Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model--Arizona and Utah, 2012-2014.

Hepatitis C virus (HCV) infection is the leading reason for liver transplantation and a common cause of hepatocellular carcinoma, the most rapidly increasing cause of cancer-related deaths in the United States. Of the approximately 3 million persons living with HCV infection in the United States, an estimated 38% are linked to care, 11% are treated, and 6% achieve cure. Recent development of highly effective and well-tolerated medications, such as sofosbuvir and simeprevir, to treat chronic HCV infection shows promise in curbing rising HCV-related morbidity and mortality, with the potential to cure >90% of patients. To fully benefit from these new treatments, improvement in linkage to care and treatment is urgently needed.* Lack of provider expertise in HCV treatment and limited access to specialists are well-documented barriers to HCV treatment. In September 2012, CDC funded programs in Utah and Arizona to improve access to primary care providers with the capacity to manage and treat HCV infection. Both programs were modeled on the Extension for Community Healthcare Outcomes (Project ECHO), developed by the University of New Mexico's Health Sciences Center in 2003 to build primary care capacity to treat diseases among rural, underserved populations through videoconferencing and case-based learning in "teleECHO" clinics. To assess the effectiveness of these programs in improving primary care provider capacity and increasing the number of patients initiating treatment, process and patient outcome data for each state program were analyzed. In both states, Project ECHO was successfully implemented, training 66 primary care clinicians, predominantly from rural settings. Nearly all (93%) of the clinicians had no prior experience in care and treatment of HCV infection. In both states combined, 129 (46%) of HCV-infected patients seen in teleECHO clinics received antiviral treatment, more than doubling the proportion of patients expected to receive treatment. These findings demonstrate Project ECHO's ability to expand primary care capacity to treat HCV infection, notably among underserved populations.

Vaccination as a probable cause of incontinentia pigmenti reactivation.

We report a female infant with recurrent biopsy-proven vesicobullous incontinentia pigmenti occurring after her 12-month and 18-month immunizations. To our knowledge, incontinentia pigmenti vesicobullous recurrence following immunizations has not been reported. We propose that vaccinations may serve as triggers for incontinentia pigmenti reactivation.

Open label trial of alefacept in palmoplantar pustular psoriasis.

BACKGROUND: Palmoplantar pustular psoriasis (PPP) is difficult to treat. We assessed the effectiveness of alefacept in PPP and the safety of a 30 mg/week dose. METHODS: Fifteen individuals with PPP were started on 15 mg/week intramuscularly (IM) alefacept. Efficacy was measured by the PPP severity instrument (PSI). Treatment was continued for 16 weeks, and the alefacept dose was increased to 30 mg/week IM at week 9 if the PSI did not decrease by at least 25%. Other outcomes included physician's global assessment (PGA), reported adverse events and CD4+ T-lymphocyte counts. Clinical response was observed for 12 weeks after the last injection. RESULTS: The severity of PPP improved in both the PSI and the PGA (p<0.0001 and p = 0.0009, respectively). Much of the improvement occurred after 10 weeks of therapy. Nail severity scores improved (p = 0.0003). CD4+ counts decreased, but all remained >250 cells/mm3. There were no severe adverse effects or discontinuations due to adverse events. CONCLUSIONS: Alefacept in doses up to 30 mg/week was well tolerated in patients with PPP and appeared to have some efficacy. The use of concomitant therapy, the lack of a comparator, and the small sample size are limitations of the study.

Adherence to topical therapy increases around the time of office visits.

