A phase 2a randomized vehicle-controlled multi-center study of the safety and efficacy of delgocitinib in subjects with moderate-to-severe alopecia areata.

Alopecia areata/AA is an autoimmune cause of nonscarring hair loss. The pathogenesis of AA involves many immune axes, including Th1/Th2 pathways. Delgocitinib is a pan-Janus kinase/JAK inhibitor that broadly blocks pro-inflammatory cytokines and has been effective in other inflammatory skin conditions. Recent human studies/reports have shown that use of some systemic JAK inhibitors led to hair regrowth, suggesting this medication class as a potential therapy for AA. However, topical treatment is desirable due to potential systemic side effects. To assess the efficacy and safety of topical delgocitinib in AA, we conducted a double-blind, randomized, vehicle-controlled clinical trial in 31 moderate-to-severe AA patients that were randomized 2:1 to receive delgocitinib ointment 30 mg/g (n = 20) or ointment vehicle (n = 11) for 12 weeks. The primary endpoint was change in severity of Alopecia Tool/SALT score from baseline to week 12. The secondary endpoint included safety profile by reported adverse events. Twenty-three subjects completed the trial, with eight discontinuing mostly due to voluntary withdrawal. Ten patients receiving delgocitinib ointment and three patients receiving vehicle showed SALT score improvements after 12 weeks, but the mean percent SALT improvement at week 12 compared to baseline between the two arms was not significant (p = 0.92). Our study suggests that delgocitinib ointment is not effective in moderate-to-severe AA, likely due to its inability to penetrate sufficiently deeply into the dermis of the scalp, but larger studies are necessary to assess whether a different formulation of topical JAK inhibitors may be suitable to treat mild or more localized forms of AA.

Dermatitis Artefacta, a Form of Factitial Disorder Imposed on Self, Misdiagnosed as Pyoderma Gangrenosum for Eight Years.

Dermatitis artefacta is a rare psychological disorder in which patients self-inflict cutaneous lesions to satisfy an emotional need. Due to the nature of this disease, patients can present with a wide array of sometimes very severe skin lesions. Here, we describe a case of dermatitis artefacta initially misdiagnosed as pyoderma gangrenosum and treated as such for eight years. The patient reported a long history of cutaneous ulcers on her extremities and trunk, with resultant extensive scarring. Upon presentation, she displayed rapidly progressing necrotizing skin lesions on her bilateral distal lower extremities. Both the skin manifestations and histologic sections were extremely atypical for pyoderma gangrenosum leading to extensive medical records review and subsequent diagnosis of dermatitis artefacta. This case represents the importance of the timely recognition and treatment of dermatitis artifacta to prevent its progression to severe harm and even death.

Micropapular Cutaneous Sarcoidosis Reviewed.

BACKGROUND: Micropapular cutaneous sarcoidosis (MPCS) is a rare variant of sarcoidosis. Herein we review the literature and include a recent case of MPCS discussing pathogenesis, diagnosis, treatment, and prognosis. METHOD: A review was conducted using the terms "micropapular sarcoidosis" and "micropapular sarcoid." A recent case of a 50-year-old male patient with biopsy-identified MPCS was also included in the review. RESULTS: In total, 12 cases with an aggregate of 18 patients were included in the review. Presentation among all patients was consistent, with scattered, occasionally pruritic, faintly erythematous shiny white papules. Skin biopsy demonstrated noncaseating granulomas. Systemic prednisone, oxytetracycline, and hydroxychloroquine, as well as topical betamethasone, were used for therapy. CONCLUSION: In our review there does not seem to be a clear link as to the definite cause of the MPCS. While the relationships to tuberculosis and autoimmunity seem to be often emphasized, there was no clear association with either etiology.

Ewing-Like Sarcoma: A Case of a Primary Cutaneous Primitive Neuroectodermal Tumor With Atypical Immunohistochemistry and Lack of Fusion Oncogene Detection.

We present a 25-year-old male patient with a primary cutaneous primitive neuroectodermal tumor (cPNET) with unusual immunohistochemistry and lack of fusion oncogene generation. The lesion expressed CD99 and WT-1, and the histological features were consistent with cPNET. Differential diagnoses such as rhabdomyosarcoma, desmoplastic small round blue cell tumor, hematolymphoid neoplasm, neuroblastoma, and CIC-DUX round cell sarcoma were ruled out based on immunohistochemistry, genetic studies, and histology. Previous cPNET cases have been published detailing abnormal immunochemistry and genetic expression. However, to our knowledge, fusion oncogene negativity in cPNET tumors has only been reported in one other published case series. These reports, including this study, reinforce the fact that a high index of suspicion should be used when diagnosing these tumors, regardless of immunohistochemical and genetic variability. This case highlights that the typical genetic and immunohistochemical features of cPNET may be more variable than previously thought. Future studies are needed to better understand these variations of cPNET.

Treatment preferences and treatment satisfaction among psoriasis patients: a systematic review.

