Isolated collagenoma in an HIV-positive patient on ART: a case report.

BACKGROUND: Collagenomas are rare connective tissue hamartomas composed of dermal collagen. Patients infected with human immunodeficiency virus (HIV) can present with HIV-related lipodystrophy or lipomas. There are no known associations between HIV and collagenomas. CASE PRESENTATION: Here we describe a case of an isolated collagenoma in an HIV patient on ART. The lesion was a seven by four-centimeter subcutaneous nodule with no epidermal changes located on the occipital scalp. This lesion was excised, and histopathology showed thick and randomly arranged collagen bundles, consistent with a collagenoma. CONCLUSION: This case represents an isolated collagenoma presenting in a patient with HIV. It is unclear whether HIV or ART contributed to the development of this collagenoma. Treatment of collagenomas include surgical excision and intralesional corticosteroids. In addition to lipoma or lipodystrophy, it is important to keep collagenoma in the differential diagnosis in a patient presenting with an isolated large indurated subcutaneous nodule.

Vitiligo Health Education: A Study of Accuracy and Engagement of Online Educational Materials.

INTRODUCTION: Many vitiligo patients seek healthcare information online. However, the accuracy and quality of this information is unknown. OBJECTIVE: To determine the accuracy, quality, viewer engagement, and viewer experience of vitiligo videos on social media. METHODS: We searched the term “vitiligo” on YouTube. Videos were stratified based on source categories. Video accuracy was assessed using DAS and ANDI. Video quality was assessed using GQS. Viewer experience was assessed using AVA. RESULTS: Sixty videos were evaluated for inclusion and exclusion criteria. We evaluated 49 videos with a total of 28.2 million views, 431,416 likes, and 61,976 comments. Of these videos, 27 (55%) were from healthcare sources, and 22 (45%) were from non-healthcare sources. When compared to videos from non-healthcare sources, videos from healthcare sources had significantly higher accuracy scores (ANDI = 3.69 ± 0.16 vs 2.77 ± 0.36; P=0.017 and DAS = 3.72 ± 0.13 vs 3.07 ± 0.28; P=0.029) but significantly fewer views (38,883 vs 1,231,947; P=0.005). Videos from alternative medicine sources had the lowest accuracy scores when compared to the remainder of the videos (ANDI = 0.5 ± 0.13 vs 3.66 ± 0.14; P<0.001 and DAS = 1.25 ± 0.11 vs 3.73 ± 0.11; P<0.001). CONCLUSION: Inaccurate videos on vitiligo are prevalent on social media. Misinformation can lead to potentially harmful interventions and delay in seeking evidence-based care. Videos from healthcare sources were more accurate but were viewed less than those from non-healthcare sources. Further efforts are needed to improve the visibility and viewer experience of accurate healthcare content on social media. J Drugs Dermatol. 2021;20(6):623-629. doi:10.36849/JDD.5835.

Where you live matters: Regional differences in health care resource use for psoriasis in the United States.

BACKGROUND: It is unknown which U.S. Census region offers the best access to health care resources. OBJECTIVE: To compare health care resource use and costs for patients with psoriasis among the 4 U.S. Census regions. METHODS: Cross-sectional study using the 1996-2015 Medical Expenditure Panel Survey. RESULTS: In the United States the greatest access for biologic medications was in the South (9.1% receiving biologic medications/year), followed by the Northeast (7.4%), the West (6.8%), and the Midwest (5.2%). Ambulatory visits per patient per year were highest in the West (5.02), followed by the Northeast (3.81), the South (2.95), and the Midwest (2.84). The proportion of patients with ≥1 emergency department (ED) visits was highest in the Northeast (2.73%), followed by the West (2.17%), the South (1.19%), and the Midwest (1.17%). Compared with the remainder of the country, the West incurred the lowest total health care costs (P = .035) and the lowest drug costs (P = .023); and the Northeast incurred the highest total health care costs (P = .050) and the highest ambulatory costs (P < .001). Although the South had the greatest proportion of patients using biologic medications (9.1% vs 6.4%, P = .045), it also had 30% fewer ambulatory visits per patient per year and a 39% lower proportion of ED visits for psoriasis. LIMITATIONS: Data for psoriasis severity were unavailable. CONCLUSIONS: Southern U.S. states have the greatest access to biologic medications and incurred fewer ambulatory and ED visits. The Midwest had the lowest access to biologic medications and ambulatory and ED care. The West incurred the lowest total health care costs, while the Northeast incurred the highest total health care costs.

