Frequent causes of morbidity secondary to herpes zoster include acute pain, secondary infection, and postherpetic neuralgia. A
less documented complication is pruritus, which can be either acute or postinfectious when it persists more than 3 months after
the rash has healed. We discuss a case of severe, acute neuropathic pruritus and pain secondary to active herpes zoster that
was unresponsive to standard medical therapy, including oral antihistamines, topical lidocaine, oral gabapentin, and local wound
care. Modest control of the pruritus and pain was achieved with continued multimodal therapy and the addition of topical 2%
amitriptyline/0.5% ketamine gel.
J Drugs Dermatol. 2015;14(2):115-118.
BACKGROUND: Psoriasis treatments and therapeutic response as they relate to private versus public patient insurance in the United
States have not yet been reviewed. Improved understanding could clarify factors challenging optimal psoriasis management and offer
insight for dermatologists treating psoriasis within our healthcare system.
METHODS: 258 subjects were included from a database of psoriasis patients seen at Tufts Medical Center (Boston, MA) during
2008-2014. Insurance was classified as primarily private or public (Medicare or MassHealth/Medicaid). Patients required a minimum
of two consecutive visits per treatment and at least 8 weeks within one of four treatment categories: biologics, oral systemics/
phototherapy, combined biologics and oral systemics/phototherapy, or topicals only. Primary endpoint was the Simple-Measure for
Assessing Psoriasis Activity (S-MAPA) calculated by multiplying Physician Global Assessment by Body Surface Area. S-MAPA<3
constituted absolute clearance. Insurance type was evaluated as a predictor of prescribed treatment categories, maximum S-MAPA
improvement from baseline, and total drugs used per treatment course (“drug-switching”).
RESULTS: 80.2% (n=207) and 19.8% (n=51) had primarily private and public insurance, respectively. 69.6% with private insurance
were prescribed biologics versus 66.7% (public insurance) (P=0.689). 54% (private) versus 49% (public) achieved clearance
(P=0.514). However, S-MAPA decreased 78.35% from baseline in those with private insurance compared to 61.48% (public)
(P=0.036). On average, privately insured patients used at least twice as many same-category treatments, most commonly biologics,
than publicly insured individuals (P=0.003). Drug-switching was significantly associated with clearance (P=0.024). Multivariate
analysis demonstrated no significant differences in prescribed treatment categories, drug efficacy, clearance, S-MAPA, or drugswitching
with respect to patient age.
CONCLUSIONS: Treatment categories were comparably prescribed between insurance subgroups. However, privately insured patients
achieved significantly greater degrees of clearance and switched between more medications within biologic and systemic categories,
potentially explaining their overall improved therapeutic response. Further studies including cost-analysis could clarify any difference in the effectiveness of prescribed therapy for these two patient populations.
J Drugs Dermatol. 2015;14(2):119-125.
Skin microbiome studies have elucidated clinically pertinent information regarding its potential role in the pathogenesis of certain
inflammatory skin disorders. Two of the most commonly diagnosed chronic inflammatory skin disorders that have been connected to
perturbation of the skin microbiome are psoriasis (PS) and atopic dermatitis (AD). The objective of this brief review is to recapitulate
some of the novel findings concerning the microbiome’s role in AD and PS.
J Drugs Dermatol. 2015;14(2):127-130.
BACKGROUND: Photo documentation has become increasing important in medicine, especially given the demand for cosmetic procedures.
Standard photography is not always adequate; newer techniques exploring the use of polarized, cross and ultraviolet photography
can give detailed information on subtle skin lesions including skin pigmentation and skin surface characteristics.
OBJECTIVE: To use various methods of photography including standard photography, cross polarized light, parallel polarized light and ultraviolet passing photography to assess which method most effectively captures skin features such as texture, pigment, and/ or vascularity.
METHODS: A prospective analysis comparing advanced photographic techniques including standard photography, polarized light photography,
cross-polarized light photography and ultraviolet light passing photography. The photos were then evaluated and scored by
two experts and a blinded observer to characterize the differences visualized in each type of photography compared to standard photography in terms of subsurface skin features, hypopigmentation, hyperpigmentation, and rhytids.
