Patients' Preferences Regarding Modes of Systemic Psoriasis Treatment - A Qualitative Study.

Background: Treatment with pathogenesis-directed biologics and oral systemic drugs have made complete clearance of psoriasis a realistic expectation for many patients with psoriasis. Patients' preferences among these treatments varies. Objective: To understand factors impacting psoriasis patients'preferences for injection vs oral medication. Methods: Psoriasis patients who receive systemic psoriasis treatment were asked to participate in a semi-structured interview. Sample size was based on achieving saturation with equal number of patients preferring oral vs injectable medications to ensure equal representation of both groups. Qualitative analysis was performed to interpret the results. Results: Twenty-two patients participated in the study, 12 males and 10 females. Ten patients were receiving oral medication (apremilast or methotrexate) and 12 patients were receiving injectables (guselkumab, adalimumab, risankizumab, secukinumab, ixekizumab, or tildrakizumab) due to self-reported preference. Five themes resulted from the analysis: patients receiving injectables more frequently discussed the positive impact of the medication on quality of life compared to patients on oral medication; fear of side effects, particularly fear of immunosuppression, is associated with injection medications; avoidance of needles drives patients away from injection medication and towards oral systemic medication; patients prioritize convenience when selecting systemic therapy, though the definition of convenience is subject to perception; and patients value the medication recommendation of the physician, regardless of the route of administration. Conclusion: Improving medication adherence and disease outcomes through individualized treatment plans, with an emphasis on patients' preferences using a shared decision-making approach, may be helpful.

The Influence of Psoriasis on Type 2 Diabetes Mellitus Patient Profiles: A National Inpatient Sample Study.

Background: Psoriasis is believed to be a common comorbidity of type 2 diabetes mellitus (T2DM). Little is known on the impact psoriasis has on T2DM patients' disease profiles. Objective: To assess the impact psoriasis has on T2DM patients' demographics, comorbidities, and health care outcomes. Methods: We retrospectively analyzed the 2017 U.S. National Inpatient Sample (NIS) database. We utilized ICD-10 codes to determine T2DM and psoriasis patients along with associated comorbidities. Continuous variables were compared by independent-sample t-tests and categorical variables were compared via Pearson chi-square. All analysis were conducted in IBM SPSS 25. Results: Among 7,705,988 T2DM admissions, 0.67% of them had comorbid psoriasis. T2DM psoriasis patients (64.38; SD: 12.403) were, on average, younger (64.38 vs 66.73; P < .001) and white (78.7% vs 63.1%; P < .001) and had increased foot ulcers (4.2% vs 3.8%; P < .001), hyperglycemia (22.4% vs 21.0%; P < .001), retinopathy (22.4% vs 21.0%; P < .001), hypercoagulopathy (8.5% vs 6.9%; P < .001), and hypertension (72.5% vs 70.4%; P < .001) than T2DM patients without psoriasis. T2DM psoriasis patients spent more days in the hospital (5.49 vs 5.37; P < .001), had more concurrent diagnoses (19.05 vs 16.5; P < .001), less total charges ($60,596.71 vs $61,534.66; P = 0.010) and had less in-hospital deaths (2.0% vs 2.7%; P < .001) than T2DM patients without psoriasis. Conclusions: The presence of comorbid psoriasis significantly impacts T2DM patients' demographics, comorbidities, and health care outcomes. These findings underscore the importance of early disease monitoring, cross-specialty collaboration, and medication monitoring in order to guide individualized management strategies and optimize patient care.

Physician Path to Wellness. A Qualitative Investigation of Self-Reported Strategies to Shift from Detrimental Health to Optimal Wellness.

Background: A healthy physician performs better clinically and provides superior care to patients than a physician struggling with burnout. Objective: The purpose of this study is to assess the physician perception of "health" and "burnout," to identify successful wellness-promoting behaviors, and to build a model characterizing the successful transition from poor health to wellness. Methods: Utilizing a qualitative approach, the team conducted one-on-one, in-depth, semi-structured interviews with physicians from different specialties. Questions focused on behaviors, beliefs, and system changes that facilitated their transition from poor health/burnout to wellness. Interviews were recorded and responses qualitatively coded from a set of definitions of wellness and burnout. These coded responses were quantified, and code prevalence was analyzed. Results: Fourteen physicians completed interviews. The codebook consisted of 74 total themes, with nine occurring in more than 10 (71%) of the interviews. Most themes yielded to categories of Wellness, Unwell, and Burnout, with several themes related to individual agency in facilitating wellness. Highly prevalent themes included support systems, nutrition, exercise, and cognitive health. Subjects generally described comprehensive approaches to successfully transitioning to wellness. Conclusion: This study describes strategies for the successful transition to wellness: physician-level factors such as a healthy support system, maintaining a healthy lifestyle, and developing consistent daily routines. These findings support the importance of physician autonomy and individual-level wellness-promoting strategies for a physician's transition to wellness. More research should investigate the overall effect of individual-level strategies versus system-level interventions.