BACKGROUND: The efficacy of topical medications is limited by non-adherence. Interventions to improve adherence to topical treatments are not well characterized. OBJECTIVE: To assess the impact of office visits on patients' adherence to topical treatment. METHODS: Twenty-nine subjects enrolled in a clinical trial for psoriasis and were followed for up to 8 weeks. Subjects were told to apply 6% salicylic acid gel twice daily. Electronic monitors were used to assess adherence. Results were compared to adherence in clinical trials of hand dermatitis and atopic dermatitis. RESULTS: Adherence rates were significantly higher around the time of office visits (P < .05). LIMITATIONS: This is a small study in a limited patient population. The study was observational and not a randomized trial of the effect of increased office visits. CONCLUSION: Frequent follow-up visits in clinical trials increase patients' adherence to medications. The use of a follow-up visit shortly after initiating treatment may be an effective way to boost patients' use of their medication and achieve better treatment outcomes.

Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis.

BACKGROUND: Atopic dermatitis is a common problem for which topical agents are the primary treatment. When topical medications fail, further therapy may include systemic agents with the potential for greater toxicity. Adherence to topical treatment of atopic dermatitis has not been well characterized. Poor adherence to topical medication could account for failure of topical therapy. PURPOSE: To determine adherence to topical treatment in patients with atopic dermatitis. METHODS: Thirty-seven children were given 0.1% triamcinolone ointment and were counseled to use it twice daily. They were told to return in 4 weeks, at which time they were told to continue treatment for another 4 weeks. Electronic monitors were used to measure adherence over the entire 8 week study. Patients were not informed of the compliance monitoring until the end of the study. RESULTS: Twenty-six patients completed 8 weeks of treatment. Mean adherence from the baseline to the end of the study was 32%. Adherence was higher on or near office visit days and subsequently decreased rapidly. LIMITATIONS: This study was limited by the large number of subjects who failed to return for follow-up appointments or withdrew from the study. CONCLUSIONS: Adherence to topical medications is very poor in a clinic population of children with atopic dermatitis. Office visits are one means to increase adherence. If adherence to topical treatment can be improved, exposure to more costly and potentially toxic systemic agents may be avoidable.

Comparison of different compliance behaviors in a clinical trial.

Demographics, regimen complexity, patient attitude, disease severity, and psychology determine a patient's adherence (ie, compliance) behavior. In a study of 30 patients with moderate to severe hand dermatitis, we found 2 extremes of adherence behavior: overusage and underusage. We compared these 2 patients to one patient who engaged in near-ideal usage of medication.

Cutaneous symptoms of dermatomyositis significantly impact patients' quality of life.

BACKGROUND: Dermatomyositis affects visible skin and causes disease symptoms that can affect patients' quality of life (QOL). METHODS: In all, 71 patients with dermatomyositis or dermatomyositis sine myositis completed two QOL measures (the Skindex-16 and the Dermatology Life Quality Index) and a visual analog scale for pruritus. Disease severity was assessed by Physician's Global Assessment. RESULTS: The mean Dermatology Life Quality Index score was 10.7 and the mean Skindex-16 score was 51.1. Itching contributed to impact on both the Dermatology Life Quality Index and Skindex-16. Females reported worse QOL. LIMITATIONS: The effect of treatment on quality of life was not assessed in these analyses. CONCLUSION: QOL impairment in dermatomyositis is greater than in other skin conditions including psoriasis and atopic dermatitis. Pruritus is an important treatable factor that significantly impacts QOL for patients with dermatomyositis.

Adherence in dermatology: a review of the last 20 years.

BACKGROUND: Adherence has been studied in many areas of medicine; however, there are few published articles pertaining to adherence and dermatology. OBJECTIVE: The purpose of this review is to summarize the current literature on medical adherence as it specifically applies to dermatology. METHODS: We conducted a PUBMED search between the years of 1985 and 2005 using the following terms: 1-[adherence AND dermatology] and 2-[dermatology AND treatment]. The search was limited to articles in English and human subjects. RESULTS: The literature search yielded 57 articles. Seventeen of these articles met the inclusion criteria and were reviewed in order to define, measure, quantify, validate, and understand adherence in dermatology. CONCLUSIONS: Adherence to topical therapy among dermatology patients is difficult to measure reliably, hence the few articles available on this topic. A small number of studies using new electronic monitoring technology have shown that dermatology patients have low adherence rates to treatment regimens. There are socioeconomic, cognitive, and psychological factors that contribute to non-adherence among patients. Improving patient knowledge and the doctor-patient relationship are ways to improve patient adherence.