RESULTS: 9 subjects completed the study. Overall, of the 3 photographic methods compared to standard photography, UV passing most
enhanced the visualization of subsurface features and hypopigmentation, with increased hyperpigmentation as well. Enhancement of
these features made UV passing best for capturing photodamage. Cross-polarized photography was best for visualizing hyperpigmentation,
but also heightened visualization of hypopigmentation and subsurface features such as vascularity. Parallel-polarized photography
enhanced visualization of skin texture.
CONCLUSIONS: These methods of photography show a quantifiable and reproducible selective ability to evaluate and document elements
such as skin texture, vascularity, and pigmentation. Each of these techniques has unique properties that can add to the precision
of the clinical evaluation and can be of particular value to providers of cosmetic procedures where photo documentation has become
increasingly important in providing an objective means of evaluating outcomes.
J Drugs Dermatol. 2015;14(2):134-139.
BACKGROUND: Limited data are available on acne treatment patterns in females through their adult years.
OBJECTIVE: The purpose of this analysis was to evaluate health care resource utilization (HRU) and treatment patterns in cohorts with
and without the use of acne medication and predictors of use.
METHODS: A cross-sectional, web-based survey was administered to US females (25–45 years) with facial acne (≥25 visible lesions).
Data collected included: sociodemographics and self-reported clinical characteristics, acne treatments, and health care professional
(HCP) visits. Subject characteristics associated with medication use were examined by logistic regression.
RESULTS: Approximately half of the total sample (N=208, mean age: 35±6) ever visited an HCP for acne and reported more over-the counter
(OTC) medication use (51.0%) than prescription (Rx) medication use (15.4%). Subjects did not use medications daily, averaging
from 12–18 days over the previous 4 weeks. Logistic regression showed that race and prior HCP visits for acne were significant predictors
of medication use (P<.05).
CONCLUSIONS: Adult females generally self-treated their acne using primarily OTC medications; however, poor compliance was observed
for Rx and OTC. Race and prior HCP visits for acne were significant predictors of current medication use.
J Drugs Dermatol. 2015;14(2):140-148.
Hereditary angioedema (HAE) is a rare genetic disease caused by a deficiency in functional C1-esterase inhibitor characterized by recurrent episodes of angioedema in the absence of associated urticaria. Subcutaneous swellings are experienced by virtually all patients
with HAE, and dermatologists are likely to encounter this manifestation, requiring that they be knowledgeable about diagnosis and
treatment options. Diagnosis of HAE is often delayed because several of the symptoms can mimic other disease states. Delays in
diagnosis can lead to increased inappropriate treatment and decreased patient quality of life. Once a proper diagnosis is made, treatment
needs to be targeted to the individual patient and includes on-demand therapy and an option for short- and long-term prophylaxis.
On-demand therapy is required for all patients who are diagnosed with HAE and effective options include plasma-derived and recombinant
C1 inhibitors, kallikrein inhibitors, and bradykinin B2-receptor antagonists. Options available for prophylaxis include plasma-derived
C1 inhibitors, attenuated androgens, and antifibrinolytic agents, although the latter 2 options are associated with significant adverse
events. This article reviews the diagnosis and options for effective management of patients with HAE.
J Drugs Dermatol. 2015;14(2):151-157.
BACKGROUND: The use of tumor necrosis factor inhibitors (TNFi) has been associated with a reduced incidence of type 2 diabetes mellitus.
OBJECTIVE: To compare changes in hemoglobin A1C and fasting glucose for patients exposed to TNFi.
METHODS: In this retrospective cohort study, patients with at least 3 recorded diagnosis codes for psoriasis, psoriatic arthritis, or rheumatoid
arthritis between January 1, 2004 and July 31, 2011. Patients were Kaiser Permanente Southern California members for at least
1 year prior to the index date.