Validity of facial skin analysis pore detection: A comparative analysis.

BACKGROUND: Reliable, objective measures to assess facial characteristics would aid in the assessment of many dermatological treatments. Previous work utilized an iOS application-based artificial intelligence (AI) tool compared to the "gold standard" computer-based and a physician assessment on five skin metrics (British Journal of Dermatology, 2013, 169, 474). The AI tool had superior agreement for all skin metrics except pores and subsequently underwent an algorithm update for its pore detection system. AIMS: This comparative analysis assessed the performance of the updated AI tool's pore scores across all Fitzpatrick skin phototypes to determine whether the AI tool more accurately represents a dermatologist's assessment of pores. PATIENTS/METHODS: Frontal facing photographs in uniform lighting conditions were taken of each participant. Percentile scores were generated by each of the four self-learning models of the updated AI tool. The pore percentile scores generated by the original and updated AI tool were used to rate "worse" pores among participant pairs. These ratings were compared to pore assessments performed by a "gold-standard" device and a board-certified dermatologist. RESULTS: Compared to the original pore detection tool and the computer-based program, models A and D had the highest concordance with the physician's pore assessments for Fitzpatrick skin phototypes III-IV and V-VI, respectively. CONCLUSIONS: The AI tool's pores detection update was successful in its ability to accurately detect pores on all Fitzpatrick skin types, improving on the performance of the AI prior to the update. Responsibly developed AI tools that can accurately and reliably detect skin metrics across diverse Fitzpatrick skin types can facilitate dermatologic evaluation, individualize treatment, and determine treatment response.

Qualitative investigation of disease course, characteristics and lived experience of generalized pustular psoriasis.

BACKGROUND: Generalized pustular psoriasis (GPP) is a relapsing-remitting chronic disease characterized by painful pustules with systemic symptoms that negatively impacts quality of life. The psychosocial and economic burden of this rare condition is not well characterized. OBJECTIVES: To qualitatively characterize the cumulative burden of generalized pustular psoriasis on patients' quality of life and psychosocial wellbeing. METHODS: A retrospective chart review of patients with generalized pustular psoriasis was performed to collect demographic information, followed by prospective semi-structured clinical interviews. Interview transcripts were analyzed using thematic analysis. RESULTS: Three major themes were revealed: (1) Burden of having a chronic disease with an unpredictable course, (2) an inability to fulfill societal roles results in a loss of identity, and (3) a physician-patient relationship grounded in trust and transparency can be invaluable in helping patients endure chronic disease. CONCLUSION: GPP has a negative impact on patients' quality of life and psychosocial wellbeing. Impairments in daily function and mental health primarily affects patients during flares and influences behavior during periods of quiescence. A strong patient-physician relationship may help mitigate the impact of GPP.

Full Guidelines-From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis.

BACKGROUND: Systemic immunomodulatory agents are indicated in the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis. Perioperative use of these medications may increase the risk of surgical site infection (SSI) and complication. OBJECTIVE: To evaluate the risk of SSI and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alfa [TNF-α] inhibitors, interleukin [IL] 12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte-associated antigen-4 costimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine (CsA), and methotrexate [MTX]) undergoing surgery. METHODS: We performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery. RESULTS: We examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease. CONCLUSION: For low-risk procedures, TNF-α inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, MTX, CsA, and apremilast can safely be continued. For intermediate- and high-risk surgery, MTX, CsA, apremilast, abatacept, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab are likely safe to continue; however, a case-by-case approach is advised. Acitretin can be continued for any surgery. There is insufficient evidence to make firm recommendations on tofacitinib, upadacitinib, and deucravacitinib.

Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup.

Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.

