Benign intracranial hypertension in a patient treated with ustekinumab for psoriasis.

Ustekinumab is a monoclonal antibody, which binds the p40 subunit of IL-12 and IL-23 so they are unable to bind to their receptors, ultimately reducing T-cell-mediated inflammation in psoriasis. Studies and cases have focused on the risk of infection and malignancy associated with the use of biologics medications; however, there have been limited data available on the potential neurological adverse effects of biologics. We report the case of a 44-year-old female with a longstanding history of psoriasis who developed benign intracranial hypertension while on ustekinumab for her psoriasis.

Dipeptidyl peptidase-4 inhibitors and bullous pemphigoid: A systematic review and adjusted meta-analysis.

BACKGROUND/OBJECTIVE: There have been a number of case reports and small clinical series reporting the potential association between dipeptidyl peptidase-4 inhibitors (DPPIs) for diabetes and the onset of bullous pemphigoid (BP). The aim of this study was to assess the association between DPPI use and BP, and whether this varied according to DPPI type. METHODS: We performed a systematic review and meta-analysis according to PRISMA guidelines. We identified five studies with cases and controls. We performed unadjusted and adjusted meta-analyses to assess the potential association. RESULTS: Adjusted meta-analysis revealed significant association between DPPI use and BP (OR 2.13, 95% CI 1.59-2.86, I2  = 46%, P < 0.00001). This association was stronger between vildagliptin and BP (OR 5.08, 95% CI 1.70-15.19, P = 0.004) compared to linagliptin (OR 2.87, 95%CI 1.06-7.79, P = 0.04), and no association was found between sitagliptin and BP (OR 1.29, 95%CI 0.79-2.08, P = 0.31). Subgroup analysis demonstrated that the association between DPPI use and BP remained significant in males (OR 2.35, 95% CI 1.46-3.78, P = 0.0005) and females (OR 1.88, 95%CI 1.10-3.22, P = 0.02). CONCLUSIONS: Limitations were that studies reviewed were retrospective by design which are susceptible to bias and lack of randomisation. Our adjusted analysis supports a significant association between DPPI use and onset of bullous pemphigoid. Vildagliptin had the highest odds of BP. These findings have clinical implications for dermatologists and the management of patients with diabetes and being treated with DPPI agents.

Hidradenitis suppurativa and polycystic ovarian syndrome: Systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: Hidradenitis suppurativa has been associated with a number of pathologies, including various endocrine and autoimmune disorders. Although signs of hyperandrogenism are common in hidradenitis suppurativa, few formal studies have assessed the relationship between hidradenitis suppurativa and polycystic ovarian syndrome. Therefore, we performed a systematic review and meta-analysis to assess the association between hidradenitis suppurativa and polycystic ovarian syndrome. METHODS: We performed a systematic review and meta-analysis according to PRISMA guidelines. Odds ratio was used as the effect size, with random-effects meta-analysis. RESULTS: We identified five case-control studies for inclusion. From pooled data, we found a significantly higher proportion of polycystic ovarian syndrome in hidradenitis suppurativa cases compared with controls (OR 2.64; 95% CI 1.69-4.11; P < 0.00001). There was significant heterogeneity noted (I2  = 88%, P < 0.00001). Limitations included that studies reviewed were observational by design which are susceptible to bias, and lack of randomisation. CONCLUSIONS: In summary, pooled analysis of existing case-control studies supports a significant association between hidradenitis suppurativa and polycystic ovarian syndrome. Our results imply that hidradenitis suppurativa patients with signs of hyperandrogenism may benefit from screening for polycystic ovarian syndrome, and may potentially benefit from anti-androgen therapy.

