Volume 16 | Issue 7
Mio Nakamura MD,a Michael Abrouk MD,b Henry Zhu MD,c Benjamin Farahnik MD,d John Koo MD,a and Tina Bhutani MDa|
INTRODUCTION: The potential for systemic effects due to percutaneous absorption of superpotent topical steroids has been a longstanding concern. The Food and Drug Administration currently recommends limiting the use of superpotent topical steroids to 50g per week for 2 or 4 consecutive weeks depending on the formulation, which is mostly based on the exact duration with which phase 3 clinical trials were allowed to be conducted per the FDA. This article reviews all published clinical incidence of adrenal adverse effects in the medical literature, specifically Cushing’s syndrome (CS) and pathologic adrenal suppression (PAAS), to try to ascertain a more realistic limit for the safe use of superpotent topical steroids as it pertains to its potential systemic effects.
METHODS: Literature search was conducted using PubMed. Only cases of CS and PAAS secondary to the use of Class I superpotent topical steroids were included. Pediatric cases and full articles unavailable in English were excluded.
RESULTS: There were a total of 14 cases of CS and 5 cases of subsequent PAAS found in the current literature.
DISCUSSION: From our review of these cases, if the amount used per week is within FDA guidelines, it appears that patients needed to use superpotent topical steroids for far greater than 2 or 4 weeks to develop CS or PAAS. CS did not necessarily predict occurrence of PAAS, but in all cases CS appeared to be a prerequisite for developing PAAS. All cases of CS and all but one case of PAAS were reversible. If excessive amount of greater than 50g per week is avoided, it appears that superpotent topical steroids may be safe to use consecutively for months, perhaps even years, without causing systemic effects.
J Drugs Dermatol. 2017;16(7):643-648.
Drivers of Healthcare Costs Among the Costliest Patients With Psoriasis Over Three Years in a United States Health Plan
April W. Armstrong MD MPH,a Yang Zhao PhD,b Vivian Herrera PhD,b Yunfeng Li PhD,b Tim Bancroft PhD,e Michael Hull MS,c and Aylin Altan PhDd|
OBJECTIVE: To compare patients with psoriasis by cost level over 3 years.
METHODS: Psoriasis patients in a large US health plan in 2011-2013 were identified. Four groups were created by healthcare costs excluding biologics: patients having top 10% of costs in all 3 years (Top), top 10% in 2 of 3 years (High), bottom 90% in 2 of 3 years (Medium), and bottom 90% in all 3 years (Bottom). Comorbidities, utilization, and costs between groups were compared.
RESULTS: The study included 18,653 patients: 514 (3%), 805 (4%), 2,443 (13%), and 14,891 (80%) patients in the Top, High, Medium, and Bottom groups, respectively. Significantly more patients in the Top vs Bottom group had diabetes (31.1% vs 9.4%), cardiovascular disease (26.5% vs 4.3%), psoriatic arthritis (25.7% vs 10.7%), depression (27.8% vs 6.9%), and anxiety (22.0% vs 7.9%) in 2011 (all P less than 0.05). Patients in the Top group had more unique 2011 prescriptions (17.7 vs 6.6; P less than 0.001) than the Bottom group, but similar biologic use (22.4% vs 21.6%). Patients in the Top, High, Medium, and Bottom groups had mean 2011 total costs of $68,913, $40,575, $24,292, and $8,815, and contributed to 14%, 13%, 23%, and 51% of the overall costs, respectively. Mean total costs increased 14-18% over time for all groups. Although mean 2011 total costs for patients in the Top group were 7.8 times of those in the Bottom group, psoriasis-related costs were less disparate ($8,716 vs $4,541). Compared with patients in the Bottom group, those in the Top group were more likely to have any 2011 hospitalization (36.8% vs 2.6%; psoriasis-related: 11.1% vs 0.7%) or emergency visit (50.8% vs 20.8%; psoriasis-related: 3.9% vs 1.0%).
CONCLUSION: The costliest patients with psoriasis had significantly higher prevalence of comorbidities, prescription fills, inpatient and emergency utilization, but not biologic medication use or biologic costs.
J Drugs Dermatol. 2017;16(7):651-658.
Expert Consensus on Absorbable Advanced Suspension Technology for Facial Tissue Repositioning and Volume Enhancement
Mark S. Nestor MD PhD,a Glynis Ablon MD,b Anneke Andriessen PhD,c Julius Few MD,d Michael H. Gold MD,e David J. Goldberg MD PhD,f Z. Paul Lorenc MD,g Stephen Mandy MD PhD,h and Susan H. Weinkle MDi|
BACKGROUND: Signs of facial aging include wrinkles, loss of subcutaneous volume, decreased tone, texture, and sagging of the skin. The objective of this review is to determine whether facial suspension absorbable sutures are a safe and effective modality for facial rejuvenation.
