The risk of post-operative complications in psoriasis and psoriatic arthritis patients on biologic therapy undergoing surgical procedures.

BACKGROUND: There is limited evidence as to whether biologic therapy should be stopped or continued in patients with psoriasis and/or psoriatic arthritis (PsA) who are undergoing surgical procedures. Current guidelines of care recommend a planned break from biologic therapy in those undergoing major surgical procedures. OBJECTIVE: To audit current practice of managing biologic therapy peri-operatively in a tertiary referral psoriasis clinic against guidelines of care and to investigate the effects of continuing/stopping biologic therapy in psoriasis and PsA patients. METHODS: A retrospective audit of psoriasis and PsA patients who had a surgical procedure whilst on biologic therapy. A proforma was used to collect information on the biologics used, whether they were stopped peri-operatively and whether patients developed post-operative complications and/or disease flare. RESULTS: A total of 42 patients who had 77 procedures were identified. Procedures ranged from skin surgery to orthopaedic and cardiothoracic surgery. Biologic therapy was continued in the majority of procedures (76%). There was no significant difference in post-operative risk of infection and delayed wound healing between those patients who continued and those who stopped biologic therapy, including those undergoing major surgery. Interrupting biologic therapy peri-operatively was associated with a significant (P = 0.003) risk of flare of psoriasis or PsA. CONCLUSION: Continuing biologic therapy in psoriasis and PsA patients peri-operatively did not increase the risk of post-operative complications. Interrupting biologic therapy peri-operatively significantly increased the risk of disease flare. This study is limited by cohort size and requires replication, ideally in a prospective randomized controlled manner.

Successful use of dapsone for the management of circinate balanitis.

Circinate balanitis is the commonest cutaneous manifestation of reactive arthritis (Reiter syndrome), but can also occur independently. Topical corticosteroid therapy is the most commonly used treatment, and topical calcineurin inhibitors have also been used successfully. We report a case of a 20-year-old man who presented with discrete erythematous patches with slightly raised keratotic annular borders on his glans penis. He also developed geographic tongue and severe arthritis. A clinical diagnosis of circinate balanitis was made, which was supported by the psoriasiform features on skin biopsy. The patient failed to respond to topical 0.05% clobetasol propionate cream, but a novel approach using a combination of dapsone and topical 0.1% tacrolimus ointment successfully cleared his rash.