Old Mice Demonstrate Organ Dysfunction as well as Prolonged Inflammation, Immunosuppression, and Weight Loss in a Modified Surgical Sepsis Model.

OBJECTIVES: Our goal was to "reverse translate" the human response to surgical sepsis into the mouse by modifying a widely adopted murine intra-abdominal sepsis model to engender a phenotype that conforms to current sepsis definitions and follows the most recent expert recommendations for animal preclinical sepsis research. Furthermore, we aimed to create a model that allows the study of aging on the long-term host response to sepsis. DESIGN: Experimental study. SETTING: Research laboratory. SUBJECTS: Young (3-5 mo) and old (18-22 mo) C57BL/6j mice. INTERVENTIONS: Mice received no intervention or were subjected to polymicrobial sepsis with cecal ligation and puncture followed by fluid resuscitation, analgesia, and antibiotics. Subsets of mice received daily chronic stress after cecal ligation and puncture for 14 days. Additionally, modifications were made to ensure that "Minimum Quality Threshold in Pre-Clinical Sepsis Studies" recommendations were followed. MEASUREMENTS AND MAIN RESULTS: Old mice exhibited increased mortality following both cecal ligation and puncture and cecal ligation and puncture + daily chronic stress when compared with young mice. Old mice developed marked hepatic and/or renal dysfunction, supported by elevations in plasma aspartate aminotransferase, blood urea nitrogen, and creatinine, 8 and 24 hours following cecal ligation and puncture. Similar to human sepsis, old mice demonstrated low-grade systemic inflammation 14 days after cecal ligation and puncture + daily chronic stress and evidence of immunosuppression, as determined by increased serum concentrations of multiple pro- and anti-inflammatory cytokines and chemokines when compared with young septic mice. In addition, old mice demonstrated expansion of myeloid-derived suppressor cell populations and sustained weight loss following cecal ligation and puncture + daily chronic stress, again similar to the human condition. CONCLUSIONS: The results indicate that this murine cecal ligation and puncture + daily chronic stress model of surgical sepsis in old mice adhered to current Minimum Quality Threshold in Pre-Clinical Sepsis Studies guidelines and met Sepsis-3 criteria. In addition, it effectively created a state of persistent inflammation, immunosuppression, and weight loss, thought to be a key aspect of chronic sepsis pathobiology and increasingly more prevalent after human sepsis.

Off-label dermatologic uses of IL-17 inhibitors.

IL-17 inhibitors, including secukinumab, brodalumab, and ixekizumab, have been U.S. Food and Drug Administration (FDA) approved for the treatment of psoriasis. In addition to psoriasis, IL-17 has been implicated in the pathophysiology of other inflammatory skin conditions. This review aims to synthesize and interpret the literature evaluating the off-label dermatologic uses of IL-17 inhibitors. We performed searches in PubMed and ClinicalTrials.gov for clinical trials, observational studies, case series, and case reports evaluating non-psoriatic uses of the three IL-17 inhibitors. Studies evaluated the efficacy of IL-17 inhibitors for the following conditions: hidradenitis suppurativa (HS), pityriasis rubra pilaris (PRP), Behçet's disease, alopecia areata, and allergic contact dermatitis. Based on the available literature, secukinumab appears to be a potential treatment for HS, PRP, and Behçet's disease, while ixekizumab appears to be a potential treatment for HS and PRP. However, more clinical trials data are needed to adequately assess the safety and efficacy of IL-17 inhibitors for the treatment of these conditions.

Dysregulated Genes, MicroRNAs, Biological Pathways, and Gastrocnemius Muscle Fiber Types Associated With Progression of Peripheral Artery Disease: A Preliminary Analysis.