RESULTS: For hemoglobin A1C, there were 344 patients in the MTX cohort, and 118 patients in the TNFi+MTX cohort. In the covariate
adjusted main effects ANCOVA model, the TNFi+MTX cohort had a lower mean change in hemoglobin A1C of -0.18mg/dL
(95% CI: -0.35, -0.01) compared to the MTX cohort, although the difference is small and this model was not complete as there
were significant interactions. For fasting glucose, there were 524 patients in the MTX cohort, and 121 patients in the TNFi+MTX
cohort. In the covariate adjusted main effects ANCOVA model, change in fasting glucose was not significantly different between
groups: -0.58 mg/dL (95% CI: -5.05, 3.88) for the TNFi+MTX cohort compared to the MTX cohort, although this model was not
complete as there was a significant interaction.
CONCLUSIONS: The use of TNF inhibitors with MTX was not associated with a significant difference in the change of hemoglobin A1C
or fasting glucose compared to MTX alone.
J Drugs Dermatol. 2015;14(2):159-166.
BACKGROUND: Atopic dermatitis (AD) is a highly prevalent, chronic relapsing condition in childhood with significant financial burden
and impact on the quality of life of patients and caregivers. Proactive maintenance treatment with moisturizing agents is the mainstay
AD therapy. Objectives: The aim of this study was to assess the cost-effectiveness of a non-steroidal barrier cream (Atopiclair),
compared to regular emollient in pediatric patients with mild-to-moderate AD. Methods: A Markov decision model was developed
to evaluate the cost-effectiveness of Atopiclair versus regular emollient in 12 Asia-Pacific countries, grouped by income categories
based on gross domestic product (GDP) per capita. Data was obtained from structured literature review, expert opinion, fee schedules,
and findings from a 2012 survey of 12 Asia-Pacific countries. Analysis was performed a societal perspective. Results: In the
base case analysis, Atopiclair was cost-effective against regular emollient, with USD786, USD499, and USD289 in cost savings per
year for high, middle, and low-income countries, respectively. Sensitivity analyses showed that Atopiclair remained cost-effective
versus regular emollient. Conclusions: Modelling analysis showed that Atopiclair is a cost-effective treatment compared to regular
emollient for mild-to-moderate pediatric AD in the countries included in the study.
J Drugs Dermatol. 2015;14(2):169-175.
Acne vulgaris is a common skin disease that is difficult to treat due to its multifactorial etiology. The presence of sebum and
keratinocytes within the hair follicle often prevent medication from penetrating deep into the follicle where the causal bacteria
are to be found. Medications able to penetrate into the follicle are often irritating to the skin. Recently, a technology has been
developed that can penetrate sebum and deliver medication deep in the follicle while also being gentle on the skin. This novel
microgel complex is therefore a critical next step in the treatment of acne and also an important tool for people who suffer from
a lower quality of life due to persistent acne breakouts.
J Drugs Dermatol. 2015;14(2):176-182.
Isotretinoin, the most effective therapy for severe acne, has engendered controversy. These controversies impact dermatologists’
opinions of isotretinoin and prescription behaviors. This study was designed to characterize dermatologists’ opinions of controversies
surrounding isotretinoin, as well as counseling and prescribing practices. A 25-question survey was emailed to 7,013 dermatologists
included in a proprietary database (MBD, Inc.) and anonymous responses were collected. 591 board-certified dermatologists
participated. Thirty-seven percent of the responding dermatologists believe that isotretinoin may cause psychiatric disturbances.
Dermatologists’ opinions on this relationship did not significantly impact prescription practices in patients with history of depression
(P=0.056) or in patients being treated with an antidepressant (P=0.118). A larger percentage of dermatologists surveyed believe
there is a causal relationship between isotretinoin and psychiatric disturbances than isotretinoin and IBD. Of the surveyed dermatologists,
2.7% believe there is a causal association between isotretinoin and inflammatory bowel disease IBD. In addition, physicians
with 20 or fewer years of experience, which included 50% of the responding dermatologists, were significantly less likely to have
read the patient brochure (P=0.004), and more likely to prescribe isotretinoin to patients who had not failed systemic antibiotics (P
=0.015). This questionnaire also may highlight a practice gap, as more recently trained dermatologists appear less likely to require
failure of systemic antibiotics prior to initiating isotretinoin.
J Drugs Dermatol. 2015;14(2):184-189.