Hidradenitis Suppurativa and Thyroid Disease: Systematic Review and Meta-Analysis.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by painful nodules, sinus tracts, and significant scarring. Although the pathogenesis of this disease is not well established, there is increasing evidence to suggest that it is an immune-mediated disorder. Previous studies have suggested a relationship between HS and thyroid disease, which is also driven by an autoimmune process. We sought to assess whether an association exists between HS and thyroid disease. OBJECTIVES: To determine whether HS is associated with thyroid disease via meta-analysis of case-control studies. METHODS: A systematic review and meta-analysis was performed according to recommended PRISMA guidelines. Electronic searches were performed using 6 electronic databases from their inception until August 2018. Data were extracted and analyzed according to predefined clinical endpoints. Odds ratio (OR) was used as the summary effect size. RESULTS: We identified 5 case-controls studies included for meta-analysis. There were a total of 36 103 HS cases compared with 170 517 control cases. We found a significant association between HS and thyroid disease (OR 1.36, 95% CI 1.13-1.64, I 2 = 78%, P = .001). CONCLUSIONS: This pooled analysis of existing case-control studies to date supports an association between HS and any thyroid disease. Clinicians treating patients with HS should be aware of this potential association with thyroid disease.

Rapid progression to gummatous tertiary syphilis in a patient with HIV.

Co-infection with human immunodeficiency virus-1 (HIV) and syphilis is associated with rapid progression to tertiary syphilis. This case report describes the early development of gummatous skin disease and suspected neurosyphilis in a patient with untreated HIV and approaches to treatment.

Dermatologist attitudes toward ciclosporin use in atopic dermatitis.

Ciclosporin (CsA) is a systemic immunosuppressive agent indicated for use in the treatment of patients with recalcitrant atopic dermatitis (AD). Studies demonstrate reasonable evidence of benefit compared with placebo. However as biologic agents are under development for use in AD, an assessment of the use, attitude to and safety of CsA is essential in understanding unmet needs in severe AD. We present the results of a survey asking questions relating to initial dose, duration of prescription, precautions and monitoring undertaken during treatment, adverse events seen, and hierarchy of use for systemic agents. This survey was distributed at the annual meeting of the Australasian College of Dermatologists. Twenty-two percent of respondents never prescribe CsA, and 50% prescribe it only 1-2 times per month. When prescribed, the most frequently recommended duration was 6-12 months (24%). Of prescribers, 56% start with a low dose of <3.5 mg/kg daily, and when stratified according to years of experience, a higher proportion of more junior dermatologists commenced with lower doses (p=.028). Regarding side effects, 95% of respondents expressed concern about nephrotoxicity, 37% about hypertension, and 17% infection. The results suggest that although most dermatologists consider CsA to be effective, there are concerns regarding the safety profile.

Toxic Epidermal Necrolysis and Steven-Johnson Syndrome: A Comprehensive Review.

Significance: Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are potentially fatal acute mucocutaneous vesiculobullous disorders. Evidence to date suggests that outcomes for patients with both TEN and SJS are largely dependent on stopping the causative agent, followed by supportive care and appropriate wound management in a specialized burns unit. These are life-threatening conditions characterized by widespread full-thickness cutaneous and mucosal necrosis. This article outlines the approach to holistic management of such patients, in a specialized unit, highlighting various practical aspects of wound care to prevent complications such as infection, mucosal and adhesions, and ocular scaring. Recent Advances: There is improved understanding of pain and morbidity with regard to the type and frequency of dressing changes. More modern dressings, such as nanocrystalline, are currently favored as they may be kept in situ for longer periods. The most recent evidence on systemic agents, such as corticosteroids and cyclosporine, and novel treatments, are also discussed. Critical Issues: Following cessation of the culprit trigger, management in a specialized burns unit is the most important management step. It is now understood that a multidisciplinary team is essential in the care of these patients. Following admission of such patients, dermatology, ear, nose, and throat surgery, ophthalmology, urology, colorectal surgery, and gynecology should all be consulted to prevent disease sequelae. Future Directions: Looking forward, research is aimed at achieving prospective data on the efficacy of systemic immunomodulating agents and dressing types. Tertiary centers with burns units should develop policies for such patients to ensure that the relevant teams are consulted promptly to avoid mucocutaneous complications.

Balanitis xerotica obliterans: a review of diagnosis and management.

Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin. It is associated with significant morbidity and may result in impaired urinary and sexual function. It was initially described by Stuhmer in 1928, named after its pathological features, and is considered the male equivalent of vulvar lichen sclerosis (LS).3,40 The etiology of BXO is uncertain; however, autoimmune disease, local trauma, and genetic and infective causes have been proposed. BXO occurs most commonly on the prepuce and glans penis. It is considered to have premalignant potential to transform into squamous neoplasia. This postulation rests on retrospective studies and parallels drawn with vulvar LS and squamous cell carcinoma (SCC) development. Histologically, BXO and vulvar LS are considered the same disease.41 There is a paucity of evidence-based guidelines to assist with appropriate follow-up for patients with BXO.

Hidradenitis suppurativa and metabolic syndrome - systematic review and adjusted meta-analysis.

BACKGROUND: Hidradenitis suppurativa (HS) is a debilitating and distressing chronic systemic inflammatory skin disease. There have been several prior observational studies which reported a possibility link between HS and metabolic syndrome, however the current evidence is not definitive. It is unclear in HS whether this possible relationship is independent or driven by underlying risk factors and comorbidities. OBJECTIVE: To determine whether HS is independently associated with metabolic syndrome via adjusted meta-analysis of case-control studies. METHODS: A systematic review and meta-analysis was performed according to PRISMA guidelines. Electronic searches were performed using six electronic databases (Ovid Medline, PubMed, CCTR, CDSR, ACP Journal Club, and DARE) from their inception until September 2018. Data were extracted and analyzed according to predefined clinical endpoints. RESULTS: We identified six case-control studies included for meta-analysis. Based on unadjusted analysis, we found a significant association between adult cases of HS and metabolic syndrome (OR 1.95, 95% CI 1.31-2.89, P = 0.001). Adjusted meta-analysis, after adjustment for age, sex, other cardiovascular risk factors, and comorbidities, found a significant association (OR 2.19, 95% CI 1.70-2.81, I2  = 32%, P < 0.00001). LIMITATIONS: Studies reviewed were observational by design which are susceptible to bias, and there was lack of randomization. The quality of the current systematic review is also limited by the quality of available evidence which was predominantly observational in nature. CONCLUSIONS: This pooled analysis of existing case-control studies supports an association between HS and metabolic syndrome. Clinicians treating patients with HS should be aware of this potential association.

Psoriasis in family members of patients with multiple sclerosis.

BACKGROUND: It has been noted both anecdotally and in a selection of studies that the incidence of multiple sclerosis (MS) and psoriasis may be related, however the nature of that association is unclear. Clustering among families of multiple autoimmune diseases may be linked to genetic factors. Whether family members of those with MS are at increased risk of psoriasis is not well established. METHODS: A systematic review and meta-analysis was performed according to recommended PRISMA guidelines. Data from studies assessing the proportion or effect size of psoriasis cases reported for families or relatives of MS cases versus families or relatives of control cases without MS were extracted and meta-analysed. RESULTS: From a pooled unadjusted meta-analysis of 5 studies that met criteria, we found that family members of MS patients were at increased risk of psoriasis (OR 1.45 95% CI 1.07, 1.97). CONCLUSION: Family members of those with MS may be at greater risk of developing psoriasis.

Nail clubbing in laxative abuse: case report and review of the literature.

BACKGROUND: The link between clubbing and laxative abuse has been reported several times in the literature, in all cases in young females. The nature of this relationship is not understood. CASE: A young female, with no history of hepatic, pulmonary or malignant disease was found to have nail clubbing in the context of laxative abuse. A literature review revealed several similar cases. CONCLUSION: Laxative abuse is an important consideration in the assessment of clubbing in populations at risk of eating disorders, to prevent over-investigation and facilitate management of the eating disorder itself. This case highlights a new clinical presentation of an eating disorder. CASE: A 36-year-old woman was being reviewed by a renal specialist for renal impairment and electrolyte disturbances, in the context of a background of multiple renal calculi 4 years prior, hypokalaemia and hypercalcaemia. The attending nephrologist brought attention to her nails, which demonstrated clubbing. She stated that she had had clubbing for 10 years, and that it was of gradual onset and not associated with any pain. There was no history of hepatic, cardoipulmonary or malignant disease.