Background Peripheral artery disease (PAD) is associated with gastrocnemius muscle abnormalities. However, the biological pathways associated with gastrocnemius muscle dysfunction and their associations with progression of PAD are largely unknown. This study characterized differential gene and microRNA (miRNA) expression in gastrocnemius biopsies from people without PAD compared with those with PAD. Participants with PAD included those with and without PAD progression. Methods and Results mRNA and miRNA sequencing were performed to identify differentially expressed genes, differentially expressed miRNAs, mRNA-miRNA interactions, and associated biological pathways for 3 sets of comparisons: (1) PAD progression (n=7) versus non-PAD (n=7); (2) PAD no progression (n=6) versus non-PAD; and (3) PAD progression versus PAD no progression. Immunohistochemistry was performed to determine gastrocnemius muscle fiber types and muscle fiber size. Differentially expressed genes and differentially expressed miRNAs were more abundant in the comparison of PAD progression versus non-PAD compared with PAD with versus without progression. Among the top significant cellular pathways in subjects with PAD progression were muscle contraction or development, transforming growth factor-beta, growth/differentiation factor, and activin signaling, inflammation, cellular senescence, and notch signaling. Subjects with PAD progression had increased frequency of smaller Type 2a gastrocnemius muscle fibers in exploratory analyses. Conclusions Humans with PAD progression exhibited greater differences in the number of gene and miRNA expression, biological pathways, and Type 2a muscle fiber size compared with those without PAD. Fewer differences were observed between people with PAD without progression and control patients without PAD. Further study is needed to confirm whether the identified transcripts may serve as potential biomarkers for diagnosis and progression of PAD.

Association between atopic dermatitis and conjunctivitis in adults: a population-based study in the United States.

BACKGROUND: The association between atopic dermatitis (AD) and conjunctivitis in adults has not been well established. METHODS: We conducted a cross-sectional study of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2002 to 2015 in order to evaluate the association between AD and conjunctivitis in U.S. adults. We performed multivariable logistic regression analyses adjusting for sociodemographic factors. RESULTS: An estimated total [95% CI] of 8,581,098 [7,592,037-9,570,160] weighted AD visits and 12,853,199,920 [12,808,269,186-12,898,131,033] weighted non-AD visits were utilized for our analyses. When compared to adults without AD, adults with AD had a fourfold higher risk of conjunctivitis (OR = 4.38; 95% CI, 1.39-13.79; p = .012) and specifically, an eight-fold higher risk of allergic conjunctivitis (OR = 8.03; 95% CI, 1.76-36.58; p = .007). Among adults with AD, 67.6% of their visits for conjunctivitis were for allergic conjunctivitis. Among adults without AD, 35.4% of their visits for conjunctivitis were for allergic conjunctivitis. CONCLUSIONS: Results of this study suggest that adults with AD have a significantly higher risk of conjunctivitis and specifically, allergic conjunctivitis when compared to those without AD. It is important for dermatology providers to be aware of this association and learn to recognize and potentially manage conjunctivitis in AD patients.

Does location matter? Geographic variations in healthcare resource use for atopic dermatitis in the United States.

BACKGROUND: It is unknown which region of the U.S. offers the best and worst access to care for atopic dermatitis (AD). METHODS: We conducted a cross-sectional study using the Medical Expenditure Panel Survey (MEPS) from 1996 to 2015 to compare healthcare resource use and cost of AD among U.S. census regions. We conducted multivariable regression analyses adjusting for clinicodemographic factors to evaluate regional differences in healthcare resource use and cost per patient per year (PPPY) in terms of ambulatory visits, ED visits, and medications directly attributable to AD. RESULTS: An estimated total of 6,348,578 (95% CI: 5,944,553-6,752,803) AD patients (weighted) were pooled. Compared to the remainder of the country, Midwest AD patients utilized the fewest ambulatory visits (0.55 versus 0.75 visits PPPY; p = .035). The proportion of patients with ≥1 ED visits was highest in the Midwest (7.1%), followed by the South (5.4%), Northeast (4.8%), and West (1.4%). Within the Midwest AD population, those with no ambulatory visits per year utilized nearly three times more ED visits when compared with those with one or more ambulatory visits per year (0.11 versus 0.04 visits PPPY; p = .019). CONCLUSION: Our results suggest that Midwest AD patients have differential access to outpatient care, which may be resulting in higher ED usage.