METHOD: A group of US plastic surgeons and dermatologists who practice medical aesthetics convened to review evidence obtained from literature searches and to reach a consensus on clinical practice guidelines for the use of facial absorbable suspension sutures.
RESULTS: Currently, there are different types of lifting sutures available. Absorbable, facial suspension sutures allow for superior repositioning of tissue along a vector line together with the added benefit of volumization of the area. These benefits are for patients who have moderate facial aging and require treatment beyond the use of injectable products only.
CONCLUSIONS: Treatment with absorbable facial suspension sutures, when performed properly, is associated with minor and infrequent complications and offers a beneficial clinical alternative to traditional facial rejuvenation techniques.
J Drugs Dermatol. 2017;16(7):661-666.
A 1% Colloidal Oatmeal Cream Alone is Effective in Reducing Symptoms of Mild to Moderate Atopic Dermatitis: Results from Two Clinical Studies
Toni Anne Lisante BA,a Chris Nunez PhD,b Paul Zhang PhD,c and Barbara M. Mathes MDd|
BACKGROUND: The epidermal barrier in patients with atopic dermatitis (AD) is deficient in ceramides and cathelicidins. Such epidermal defects may be a trigger for AD, thereby encouraging research toward development of skin-barrier-targeted preventive strategies.
METHODS: Two single-center, single-arm clinical trials were conducted (study 1, age greater than equal to 8 years and study 2, greater than equal to 10 years) in patients with mild to moderate AD to evaluate the effects of an over-the-counter 1% colloidal oatmeal cream administered for 14 days. Study 1 assessed the Eczema Area and Severity Index (EASI) and Investigator’s Global Atopic Dermatitis Assessment (IGADA) on day 3, and itch severity using a Visual Analogue Scale (VAS) immediately after application as primary efficacy endpoints. In study 2, the primary efficacy endpoint was change from baseline in patients’ assessment of itch. Both studies assessed safety through adverse event (AE) recording.
RESULTS: Study 1: 29 patients were enrolled (mean age [range], 27.07 [8 –67]). Comparing to baseline, EASI, IGADA, and itch were improved after the application, and improvements were maintained until day 14. Improvements of greater than/equal to 20% over baseline were noted in 53.6% and 25.0% patients at day 3 for EASI and IGADA scores, respectively, and in 37.9% patients for itch score immediately after the product application. On day 14, these percentages were 82.8%, 62.1%, and 85.7%, respectively.
STUDY 2: 30 patients were enrolled (mean age [range], 32.9 [10-80]). Itch severity and EASI score were significantly improved after product application and improvements were maintained until day 14. Transepidermal water loss values were significantly reduced and skin hydration was significantly increased at all assessment time points. No adverse events (AEs) were reported in study 2 and 2 AEs were reported by 1 patient in study 1.
CONCLUSIONS: The colloidal oatmeal cream was well tolerated and clinically effective in patients with mild to moderate AD.
J Drugs Dermatol. 2017;16(7):671-676.
Zoe Diana Draelos MD|
New cosmeceutical ingredients that improve skin appearance are of interest to the dermatologist. Cryptomphalus aspersa is a snail raised on farms in Spain for its mucinous secretions and eggs. These natural products have been demonstrated in vitro to trigger mesenchymal stem cell differentiation, promote dermal fibroblast and keratinocyte migration, prevent keratinocyte aging, prevent oxidative damage, stimulate the extracellular matrix, and regulate MMPs. This 12-week study enrolled 40 male and female subjects age 40-70 years of Fitzpatrick skin types I-IV with moderate to severe facial aging and Rao-Goldman scores of 4-5 who applied an eye and face anti-aging cream twice daily containing a mollusk egg extract. Dermatologist investigator, subject, and elasticity assessments were performed at baseline, week 8, and week 12. At week 12, the investigator rated a 53% reduction in skin roughness (P less than 0.001), 26% improvement in skin brightness (P less than 0.001), and 12% reduction in skin dyspigmentation (P=0.033). The noninvasive elastometer measurements demonstrated an increase in skin elasticity at week 8 of 11% with a continuing elasticity increase at week 12 of 39% (P less than 0.001). The formulation studied included moisturizing, emollient, film-forming, and retinoid ingredients in addition to the mollusk egg extract to produce the clinical improvement.
J Drugs Dermatol. 2017;16(7):678-681.