A critical gap exists in determining treatment preferences and treatment satisfaction from patient perspectives, which is paramount to achieving therapeutic success. The objective of this systematic review is to determine factors influencing treatment preferences and treatment satisfaction among psoriasis patients. PubMed, EMBASE, and Web of Science databases were searched between November 1, 2010, and December 1, 2017. Observational and interventional research studies published in the English language that discussed patient preferences and patient satisfaction in the treatment of psoriasis were reviewed and synthesized. We utilized data on treatment preferences and treatment satisfaction from 35,388 psoriasis patients based on 60 articles from the years 2010 to 2017. Treatment preferences were heterogeneous and changed over time among psoriasis patients. Across all treatment modalities, the most important treatment attributes were treatment location, probability of improvement, and delivery method. For biologics specifically, the most important attributes were risk of adverse events and probability of treatment benefit. Factors that influenced patients' preferences for certain treatments included age, sex, comorbidities, disease duration, and prior treatments. Notably, some psoriasis patients placed higher importance on a treatment's process attributes (e.g., access and delivery) over its outcome attributes (e.g., efficacy). Overall, patient satisfaction with existing therapies remains modest; however, those treated with biologic agents exhibited highest treatment satisfaction over oral therapy, phototherapy, and topical therapy.

Teledermatology in the United States: An Update in a Dynamic Era.

BACKGROUND: Teledermatology is rapidly advancing in the United States. The last comprehensive survey of U.S. teledermatology programs was conducted in 2011. INTRODUCTION: This article provides an update regarding the state of teledermatology programs in the United States. MATERIALS AND METHODS: Active programs were identified and surveyed from November 2014 to January 2017. Findings regarding practice settings, consult volumes, payment methods, and delivery modalities were compared to those from the 2011 survey. Findings from the Veterans Affairs (VA) were reported as an aggregate. RESULTS: There were 40 active nongovernmental programs, amounting to a 48% increase and 30% discontinuation rate over five years. Academia remained the most common practice setting (50%). Median annual consultation volume was comparable with 263 consultations, but maximum annual consultation volume increased (range: 20-20,000). The most frequent payment method was self-pay (53%). Store-and-forward continued to be the most common delivery modality. In Fiscal Year 2016, the VA System consisted of 62 consultation sites and performed a total of 101,507 consultations. DISCUSSION: The limitations of this study were that consult volume and payment methods were not available from all programs. CONCLUSION: U.S. teledermatology programs have increased in number and annual consultation volume. Academia is the most prevalent practice setting, and self-pay is the dominant accepted payment method. Innovative platforms and the provision of direct-to-patient care are changing the practice of teledermatology.

Effectiveness of Online vs In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial.

Importance: Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes. Objective: To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care. Design, Setting, and Participants: The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis. Interventions: Participants were randomized 1:1 to receive online or in-person care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The in-person group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months. Main Outcomes and Measures: The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score. Results: Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was -0.27 (95% CI, -0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was -0.05% (95% CI, -1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was -0.11 (95% CI, -0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement. Conclusions and Relevance: The online, collaborative connected-health model was as effective as in-person management in improving clinical outcomes among patients with psoriasis. Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be transformative to improving patient-centered outcomes in chronic diseases. Trial Registration: ClinicalTrials.gov Identifier: NCT02358135.

Rate of serious infection in patients who are prescribed systemic biologic or nonbiologic agents for psoriasis: A large, single center, retrospective, observational cohort study.

BACKGROUND: Systemic biologic and nonbiologic agents used to treat psoriasis may or may not contribute to serious infection (SI) risk. Safety data, particularly for biologic agents, and associated risk for SI, are scarce. The study's aim was to explore the risk for SI in psoriasis patients exposed to systemic biologic or nonbiologic agents. METHODS: A large, single-center electronic medical record repository was searched between January 2010 and December 2014. Records for patients prescribed a systemic agent for psoriasis (SAP) with psoriasis or psoriatic arthritis diagnoses were included (ICD-9 codes 696.1 and 696.0, respectively). SIs were those who required hospitalization, and/or injectable antibacterial, antiviral or antifungal therapy. SIs occurring within 120 days after exposure to a SAP, were included for study. RESULTS: A total of 1,346 patients were exposed to a SAP between January 2010 and December 2014; 27 (2%) had a SI. Comparing biologic and nonbiologic agent exposure, no statistically significant difference for risk of SI was detectable (p = .83). CONCLUSION: In this population, the SI rate for biologic and nonbiologic systemic agents was clinically indistinguishable, thereby supporting consideration of the entire spectrum of available systemic therapeutic agents, both biologic and nonbiologic agents, for management of moderate to severe psoriasis.

Evidence for the association of Hashimoto's thyroiditis with psoriasis: a cross-sectional retrospective study.