Risk for deep fungal infections during IL-17 and IL-23 inhibitor therapy for psoriasis.

Psoriasis is an inflammatory disease with both skin and joint manifestations. Focused biologics have been developed to target specific cytokines implicated in psoriasis and are becoming increasingly utilized. Recently, the advent of newer biologics, including IL-17, IL-12/IL-23, and IL-23 inhibitors, have garnered interest as promising treatments for psoriasis and other inflammatory conditions. Although IL-17 and IL-23 have been studied in the pathophysiology of psoriasis, they also play a central role in immunologic defenses, including those against fungi. Therefore, use of these interleukin inhibitors may theoretically impair the immune system against deep fungal infections. We reviewed the available literature investigating the risk for invasive fungal infections in patients treated with IL-17 and IL-23 inhibitors for psoriasis or other inflammatory conditions. Randomized controlled trials (RCTs), including extended trials and clinical trials, were reviewed, and we found that although there was a small number of patients who developed superficial candidiasis, there were no reports of invasive fungal disease. Although these results support the safety and the low risk for deep fungal infection with these biologics, caution is still warranted, as these medications are relatively new. Appropriate screening and management of fungal disease should still be practiced when utilizing these medications in the treatment of psoriasis and other inflammatory conditions.

Risk of herpes zoster with IL-17 inhibitor therapy for psoriasis and other inflammatory conditions.

Background: Psoriasis is a chronic inflammatory skin disease that has been associated with a significantly higher risk of herpes zoster (HZ). Several newer biologics such as secukinumab, ixekizumab, and brodalumab inhibit IL-17 and have been highly effective for treatment of psoriasis. However, adverse events related to the immunosuppressive properties of these biologics have been observed.Methods: This review aims to synthesize and evaluate the literature investigating the risk of HZ in patients treated with IL-17 inhibitors, with a focus on psoriasis patients. We performed searches using the PubMED database with the following search terms: 'psoriasis,' 'herpes zoster,' 'secukinumab,' 'ixekizumab,' 'brodalumab,' 'IL-17,' 'anti-IL-17,' and 'safety.' Clinical trials, cohort studies, review articles, and meta-analyses were evaluated.Results: Studies did not detect a higher risk of HZ infections in psoriasis patients treated with IL-17 inhibitors when compared to those treated with placebo or other therapies. Studies of IL-17 inhibitors for other indications including psoriatic arthritis, rheumatoid arthritis, ankylosing spondylitis, and asthma yielded similar results.Conclusion: IL-17 inhibitors do not appear to increase risk of HZ. However, IL-17 inhibitors are relatively new medications, and further long-term data may be necessary to confirm this finding. Nevertheless, HZ vaccination should be considered on a case-bycase basis prior to initiating IL-17 therapy.

Suicidality among psoriasis patients: a critical evidence synthesis.

Psoriasis is a chronic inflammatory skin disease with under-investigated and underappreciated links to psychiatric comorbidities, including anxiety, depression, and suicidality. In this review, we synthesize and discuss the literature investigating the association between psoriasis and three measures of suicidality: suicidal ideation, suicide attempts, and completed suicide. Studies have shown that psoriasis is significantly linked to all three measures of suicidality, but the available data on suicide attempts and completed suicides is limited and less consistent. Studied risk factors for suicidality in psoriasis patients include age, gender, and severity of psoriasis. Younger patients and patients with more severe psoriasis are at significantly higher risk of suicidality; gender was not associated with suicidality in most studies. Higher levels of psoriasis-related stressors and decrements to quality of life were significantly associated with suicidality in psoriasis patients. Most biologic treatments for psoriasis appear to be helpful in decreasing rates of depression, but data on their impact on suicidality is less well known. Understanding the risk of suicidality in psoriasis patients is key to engaging all stakeholders to screen psoriasis patients for mental health conditions. Clinicians may incorporate simple screening tools to screen for suicidal ideation and refer appropriately.

Association Between Atopic Dermatitis and Suicidality: A Systematic Review and Meta-analysis.