Topical tacrolimus ointment combined with 6% salicylic acid gel for plaque psoriasis treatment.

BACKGROUND: While oral tacrolimus is effective for the treatment of psoriasis, tacrolimus ointment has shown only spotty efficacy in the treatment of plaque psoriasis. The efficacy of tacrolimus ointment for the treatment of facial and intertriginous psoriasis suggests that if tacrolimus penetration can be increased, the ointment could be used for effective treatment of plaque psoriasis. OBJECTIVE: To assess whether tacrolimus ointment is an effective psoriasis treatment when used in a combination regimen with the penetration-enhancer salicylic acid. METHODS: A total of 30 adult subjects with generally symmetrical plaque-type psoriasis were randomized to treatment with 6% salicylic acid gel plus vehicle or 6% salicylic acid gel plus 0.1% tacrolimus ointment in a 12-week left-right comparison study. The primary outcome was the difference between tacrolimus- and vehicle-treated target lesions in the change in the sum of erythema, scale, and thickness scores from baseline to end of treatment. RESULTS: A total of 24 subjects completed the trial. Combination treatment with tacrolimus ointment or vehicle plus salicylic acid gel was well tolerated. There was greater improvement of the sum score in the tacrolimus plus salicylic acid-treated target plaques than in the vehicle plus salicylic acid-treated plaques at weeks 1, 2, and 8 (P<.05). The efficacy of this regimen was confirmed by investigator and subject global assessments of plaque severity. CONCLUSIONS: The combination of 0.1% tacrolimus ointment and 6% salicylic acid gel is an effective treatment for psoriasis. Although the results reported herein are from a small exploratory study, the magnitude of the effect was sufficiently large as to be detectable with statistical significance (P<.05).

An open label study of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of mild to moderate acne keloidalis.

Acne keloidalis (AK) is a disease affecting primarily African American men. Topical steroids are a widely accepted treatment of AK; however, no studies have been published investigating their effectiveness. The purpose of this open-label study was to assess the efficacy and tolerability of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of AK in 20 African American patients. These patients were treated for 8 to 12 weeks using a pulsed-dose regimen. We found topical clobetasol propionate foam to be effective in improving AK, and our patients found the foam vehicle to be cosmetically acceptable.

Adherence to topical therapy decreases during the course of an 8-week psoriasis clinical trial: commonly used methods of measuring adherence to topical therapy overestimate actual use.

INTRODUCTION: Medication nonadherence is common throughout medicine, and research into this area is increasing; however, knowledge about topical medication adherence is limited. METHODS: A total of 30 patients were enrolled in a clinical trial for psoriasis and followed up for 8 weeks using 3 methods of adherence monitoring: electronic monitoring caps; medication logs; and medication usage by weight. RESULTS: Adherence rates calculated from the medication logs and medication weights were consistently higher than those of the electronic monitors (P <.05). Electronically measured adherence rates declined from 84.6% to 51% during the 8-week study (P <.0001). Female sex and increasing age by 1 year predicted improved adherence of 5% and 0.8%, respectively (P <.0001). The number of treatment gaps increased from the first half to the last half of the study, and weekend days were overrepresented in treatment gaps. CONCLUSION: Medication logs and weights do not ensure medication adherence to topical therapy. Electronic monitoring allows a more precise method of adherence measurement.

Effects of an episode of specialist care on the impact of childhood atopic dermatitis on the child's family.

