Herbal products have steadily gained popularity as alternatives to conventional, synthetic medications and are sought after by patients
for the treatment of chronic dermatologic diseases and for cosmeceutical use. The production and distribution of botanical extracts is
largely unregulated and therefore extensive research into their mechanism of action, safety, physiologic stability, and optimal dosing
has been overlooked. One of the major pathways through which natural supplements, particularly polyphenols, act is via inhibition of
oxidative stress and its downstream mediators. Endogenous defense mechanisms are inadequate to combat oxidative stress and
therefore dietary and/or topical supplementation with polyphenols are an important complementary preventative and therapeutic
strategy. This review focuses on the molecular targets of common polyphenols used in topical preparations, particularly soy, green tea,
oats, curcumin, and silymarin. Continued research into bioavailability and function of these agents will help translate their therapeutic
potential to treat clinical disease.
J Drugs Dermatol. 2014;13(8):937-943.
Ustekinumab is a human IgG1κ monoclonal antibody that binds with high affinity and specificity to the p40 protein subunit shared by both
the interleukin-12 and interleukin-23 cytokines. This study reviews clinical response and adverse events in 119 psoriasis patients who have
received ustekinumab for a minimum of 1 year. The medical records of 119 psoriasis patients treated with ustekinumab at our referral clinic
in Dallas between 2009 and 2013 were reviewed for response rates, side effects, and concomitant therapies. Of 119 patients, 117 (98%)
had plaque type psoriasis, with 40 (34%) patients having psoriasis affecting either their palms and/or soles. Forty-four (37%) patients had
psoriatic arthritis. The median follow-up period was 31 months. Fifty-six (47%) of the 119 patients obtained near complete clearance (response
of more than 90% of initial body surface area involvement) upon the final follow-up visit or at the time of ustekinumab treatment
discontinuation. Concomitant systemic treatments, primarily methotrexate, were given to 59 (50%) patients. Twenty-three (19%) patients
discontinued treatment, primarily for sub-optimal response or loss of response. Fifty (42%) patients required either an increase in the
dose of ustekinumab to 90 mg and/or administration more frequently than every 12 weeks to achieve and maintain psoriasis clearance.
J Drugs Dermatol. 2014;13(8):905-910.
OBJECTIVES: To demonstrate the efficacy and safety of calcitriol ointment (3 mcg/g) compared to betamethasone diproprionate ointment
in the treatment of nail psoriasis.
DESIGN: Single-center, double-blind study.
SETTING: One academic center.
PARTICIPANTS: 10 adult male and female subjects with psoriasis of the fingernails and/or toenails.
MEASUREMENTS: The primary efficacy evaluation was the absolute reduction of nail thickness (mm) of the target nail. A secondary
endpoint was the improvement in the Physician Global Assessment score of disease severity.
RESULTS: Patients treated with either betamethasone diproprionate ointment or calcitriol ointment demonstrated a similar reduction of
nail thickness of the selected target nail. The difference between the two groups was not statistically significant (P=0.42).
CONCLUSION: This small study illustrates that calcitriol ointment may be as effective as betamethasone diproprionate in the treatment
of nail psoriasis, and its promise should be further investigated in a subsequent larger trial.
J Drugs Dermatol. 2014;13(8):912-915.
BACKGROUND: Moderate-to-severe psoriasis generally requires systemic therapy, and is often undertreated.
OBJECTIVE: To determine and analyze what courses of treatment and in what frequency are being utilized to combat psoriasis in the
METHODS: Analysis of data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical
Care Survey (NHAMCS) of the National Center for Health Statistics. Data were analyzed to examine the prevalence of different therapy
techniques to combat psoriasis from 1993 through 2010. The trends for phototherapy, methotrexate (MTX), retinoids, cyclosporine A
(CSA), systemic steroids, and biologics were all analyzed over the entire 18-year period and independently before and after the introduction
of biologics in 2002.
RESULTS: From 1993 to 2010, the trend for total systemic treatments has not significantly increased (P=0.5). Frequency of phototherapy
treatments significantly decreased from 1993 to 2010 (P<0.001). Since the introduction of biologics in 2002, their frequency has significantly
increased, becoming the most frequently used treatment from 2008-2010 (P<0.0001).
LIMITATIONS: Severity of psoriasis was not recorded in the NAMCS and NHAMCS.