Importance: Atopic dermatitis (AD) is a chronic inflammatory skin disease associated with numerous psychiatric comorbidities. However, the association between AD and suicidality has not been well established. Objective: To synthesize the available literature to evaluate the association between AD and suicidality. Data Source: The protocol was prospectively registered in the PROSPERO database (CRD42018105291). Study Selection: Per PRISMA guidelines, PubMed, Embase, PsycINFO, and Cochrane databases were systematically searched for relevant articles published from 1946 to May 25, 2018. The search criteria for PubMed were as follows: (dermatitis, atopic [MeSH] OR eczema [MeSH]) AND (suicidal ideation [MeSH] OR suicide, attempted [MeSH] OR suicide [MeSH] OR suicidality OR suicidal behavior). The search criteria for Embase, PsycINFO, and Cochrane were as follows: (atopic dermatitis OR eczema) AND (suicidal ideation OR suicide attempt OR suicide OR suicidality OR suicidal behavior). Data Extraction and Synthesis: This systematic review and meta-analysis performed in an academic medical setting included observational studies that evaluated suicidal ideation, suicide attempts, and completed suicide among patients with AD. Main Outcome and Measure: The quality of included studies was assessed using the Newcastle-Ottawa Scale for observational studies. Results: The analysis identified 15 studies with a total of 4 770 767 participants, of whom 310 681 were patients with AD (52.7% female) and 4 460 086 served as controls (50.9% female). In the meta-analyses, patients with AD were 44% more likely to exhibit suicidal ideation (pooled odds ratio, 1.44; 95% CI, 1.25-1.65) and 36% more likely to attempt suicide (pooled odds ratio, 1.36; 95% CI, 1.09-1.70) compared with patients without AD. Studies investigating completed suicides in patients with AD had inconsistent results. Conclusions and Relevance: Results of this study suggest that patients with AD are at significantly increased risk of suicidal ideation and suicide attempts. It is important for dermatology providers to be aware of this risk, screen for suicidality in patients with AD, and make mental health referrals when necessary.

Psoriasis risk factors and triggers.

Numerous factors contribute to the onset and exacerbation of psoriasis. Genetic risk factors include HLA-Cw6 and mutations in the caspase recruitment domain family member 14 gene, CARD14. Environmental risk factors, including infectious diseases, medications, and lifestyle, also have been implicated. It is important for clinicians to be aware of these risk factors and triggers because they might provide insight into the pathogenesis of psoriasis as well as help patients understand more about their disease.

Differences in Face-to-Face Time Spent With a Dermatologist Among Patients With Psoriasis Based on Race and Ethnicity.

This cross-sectional study examines whether a physician's time spent with a patient with psoriasis differs based on the patient's race and ethnicity.

Long-term caregiving is associated with impaired cardiovagal baroreflex.

OBJECTIVE: Caregiving stress is associated with increased risk of cardiovascular disease (CVD). Inability to adequately regulate blood pressure is a possible underlying mechanism explaining this risk. We examined the relationship between length of caregiving and cardiovagal baroreflex sensitivity (cBRS) to better understand the link between caregiving and CVD risk. METHODS: A total of 146 elderly individuals (≥55years) participated in this study, of whom 96 were providing in-home care to a spouse with dementia and 50 were healthy controls married to a non-demented spouse (i.e., non-caregivers). Among the caregivers, 56 were short-term caregivers (caring<4years) and 40 were long-term caregivers (caring≥4years). A multiple linear regression model, with contrast codes comparing short and long-term caregivers with non-caregivers was used to understand relationships between chronic caregiving and cBRS. RESULTS: After controlling for relevant demographic and health characteristics, mean±SE log transformed cBRS for non-caregivers was 0.971±0.029. Relative to non-caregivers, the long-term caregivers had significantly impaired cBRS (0.860±0.033; p=0.013). However, mean cBRS for short-term caregivers did not significant differ from non-caregivers (0.911±0.028; p=0.144). CONCLUSION: These results suggest that long-term caregiving stress is associated with an impaired cBRS. Accumulation of stress from years of caregiving could result in worse cBRS function, which could be a mechanistic explanation for the correlation between caregiving stress and the increased risk of CVD.