INTRODUCTION: Although some preliminary work has examined the impact of atopic dermatitis (AD) on families, no empirical work has examined changes in the impact on families dealing with AD over time. An exploratory analysis of change in impact on families dealing with AD before and after an episode of medical care in a physician office setting was conducted. METHOD: Baseline and follow-up surveys were completed by 35 parent caregivers before and 1 month after a dermatologist visit for the child at an academic medical center. RESULTS: In the postcare survey, there was a 43% reduction in the Dermatitis Family Impact Questionnaire (DFI) scores (P <.01) compared with baseline. Significant differences were also observed in other parent caregiver-reported characteristics. The significant change in parent caregiver characteristic associated with the decreased DFI score was the increased satisfaction with the medical care related to the child's treatment (P <.01). DISCUSSION: These data reveal that there is a strong decrease in impact on a family associated with an episode of specialist care for children with AD. The importance of pediatric health care professionals in decreasing the impact of AD on families needs further exploration.

Innovative telementoring for pain management: project ECHO pain.

INTRODUCTION: Project ECHO Pain, the innovative telementoring program for health professionals, was developed in 2009 at the University Of New Mexico Health Sciences Center to fill considerable gaps in pain management expertise. Substantive continuing education for clinicians who practice in rural and underserved communities convenes weekly by means of telehealth technology. Case-based learning, demonstrations, and didactics are incorporated into the interprofessional program that helps to improve pain management in the primary care setting. METHOD: Three different approaches were used to evaluate the program over a 3-year period: (1) evaluation of all weekly continuing medical education surveys; (2) aggregation of annual clinic data; and (3) assessment of practice change in clinicians who joined Project ECHO Pain for at least 1 year. RESULTS: Between January 2010 and December 2012, 136 Project ECHO Pain clinics were held, with 3835 total instances of participation, representing 763 unique individuals from 191 different sites. Sixty percent self-identified as advanced practice or other nonphysician health professional. Statistically significant improvements in participant self-reported knowledge, skills, and practice were demonstrated. Focus group analyses of 9 subjects detailed specific practice improvements. DISCUSSION: Project ECHO Pain is a successful continuing professional development program. The telementoring model closes the large knowledge gap in pain education seen in primary care and other settings. Expertise is delivered by implementing effective, evidence-based, and work-based education for diverse health professionals. Project ECHO Pain serves as a model for interprofessional collaborative practice.

A comparative study of clinical characteristics, work-up, treatment, and association to malignancy in dermatomyositis between two tertiary skin centers in the USA and Singapore.

BACKGROUND: To date, no study has compared the clinical characteristics, malignancy associations, and treatment of dermatomyositis in predominantly Caucasian vs. Asian populations. MATERIALS AND METHODS: This prospective study was conducted to compare clinical characteristics of dermatomyositis, its relationship to malignancy, and treatment between two tertiary medical centers in the USA and Singapore. A total of 19 newly-diagnosed patients in the USA and 15 patients in Singapore were enrolled. Dermatomyositis or amyopathic dermatomyositis were diagnosed based on clinical assessment, skin and muscle biopsies, and muscle testing. RESULTS: Ninety-five percent of patients in the USA group were of Caucasian descent, while 93% of patients in the Singapore group were of Chinese descent. Both groups were predominantly female. Pruritus was the most common initial symptom reported in both groups, while periungual erythema and Gottron's papules were the most common skin presentations. Heliotrope eruption was more common in the Singapore group, occurring in 80% of patients vs. 32% of patients in the USA group (P = 0.007). Three patients in the Singapore group developed a malignancy, with two of these patients having nasopharyngeal carcinoma. None of the USA patients developed malignancies in a follow- up period of 2-5 years. Immunosuppressive steroid sparing therapy with hydroxychloroquine was more frequently used in Singapore, while topical tacrolimus was more frequently used in the USA. CONCLUSION: The clinical presentations of dermatomyositis vary among different ethnic populations. Chinese patients with dermatomyositis have a significant risk for nasopharyngeal carcinoma.

Cutaneous blood flow in dermatomyositis and its association with disease severity.

