High-dose, high-frequency infliximab: A novel treatment paradigm for hidradenitis suppurativa.

BACKGROUND: The permanent disfigurement associated with hidradenitis suppurativa (HS) necessitates early aggressive disease intervention. Although limited data support the use of infliximab (IFX) in HS, the efficacy of high-dose, high-frequency IFX has yet to be defined. OBJECTIVE: To evaluate the efficacy of IFX 7.5 to 10 mg/kg, with a maintenance frequency every 4 weeks. METHODS: Prospective analysis of 42 patients initiating IFX 7.5 mg/kg every 4 weeks (IFX 7.5) and 16 patients receiving dose escalation to IFX 10 mg/kg every 4 weeks (IFX 10) between March 1, 2018, and February 28, 2019. The primary outcome measure (clinical response) was the proportion of patients with Physician Global Assessment of clear, minimal, or mild (score of 0-2) HS with at least a 2-grade improvement from baseline scores. RESULTS: The proportion of patients achieving a clinical response after initiating IFX 7.5 was 20 of 42 (47.6%) at week 4 and 17 of 24 (70.8%) at week 12. For patients receiving dose escalation to IFX 10 because of incomplete initial response, 6 of 16 (37.5%) achieved clinical response at week 4 and 6 of 12 (50%) at week 12. CONCLUSIONS: Initiation of IFX 7.5 every 4 weeks, with possible dose escalation to IFX 10, if needed, provides optimal mitigation of HS-related disease activity.

Pathophysiology of hidradenitis suppurativa.

The pathophysiology of hidradenitis suppurativa (HS) is not well understood. Some of our knowledge comes from clinical and epidemiological observations, along with studies of the histopathology and immunohistochemistry of affected skin. More recently, cutaneous molecular studies and transcriptomic analyses have provided additional information regarding inflammatory processes. The chronic cutaneous inflammation, systemic symptoms, and associated comorbidities suggest that HS should be classified as an immune-mediated disease, rather than a primary infectious disease. As such, a proposed integrated disease pathway is presented. At a fundamental level, there appears to be a primary abnormality in the pilosebaceous-apocrine unit, which leads to follicular occlusion, perifollicular cyst development that traps commensal microbes, and rupture into the dermis. This can trigger an exaggerated response of the cutaneous innate immune system. Initially this is an acute event, but ongoing intermittent disease activity can lead to recurrent inflammatory nodules and dermal tunnels. Once underway, the cutaneous inflammation is very difficult to turn off, leading to suppurative inflammation in whole anatomic regions. As the disease progresses, we propose that there is recruitment of the systemic immune system perpetuating the chronic cutaneous inflammatory process. There remains much to be done to understand the pathogenesis and immune signature of this challenging disease.

Major gaps in understanding and treatment of hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a complex dermatological disease characterized by recurrent painful nodules and suppuration in areas such as the axilla and groin. The disease is poorly understood and treatment is not satisfactory. In October 2016, the Canadian and United States Hidradenitis Suppurativa Foundations organized the inaugural Symposium on Hidradenitis Suppurativa Advances (SHSA) in Toronto, Canada. This meeting brought together experts from Canada, the United States, and Europe to discuss the latest advances in HS. After this important event, we considered that it would be helpful to outline current HS knowledge and to identify important gaps in treatment and research in order to move forward more efficiently. This paper briefly summarizes current knowledge in key areas including epidemiology, clinical presentation and morphological classification, natural history and prognosis, genotype-phenotype correlations, clinico-pathological correlation, pathogenesis, optimal treatment and outcome measures. General and initial suggestions for addressing these gaps are presented.

Efficacy, perception, and utilization of pediatric teledermatology: A systematic review.

Background: The use of teledermatology abruptly expanded with the arrival of COVID-19. Here, we review recent studies regarding the efficacy, perception, and utilization of telemedicine in the pediatric population. Objective: To evaluate the current state of pediatric teledermatology. Methods: A literature search was performed using the terms "pediatric," "teledermatology," "dermatology," "telemedicine" and "telehealth" in PubMed, Scopus, Embase, and Google Scholar. 44 articles published between 2008 and 2022 were included. Results: Diagnostic concordance between pediatric teledermatologist and in-person dermatologist ranged from 70.1% to 89%. Conditions treated with pediatric teledermatology were similar to those treated in-person. The rate of in-person follow-up after an initial telemedicine appointment pre and postpandemic was 12% to 51.9% and 13.5% to 28.1%, respectively. Patient satisfaction with teledermatology was between 70% to 98% and provider satisfaction was approximately 95%. The integration of teledermatology can reduce missed appointments and wait times among pediatric patients. However, considerable technological challenges exist, particularly in underserved communities. Globally, teledermatology may expand access to care though limited literature exists regarding its use in pediatric populations. Conclusion: Telemedicine is effective for the diagnosis and treatment of many dermatological conditions in children, with high patient and provider satisfaction. Implementation of teledermatology can potentially increase access to care both locally and globally, but obstacles to engagement remain.

Role of the Complement Pathway in Inflammatory Skin Diseases: A Focus on Hidradenitis Suppurativa.

Although the role of immune dysregulation in hidradenitis suppurativa (HS) has yet to be elucidated, recent studies identified several complement abnormalities in patients with HS. The complement system serves a critical role in the modulation of immune response and regulation of cutaneous commensal bacteria. Complement is implicated in several inflammatory skin diseases including systemic lupus erythematosus, angioedema, pemphigus, bullous pemphigoid, and HS. A model of HS pathogenesis is proposed, integrating the role of commensal bacteria, cutaneous immune responses, and complement dysregulation. The role of complement in disease pathogenesis has led to the development of novel anticomplement agents and clinical trials investigating the efficacy of such treatments in HS.

Dispelling myths in dermatologic surgery.

Several common practices and widely accepted principles implemented in dermatologic surgery are based on perpetuated beliefs not supported by evidence-based medicine. After evaluating the validity of misconceptions in dermatologic surgery, updated recommendations include restriction of antibiotic prophylaxis to patient-specific risk factors, continuation of anticoagulant therapy perioperatively, safe use of epinephrine for digital anesthesia, clean technique as an efficacious substitute for sterile, topical emollients and petroleum instead of antimicrobials to prevent surgical site infection, alternatives to elliptical excisions for decreasing scar length, wound eversion for areas of greater cosmetic concern, and cessation of systemic retinoids as an unnecessary prerequisite for most cutaneous procedures. Surgical procedures in dermatology are not as conducive to extensive validation studies, leading to the propagation of myths based on anecdotal evidence. Although current reports in the literature discredit several misconceptions, well-designed and adequately powered randomized studies are needed to verify optimal procedural guidelines.

The Utility of Smartphone Applications and Technology in Wound Healing.

Appropriate management of both acute and chronic wounds is a dynamic practice that consumes large amounts of time and financial resources within the health care system. Traditionally, wounds were measured clinically and subjectively, leading to inaccuracies in assessing wound progression and healing over time. The recent development of mobile applications and digital equipment in medicine provides an opportunity for significant improvement in wound care through the incorporation of "smart" technologies in clinical practice. The utility of these technologies has been assessed regarding the treatment of diabetic foot ulcers, burns, and general wounds. The focus of this review is to provide an update on the current status of mobile applications and digital technology in the management of wounds.