BACKGROUND: Current information indicates that psoriasis is a metabolic disorder with systemic manifestations. Reports have revealed an association between psoriasis and several chronic autoimmune disorders. For one of these disorders, Hashimoto's thyroiditis (HT), there are scarce, and relatively unconfirmed, reports of an association with psoriasis. We sought to determine if such an association is detectable in a large medical record data repository. METHODS: We searched one institution's electronic medical record data repository from January 2010 to December 2013. Patients were identified by ICD-9 codes (psoriasis: 696.0; 696.1, HT: 245.2). Only data from patients with laboratory-confirmed HT (anti-thyroid peroxidase [anti-TPO] antibodies; thyroglobulin antibodies; serum thyroid-stimulating hormone; and free T3) were eligible for inclusion. Logistic regression analysis was used to obtain an odds ratio (OR) to establish an association between psoriasis and HT. Stratified analyses were performed to test for confounding variable and effect modification. RESULTS: Medical records for 856,615 individuals with documented encounters between January 1, 2010, and December 31, 2013, were detected. A total of 9654 had a diagnosis of psoriasis, and 1745 had a diagnosis of HT. Of these, 41 subjects were diagnosed with both conditions. A significant association existed for psoriasis and HT, even after adjusting for confounding variables that included gender, age, psoriatic arthropathy, and the use of systemic anti-psoriatic agents (OR = 2.49; 95% CI 1.79-3.48; P < 0.0001). CONCLUSIONS: This association has broad clinical impact and deserves further attention with regard to patient care, clinical research, and developmental therapeutics.

Case reports in medical education: a platform for training medical students, residents, and fellows in scientific writing and critical thinking.

A case report is a detailed narrative that usually illustrates a diagnostic or therapeutic problem experienced by one or several patients. Case reports commonly serve as the first line of evidence for new interventions or they function as alarms that an issue exists with an already established therapy. Case reports are of minor importance in evidence-based medicine; however, they make meaningful contributions to both the knowledge and education of medical students, residents, and fellows. Case reports are written with the goal of sharing information for medical, scientific, or educational purposes. They often serve as medical or even undergraduate students' first experience with medical writing and they provide a solid foundation for manuscript preparation and publication. In the last few decades, there has been an exponential increase in medical student research, specifically in the number of manuscripts published by medical students. It is important to foster this academic spirit among students by encouraging them to become involved in research. This editorial will focus on the value and educational benefits of writing case reports for medical students, university students, residents, and fellows.

A case of Kaposi sarcoma in an immunocompetent, heterosexual Irish man: a discussion of etiology and viral transmission.

Four types of Kaposi sarcoma (KS) have been described, all of which are caused by human herpesvirus-8 (HHV-8).  The incidence of KS in the United States is highest among HIV-positive homosexual men and elderly men of Eastern European, Jewish, or Mediterranean descent. However, few reports describe KS in HIV-negative, immunocompetent heterosexual men in the United States. HHV-8 is transmitted largely via saliva and close sexual contact, whereas there are only a handful of reports of transmission via blood and blood products. We report a case of an HIV-negative, immunocompetent heterosexual man who acquired KS via blood transfusion. A 77-year-old immunocompetent, monogamously heterosexual, HIV-negative Irish man presented with a biopsy-proven KS lesion on the right thigh. Past surgical history included a coronary artery bypass graft, during which he received a blood transfusion from an unknown donor source.  His ecchymotic KS lesions progressed while on doxycycline, intralesional vinblastine, and topical anti-angiogenic medications.  The patient eventually achieved stabilization of KS lesions with acitretin. Our case report emphasizes the need to characterize the phenotype and transmission route of HHV-8 in heterosexual, immunocompetent patients in geographic regions with low HHV-8 seroprevalence.

Effect of tonsillectomy on psoriasis: a systematic review.

BACKGROUND: Streptococcal infection is associated with psoriasis onset in some patients. Whether tonsillectomy decreases psoriasis symptoms requires a systematic review of the literature. OBJECTIVE: We sought to determine whether tonsillectomy reduces psoriasis severity through a comprehensive search of over 50 years of literature. METHODS: We searched MEDLINE, CINAHL, Cochrane, EMBASE, Web of Science, and OVID databases (from August 1, 1960, to September 12, 2013) and performed a manual search of selected references. We identified observational studies and clinical trials examining psoriasis after tonsillectomy. RESULTS: We included data from 20 articles from the last 53 years with 545 patients with psoriasis who were evaluated for or underwent tonsillectomy. Of 410 reported cases of patients with psoriasis who underwent tonsillectomy, 290 experienced improvement in their psoriasis. Although some patients who underwent tonsillectomy experienced sustained improvement in psoriasis, others experienced psoriasis relapse after the procedure. LIMITATIONS: Fifteen of 20 publications were case reports or series that lacked control groups. Publication bias favoring reporting improved cases needs to be considered. CONCLUSION: Tonsillectomy may be a potential option for patients with recalcitrant psoriasis associated with episodes of tonsillitis. Studies with long-term follow-up are warranted to determine more clearly the extent and persistence of benefit of tonsillectomy in psoriasis.