Monitoring adherence to vulvar lichen sclerosus treatment - a prospective study.

Background: Vulvar lichen sclerosus treatment consists of topical corticosteroids followed by maintenance therapy. Self-reported adherence to topical corticosteroids in vulvar lichen sclerosus is approximately 66-70.4% and adherence to chronic topical medications is poor.Objective: To measure treatment adherence for vulvar lichen sclerosus.Methods: Adults with vulvar lichen sclerosus who were receiving or who were candidates to receive treatment with topical clobetasol propionate 0.05% ointment twice daily received medication tubes equipped with adherence monitors capturing the time and amount of dose dispensed. After 2 months, monitors were returned, and patients were surveyed regarding their adherence.Results: Ten patients participated for a median (range) of 8.5 (7-11) weeks. Eight (80%) and 7 (70%) caps captured medication timing and dosing events, respectively. Median (interquartile range) adherence was 65% (42-77) and median (interquartile range) medication dispensed per use was 0.15 (0.14 - 0.5) grams. Of the 8 patients using active adherence monitors, 2 did not clinically improve; adherence rates and mean quantity dispensed for these two patients were 31% and 0.13 grams, and 9% and 0.74 grams, respectively.Conclusion: Poor adherence to both twice daily application and prescribed medication quantity occurred frequently. Factors related to self-reported non-adherence included perceived greater efficacy, inconvenience, and time-constraints. Patient adherence to recommended treatment and clinical outcomes are areas for improvement in patients with vulvar lichen sclerosus.

Non-Systemic Medication for the Treatment of Prurigo Nodularis: A Systematic Review.

Prurigo nodularis (PN) is a skin disease characterized by firm, itchy, erythematous lesions. Treatment consists of systemic and non-systemic modes of therapy. Non-systemic forms of treatment are first-line and include topical corticosteroids, topical steroid-sparing agents, and phototherapy. The objective was to review the efficacy of non-systemic treatment used to treat PN. A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with PROSPERO (CRD42023412012). The search consisted of keywords and Medical Subject Heading (MeSH) terms and translated to Ovid MEDLINE, Embase, and Scopus. Google Scholar was also searched for the first 200 articles. Article quality of evidence was scored using GRADE criteria. The search yielded 1151 results; 37 met criteria for inclusion. There were 14 studies on phototherapy, and 11 studies on topical corticosteroids, most of which were also combined with topical antihistamines, antipruritics, and/or phototherapy. There were 2 studies each on topical antipruritics used in isolation, vitamin D analogues, and intralesional triamcinolone acetonide. There was 1 study each on topical pimecrolimus, tacrolimus, 2% dinitrochlorobenzene, cryotherapy, acupuncture, and the Paul Gerson Unna boot. Most were case reports and case series, although 2 randomized controlled trials on phototherapy and topical pimecrolimus were included. Corticosteroids had varying levels of positive response in patients and appeared more effective when used in combination or under occlusive dressing. Phototherapy is likely effective, but the risk of relapse is high. Cryotherapy may also be a lesion-directed agent to circumvent challenges to adherence and avoidance of systemic medication.

Innate Error Immunities of the Th17 Immune Pathway Associated With Chronic Mucocutaneous Candidiasis: A Systematic Review.

BACKGROUND: Candida albicans is an opportunistic pathogenic yeast commensal in human mucosa. In individuals with compromised immune systems, it can present as chronic mucocutaneous candidiasis (CMC) or systemic infection. CMC often exists in the presence of other infectious phenotypes due to dysfunction of the Th17 immune response. OBJECTIVE: To examine innate error immunities (IEI) of the Th17 immune response associated with CMC. METHODS: MEDLINE PubMed, Embase, and Web of Science were searched for keywords and Medical Subject Headings (MeSH) related to the subject of interest. Nonapplicable and non-primary research methodologies were excluded. RESULTS: We identified 266 articles; 89 were removed for being a duplicate, 108 for irrelevance, and 51 for being a review. We examined 18 studies, 5 on murine models, and 13 human studies. CONCLUSION: Case reports in patients with CMC have identified a range of mutations in IL-17F, IL-17RA, IL-17RC, and ACT1. Mouse models confirm the role of IL-17A and IL-17F in disease susceptibility. J Drugs Dermatol. 2023;22(12):1197-1203. doi:10.36849/JDD.7579.