BACKGROUND: Several studies using nailfold capillary microscopes have demonstrated capillary changes in patients with dermatomyositis (DM); however, no previous study has examined cutaneous blood flow in this disease. PURPOSE: To determine cutaneous blood flow in involved and non-involved skin surfaces of patients with DM and to assess possible correlation with clinical measures of disease severity. METHODS: Using a Laser Doppler perfusion imager, cutaneous blood flow was measured at six targeted sites of involved and apparently non-involved skin of 13 DM patients and the corresponding non-involved sites of 13 healthy controls. Overall disease severity of DM patients was determined by physician's global assessment (PGA), creatinine phosphokinase (CPK) levels, medical research council (MRC) scores, and the DM skin severity index (DSSI). RESULTS: Skin blood flow was significantly elevated in involved vs. non-involved skin of DM patients at all anatomic sites measured: periungual (P=0.001), knuckle (P=0.001), elbow (P=0.013), periorbital (P=0.015), chest (P=0.028), and back (P=0.001). Blood flow was also higher in apparently non-involved skin of DM patients vs. skin of healthy controls at all anatomic sites, although statistical significance was not achieved. A significant negative correlation was observed between the DSSI and blood flow in involved skin of the chest (P=0.003), back (P=0.002), and knuckle (P=0.026). CONCLUSION: DM is associated with significantly increased cutaneous blood flow, even at sites where no erythema is evident. This suggests significant involvement of the skin vasculature in this disease process.

Tacrolimus: focusing on atopic dermatitis.

Tacrolimus ointment is an effective treatment for atopic dermatitis. As a calcineurin inhibitor, it works through the FK-binding protein, inhibiting calcineurin and preventing dephosphorylation of nuclear factor of activated T cells (NFAT). Systemic absorption from the drug is minimal, allowing a favorable safety profile. In head-to-head clinical trials with pimecrolimus, tacrolimus proved to be a more effective treatment. Tacrolimus ointment has also been compared to standard topical cortico-steroid treatments and is equally effective if not superior to several topical steroids. Overall, tacrolimus ointment is a safe and effective treatment for atopic dermatitis and can be used as an adjunctive treatment to standard management with topical corticosteroids.

The burden of atopic dermatitis: impact on the patient, family, and society.

Atopic dermatitis is a common disease of increasing prevalence. Affected individuals must cope with a significant psychosocial burden, in addition to dealing with the medical aspects of the disease. Furthermore, because this is primarily a disease of childhood, family members, especially parents, are also affected by the condition. Individuals and family members are burdened with time-consuming treatment regimens for the disease, as well as dietary and household changes. The financial impact of atopic dermatitis on families can also be great. Moreover, the cost to society is significant, with estimates ranging from less than 100 dollars to more than 2000 dollars per patient per year. It is estimated that the direct cost of atopic dermatitis in the United States alone is almost 1 billion dollars per year. Reducing the onus of this disease must take into account the full breadth of its burden. Targeting parents and caregivers with education and psychosocial support can decrease family and personal burden, which in turn may decrease the cost of treating the condition because of better medical, psychosocial, and family outcomes.

Tacrolimus ointment: the treatment of atopic dermatitis and other inflammatory cutaneous disease.

Topical tacrolimus (FK506, Protopic) has been developed and marketed for the treatment of atopic dermatitis (AD). Tacrolimus works as an inhibitor of calcineurin, which creates a downregulation of the inflammatory cascade. Numerous trials have shown the efficacy and safety of tacrolimus in treating AD in both adults and children. Additionally, comparison data with other medications commonly used for AD, such as topical steroids and pimecrolimus, show improved efficacy of tacrolimus. A comprehensive review of the off-label uses of tacrolimus in other dermatoses, including psoriasis, lichen planus and seborrhoeic dermatitis, is provided. The efficacy of tacrolimus in treating these diseases is based on Phase IV clinical trials and on case reports or series in the literature. Overall, tacrolimus has proven to be a safe and useful topical therapy for many inflammatory dermatological conditions, with AD being the principal indication.