CONCLUSIONS: The frequency of systemic treatments to treat psoriasis has not significantly increased from 1993 to 2010. Despite the
introduction of biologics, it appears that little progress has been made in reducing under-treatment of moderate-to-severe psoriasis.
J Drugs Dermatol. 2014;13(8):917-920.
IMPORTANCE: UV phototherapy remains a useful and frequently employed treatment for chronic plaque psoriasis. In those patients with
plaque body surface area less than 10%, targeted treatment is the safest and most effective modality.
OBJECTIVE: We aimed to evaluate the efficacy of the Levia® localized NB-UVB phototherapy machine in the treatment of patients with
symmetrical psoriatic lesions.
DESIGN: We performed a prospective, double-blinded, sham-treatment controlled study of this device beginning March 2012 through
SETTING: a comprehensive dermatology clinic in the northeastern United States.
PARTICIPANTS: 21 subjects with chronic plaque psoriasis.
INTERVENTIONS: Each patient had one lesion randomized to receive the Levia treatment and one lesion (the control) treated with visible
light. Treatment was administered three times a week for twelve weeks. Target lesion score (TLS), a rating of 0-4 each of erythema,
scaling, and thickness, was measured biweekly by a blinded assessor, and visual analogue scale of pruritus was recorded by subjects.
MAIN OUTCOMES AND MEASURES: The primary outcome, formulated prior to study initiation, was the percentage of lesions achieving
clear or almost clear TLS after 12 weeks of treatment. Secondary endpoints included changes in target lesion pruritus VAS, percentage
improvement in TLS, and the percentage of subjects achieving 50% improvement in TLS (TLS-50).
RESULTS: The primary endpoint, TLS of three or less, was not achieved (P
=0.118), but the secondary endpoints of percentage improvement
in TLS (P
=0.043) and TLS-50 (P
=0.0195) were significantly superior in treated compared to sham-treated lesions. Percentage
improvement in pruritus VAS was not significant (P
CONCLUSIONS AND RELEVANCE: This device was found to be efficacious, though not necessarily to the point of clearance, in the treatment
of psoriasis over a 12-week period.
TRIAL REGISTRATION: www.clinicaltrials.gov, identifier: NCT02107482, http://clinicaltrials.gov/show/NCT02107482
J Drugs Dermatol
For nearly 5 decades, methotrexate has been the backbone of moderate-to-severe psoriasis treatment. The benefits of methotrexate
therapy include reliable efficacy, low cost, relative ease of administration, and its usefulness as part of combination therapy regimens,
making it a drug of choice for treating psoriasis. While methotrexate can be administered orally, intravenously, or intramuscularly, the
self-administered subcutaneous use of the drug is the most advantageous route. Subcutaneous methotrexate is associated with fewer
adverse events and higher absorption rates, accompanied by bioavailability that is both linear and predictable throughout the range of
possible doses. In addition, the subcutaneous route, when compared with oral administration, facilitates improved efficacy by
promoting higher intracellular levels of long-chain methotrexate polyglutamates. Taken together, these features allow patients the
highest probability of a successful therapeutic experience. Subcutaneous methotrexate should be considered a viable option for the
appropriate patient with moderate-to-severe psoriasis.
J Drugs Dermatol. 2014;13(8):929-931.
OBJECTIVES: To stratify MI risk reduction in those treated with a TNF inhibitor for psoriasis only, psoriatic arthritis only, or both psoriasis
and psoriatic arthritis.
DESIGN: Retrospective cohort study
SETTING: Between January 1, 2004 and November 30, 2010
PARTICIPANTS: At least 3 ICD9 codes for psoriasis (696.1) or psoriatic arthritis (696.0) (without antecedent MI.
MAIN OUTCOME MEASURE: Incident MI
RESULTS: When comparing to those not treated with TNF inhibitors (reference group), of those treated with TNF inhibitors: those with
psoriasis only (N= 846) had a significant decrease in MI risk (hazard ratio (HR), 0.26; 95% CI, 0.12-0.56); those with psoriatic arthritis
only (N= 112) had a non-significant decrease in MI risk (HR, 0.86; 95% CI, 0.28-2.70); those with both psoriasis and psoriatic arthritis
(N= 715) had a non-significant decrease in MI risk (HR, 0.76; 95% CI, 0.47-1.24).
CONCLUSIONS: In the TNF inhibitor cohort, those with psoriasis only have the strongest association with MI risk reduction, followed by
those with psoriatic arthritis only, and then followed by those with both psoriasis and psoriatic arthritis.