Joseph V. Caravaglio MDa and Amor Khachemoune MD FAAD FACMSb|Ecthyma contagiosum, also called contagious pustular dermatosis, is a zoonotic disease caused by the orf virus (OrfV). As a member of the poxviridae family and parapoxvirus genus, this dermatotropic virus has developed an array of mechanisms by which to evade the host immune system in both humans and animals. The ubiquitousness of this pathogen in sheep, goats, and deer has led to the development of orf in diverse areas around the world. Human disease occurs via direct contact with infected animals or fomites. Rarely, human-to-human transmission has been reported. The disease progresses through six clinically distinct dermatologic stages and lesions usually heal in three to six weeks without scarring. Farmers, veterinarians, and hunters represent high-risk groups, as their repeated contact with livestock and wild animals predisposes them to infection. With an increasing number of cattle, livestock, and wild animals being kept as pets, human orf may become more prevalent in the future. Taken with the lack of a widely accepted and successful antiviral treatment regimen, this demonstrates the importance of conducting additional research to further elucidate the pathogenic effects of the OrfV in humans. J Drugs Dermatol. 2017;16(7):684-689.
Gabriella DiMarco MDa and Amy McMichael MDb|
INTRODUCTION: Hair loss is a common complaint seen in dermatology clinics. From frustration and attempts at self-help, patients with hair loss may present to the dermatologist with false beliefs, or myths, about the causes of their condition and what treatments are effective.
METHODS: We identified 12 common myths about hair loss, categorized as myths about minoxidil treatment, vitamin and mineral supplements, natural topical treatments, and hair care practices. We performed a PubMed search to find evidence to support or refute each myth.
RESULTS: We found that there is little evidence to support many of these common hair loss myths. In some cases, randomized controlled trials have investigated the effects of particular therapies and point to the effectiveness of certain hair loss treatments.
DISCUSSION: In many cases, there have not been sufficient randomized controlled trials to evaluate the effect of different therapies and hair care practices on hair loss. It is best to guide patients toward treatments with a long track record of efficacy and away from those where little is known scientifically.
J Drugs Dermatol. 2017;16(7):690-694.
Meagan-Helen Henderson Berg MDCMa and Daniel Carrasco MDb|
Psoriasis is a chronic inflammatory cutaneous disease that affects 2-3% of the general population. Up to 30% of patients with psoriasis also develop psoriatic arthritis, a chronic inflammatory and progressive arthritis. Although their precise pathogeneses remain unclear, psoriasis and psoriatic arthritis involve altered expression of proinflammatory cytokines, including tumor necrosis factor-α, interleukin (IL)-12, IL-17, IL-22, and IL-23. The development of biologic agents that target these cytokines has greatly improved the treatment of psoriatic disease. Injection site reactions have been reported with many of these therapies. In this paper, we will present cases and review the literature on injection site reactions with the major biologic agents administered subcutaneously for the treatment of psoriasis and psoriatic arthritis.
J Drugs Dermatol. 2017;16(7):695-698.
Aubrey Wagenseller MD, Cecilia Larocca MD, and Neelam A. Vashi MD|
Annular elastolytic giant cell granuloma, also known as actinic granuloma, is a rare skin condition with a chronic course that is often resistant to treatment. Literature is sparse, and only a handful of case reports are available to guide treatment decisions. Typical first line treatment options include topical and intralesional steroids, topical pimecrolimus, and cryotherapy. Resistant cases have been treated with cyclosporine, systemic steroids, antimalarials, and oral retinoids. In particular, acitretin and isotretinoin have shown success in three cases. However, these medications can have side effects and require frequent lab monitoring. We present a case of a 47-year-old woman with bilateral forearm lesions consistent with annular elastolytic giant cell granuloma who was successfully treated with topical tretinoin.
J Drugs Dermatol. 2017;16(7):699-700.
Acquired Epidermodysplasia Verruciformis and Its Relationship to Immunosuppressive Therapy: Report of a Case and Review of the Literature
Channa G. Ovits MD, Bijal D. Amin MD, Caroline Halverstam MD|Introduction: Epidermodysplasia verruciformis (EV) is a rare inherited dermatosis characterized by increased susceptibility to human papilloma virus infection. Acquired EV occurs in patients with compromised cell-mediated immunity, such as patients with HIV and transplant recipients. Optimal management of acquired EV has not yet been established, as cases are rare and are due to a variety of underlying conditions. Additionally, no distinctions have been made between different immunosuppressive medications and their respective link to EV. Methods and Results: We report a patient with systemic lupus erythematosus who developed EV while on azathioprine and prednisone. The patient’s lesions resolved completely after she was switched from azathioprine to mycophenolate mofetil. Her lesions recurred when her immunosuppressive regimen was again changed from mycophenolate mofetil to methotrexate. A review of the literature revealed azathioprine to be related to other cases of acquired EV. Discussion: This case indicates a possible link between specific immunosuppressive drugs and the development of EV, allowing for new EV treatment considerations. In this case and previous cases, azathioprine is indicated as being particularly linked with the development of EV, while mycophenolate mofetil may be an immunosuppressive option that is less likely to induce EV in patients predisposed to this condition. J Drugs Dermatol. 2017;16(7):701-704.
