adherence and treatment refusal. The use of a common identifiable risk, such as the risk of automobile injury warranting a visit to the emergency department, could provide a helpful tool for putting risks into perspective. PubMed and US Department of Transportation data were searched to quantify lifetime risk (LTR) of different dermatologic interventions and compare them to an automobile injury risk unit (RU). The LTR of automobile injury was 32%, defined as 1.0 RU. Herein, we review the dermatologic interventions that are less common and much safer than the risk of automobile injury. The use of a visual tool, using an automobile injury RU as comparator, might help alleviate fears and improve patient outcomes.

A Randomized, Double-Blind, Placebo-Controlled Study of the Vasoconstrictor Potency of Topical 0.25% Desoximetasone Spray: A High to Super High Range of Potency (Class I to Class II) Corticosteroid Formulation.

BACKGROUND: Topical corticosteroids offer great efficacy in controlling a wide variety of dermatoses. Traditional ointment vehicles are messy and difficult to apply, which might limit adherence. Alternative vehicle formulations such as topical sprays might improve adherence due to their ease of application. The potency of desoximetasone spray is not fully characterized. OBJECTIVE: To evaluate the relative vasoconstrictive potency of desoximetasone 0.25% topical spray formulation. METHODS: This is a randomized, blinded, single-center study comparing the vasoconstrictive properties of desoximetasone 0.25% topical spray to placebo and seven other known potency topical corticosteroid formulations. The primary endpoint was the degree of vasoconstriction measured using a colorimeter device. RESULTS: Thirty-two healthy subjects met eligibility criteria. Desoximetasone 0.25% topical spray (REGWQ Grouping = A) showed a trend toward greater vasoconstrictive potency compared to clobetasol propionate 0.05% spray (REGWQ Grouping = A). No adverse or serious events were reported. LIMITATIONS: The trial enrolled 90% females, which may affect the external validity of the study. Different populations may respond differently to desoximetasone spray. CONCLUSIONS: Desoximetasone 0.25% topical spray is a high to super high range of potency (Class I to Class II) steroid formulation. Given the cosmetic acceptability of spray products, we anticipate that this type of product would be highly effective for the treatment of inflammatory diseases in clinical practice.

J Drugs Dermatol. 2017;16(10):972-975.

Severe and acute complications of biologics in psoriasis.

Biologic therapies have revolutionized the approach to immune-mediated diseases such as psoriasis. Due to their favorable safety profiles and excellent efficacy, biologic agents are considered the gold standard for moderate-to-severe psoriasis. The aim of this paper is to saliently review the severe and acute complications of the Food and Drug Administration (FDA) approved biologic agents for psoriasis. Reviewed agents include tumor necrosis factor alpha inhibitors (etanercept, infliximab, and adalimumab), interleukin 12/23 inhibitors (ustekinumab), and interleukin 17 (IL-17) inhibitors (secukinumab and ixekizumab). While malignancies, serious infections, and major adverse cardiovascular events have been reported, their association with biologic therapy are not hypothesized as causal. However, IL-17 inhibitors appear to cause exacerbations and new cases of inflammatory bowel disease. While more long-term studies are warranted in understanding the biologic's long-term side effect profile, short-term studies have confirmed that the biologics are some of the safest treatment options for psoriasis. Nevertheless, certain populations yield higher risk to acute complications with the biologics than others - physicians must use their judgement and vigilance when monitoring and treating patients undergoing therapy with biological agents.

Accountability: a missing construct in models of adherence behavior and in clinical practice.

Piano lessons, weekly laboratory meetings, and visits to health care providers have in common an accountability that encourages people to follow a specified course of action. The accountability inherent in the social interaction between a patient and a health care provider affects patients' motivation to adhere to treatment. Nevertheless, accountability is a concept not found in adherence models, and is rarely employed in typical medical practice, where patients may be prescribed a treatment and not seen again until a return appointment 8-12 weeks later. The purpose of this paper is to describe the concept of accountability and to incorporate accountability into an existing adherence model framework. Based on the Self-Determination Theory, accountability can be considered in a spectrum from a paternalistic use of duress to comply with instructions (controlled accountability) to patients' autonomous internal desire to please a respected health care provider (autonomous accountability), the latter expected to best enhance long-term adherence behavior. Existing adherence models were reviewed with a panel of experts, and an accountability construct was incorporated into a modified version of Bandura's Social Cognitive Theory. Defining accountability and incorporating it into an adherence model will facilitate the development of measures of accountability as well as the testing and refinement of adherence interventions that make use of this critical determinant of human behavior.

Interleukin-31 pathway and its role in atopic dermatitis: a systematic review.

BACKGROUND: Atopic dermatitis, a chronic inflammatory disease, has a lifetime prevalence of 10-20%. Atopic dermatitis reduces quality of life, primarily due to pruritus. Interleukin-31 and its target receptor are newly discovered entities that are involved in pruritus. PURPOSE: To summarize the current understanding of interleukin-31 and its role in atopic dermatitis, potential therapeutic interventions and future prospects. METHODS: A systematic review was designed to identify articles related to interleukin-31 and its role in pruritus. Predefined queries containing interleukin-31 and related key terms were searched with no past date restriction, through 31 August 2016, using MEDLINE, Cochrane Controlled Trials Register, ClinicalTrials.gov and the International Clinical Trials Registry Platform Search Portal database. RESULTS: Of 151 identified articles, 61 met eligibility criteria. Interleukin-31 receptors are expressed constitutively on the surface of keratinocytes, eosinophils and small diameter neurons. Overexpression of interleukin-31, independent of mast cells and lymphocytes, induces clinical and histological features consistent with atopic dermatitis. In addition, overexpression of interleukin-31 causes reversible alopecia. Human monoclonal interleukin-31 antagonist, CIM331, decreased pruritus in phase-I and phase-II clinical trials. CONCLUSIONS: Interleukin-31 plays an important role in atopic dermatitis and alopecia. Inhibiting this pathway may provide an alternative to antihistamines for the pruritus of atopic dermatitis.