J Drugs Dermatol. 2014;13(8):932-934.
The field of cutaneous oncology is exploding with innovative treatment options, specifically in the field of targeted therapy. These advances
offer new hope to select patients with high risk skin cancers. Here we provide a two part series reviewing targeted therapy for
non-melanoma skin cancer. We begin our discussion with basal cell carcinoma, moving beyond the first-in-class hedgehog inhibitors
and highlighting promising clinical trials.
J Drugs Dermatol. 2014;13(8):947-952.
The field of cutaneous oncology is exploding with innovative treatment options, specifically in the field of targeted therapy. These advances
offer new hope to select patients with high risk skin cancers. In part two of our series on targeted therapy for skin cancer, we
focus our attention on squamous cell carcinoma. We begin with the epidermal growth factor receptor inhibitors and branch out into
newer areas of active research.
J Drugs Dermatol. 2014;13(8):955-958.
There are many over-the-counter products used to treat dermatological conditions. Patients are inundated with information about these
products. Dermatologists often encounter questions about the usefulness of over-the-counter products as anecdotal data about such
products is often adapted as common practice in the medical field. Modern dermatology training does not include pharmacological
education on many of the over-the-counter products commonly used by patients. In this current age when patients have increasing
interest in using “natural” remedies, it is important that dermatologists can provide guidance to patients regarding some of the most
common products that they may encounter. This article is designed to provide introductory information on the common uses for several
over-the-counter products as well as to display any evidence in support of these products for dermatological diseases.
J Drugs Dermatol. 2014;13(8):960-966.
INTRODUCTION: Skin defects can be repaired via primary closure, secondary intention healing, local and distant flaps, skin grafts or application
of natural and synthetic skin substitutes. When possible, primary linear repair is favored due to simplicity, minimal morbidity
and rapid healing. A number of suture techniques are available to the surgeon for primary closure, the selection of which depends on
defect size, anatomic location, wound eversion, and tension.
OBJECTIVE: To review suture techniques and how they influence scar cosmesis.
METHODS: PubMed was searched using the following key words: cosme* in combination with cutaneous suture, simple interrupted,
simple running, running locked, vertical mattress, horizontal mattress, buried, subcuticular, running vertical mattress, running horizontal
mattress, buried vertical mattress, butterfly suture, or pulley suture. Information on study type, number of patients, age, gender, defect
type, anatomic location, suture technique, scar length, follow up, and outcomes measured were tabulated.
RESULTS: Twenty-four articles - 17 prospective randomized controlled trials including 1,473 subjects and 1,608 repairs and seven case series
including 465 subjects and repairs - were reviewed. Fifteen articles - 12 randomized controlled trials and three case series - demonstrated
that aesthetic outcome was influenced by suture technique, the majority of which showed subcuticular closure to be superior to simple
interrupted or simple running sutures. No difference in aesthetic outcome was observed in nine studies, which included 370 repairs.
DISCUSSION: Review of the literature supports the use of subcuticular closure over simple interrupted or simple running sutures on the
trunk and extremities for improved aesthetic outcome.
J Drugs Dermatol. 2014;13(8):967-969.
BACKGROUND: There are few studies analyzing the behavior of ustekinumab in the complex management of psoriasis within diary clinical
OBJECTIVE: To assess the utility of ustekinumab in a psoriasis unit.
METHODS: Analysis of the prospective data gathered during the follow-up of 30 consecutive psoriasis patients treated with ustekinumab at
a single referral centre. Three effectiveness endpoints were defined 12 weeks, 28 and “long-term treatment”. The main outcome measure
was improvement from baseline PASI at week 28 and at a point of adjustment of prolonged treatment signed as “long-term treatment”.
RESULTS: Overall 82.1% and 42.8% patients achieved respectively PASI75 and PASI90 response rates at week 28. Long-term treatment
maintained efficacy outcomes 81.5% and 40.7% PASI75 and PASI90, respectively were observed. At week 28, patients naïve to TNFα-
blockers agents and patients with a baseline PASI >10 had better PASI75 and PASI90 response rates than previously treated patients.
CONCLUSIONS: In clinical practice, the efficacy and patient adherence to ustekinumab are excellent and even better to the data obtained
in clinical trials. Clinical indicators of psoriasis severity: previous treatments with tumor necrosis factor α blockers agents and active
treatment beside small increases in PASI determine a delayed maximal response.
J Drugs Dermatol. 2014;13(8):971-974.