Anna Cristina Garza-Mayers BA PhDa,b and Daniela Kroshinsky MD MPHa,b|
BACKGROUND: Treatment of vitiligo is aimed at repigmentation and often consists of multiple modalities, none of which are universally or rapidly successful. Extensive cases are most often treated with ultraviolet light therapy, which can be both costly and time-consuming. Though vitiligo is an autoimmune disease, there is no current data to support systemic immunosuppressive monotherapy.
CASE SUMMARY: Here we present a case series of 3 patients with vitiligo treated for 11-16 months with low-dose methotrexate (12.5-25 mg per week) with folic acid supplementation with clinically significant skin repigmentation, with response within 6 months in one case. There were no severe adverse effects reported.
CONCLUSION: These cases demonstrate an unexplored effective and steroid-sparing therapeutic alternative in patients with vitiligo for whom topical therapy has failed and phototherapy is cost-prohibitive or ineffective.
J Drugs Dermatol. 2017;16(7):705-706.
Randomized, Split-Face/Décolleté Comparative Trial of Procedure Enhancement System for Fractional non-Ablative Laser Resurfacing Treatment
Deanne Mraz Robinson FAAD MDa,b and Ashton P. Frulla RNb|
INTRODUCTION: A topical proprietary procedural enhancement system (PES) containing a combination of active ingredients including a tripeptide and hexapeptide (TriHex Technology™, Alastin Procedure Enhancement Invasive System, ALASTIN Skincare™, Inc., Carlsbad, CA) has been used successfully to aid in healing and improve symptomatology following resurfacing procedures.
METHODS: PES (Gentle Cleanser, Regenerating Skin Nectar with TriHex Technology™, Ultra Nourishing Moisturizer with TriHex Technology™, Soothe + Protect Recovery Balm, Broad Spectrum 30+ Sunscreen) was compared to a basic regimen (Aquaphor™, Cerave™ cleanser, Vanicream™, Alastin Broad Spectrum 30+ Sunscreen) in a split face/ décolleté trial following fractional non-ablative thulium-doped resurfacing treatment to the face or décolleté. The skin was pre-conditioned and treated during and after the procedure using the two regimens.
RESULTS: A blinded investigator rated the PES statistically superior to the basic regimen on healing post-laser treatment on day 4 based on lentigines, texture, and Global Skin Quality. Subjects also reported ‘better looking and feeling’ skin on the PES side.
CONCLUSION: PES appears to improve healing post-non ablative thulium-doped resurfacing treatment to the face/décolleté in comparison with standard of care.
J Drugs Dermatol. 2017;16(7):707-710.
Stanislav N. Tolkachjov MD,a Philip Y. Sun MS,b and Alina G. Bridges DOa|
Pyoderma gangrenosum (PG) is a neutrophilic, ulcerative dermatosis that can develop at sites of cutaneous trauma, including surgical incisions, a phenomenon known as pathergy. The characteristic lesion is a painful, rapidly expanding ulceration with a violaceous undermined border.1 A biopsy taken from the expanding violaceous border shows predominantly neutrophilic dermal inflammation with neutrophilic abscess formation.
The etiology of PG appears to be variable among patients, as about a half of the reported cases are associated with systemic disease such as inflammatory bowel disease, rheumatoid arthritis, or myeloproliferative disorders, while the other half seem to be idiopathic.2 PG is difficult to diagnose as other etiologies, including infectious, vasculitic, and other inflammatory dermatoses, must be excluded.1 Histopathologic and biochemical markers of PG, such as dermal neutrophilic infiltrate or overexpression of interleukin-8,3 respectively, are not pathognomonic. Given that several drugs, such as hydralazine, mesalamine, and sunitinib, are reportedly associated with PG, failure to recognize this association and stop these medications may delay diagnosis and therapy. We report a case of idiopathic postoperative PG following video-assisted thoracic surgery (VATS).
J Drugs Dermatol. 2017;16(7):711-713.
Lichenoid Dermatitis From Interferon alpha-2a in a Patient With Metastatic Renal Cell Carcinoma and Seronegative HCV
Amelia E. Bush MD,a Sharon R. Hymes MD,b and Sirunya Silapunt MDc|
Cutaneous reactions to interferon, including a lichenoid drug reaction, are most commonly reported in patients undergoing treatment for hepatitis C virus (HCV) infection. There have been case reports of interferon-induced lichen planus in seronegative HCV patients with lymphoproliferative disorders and melanoma. We report the case of a 71-year-old man undergoing treatment with interferon for metastatic renal cell carcinoma (RCC) who developed an eruption 2 months after starting interferon. Clinical and histological findings from biopsies supported a diagnosis of interferon-induced lichen planus. To our knowledge, this is the first known case of a lichenoid drug eruption from interferon in a seronegative HCV patient with metastatic RCC.
J Drugs Dermatol. 2017;16(7):714-716.