Sociodemographic and clinical characteristics associated with multiple biologic failure in psoriasis: A 2015-2022 prospective cohort analysis of the CorEvitas psoriasis registry.

BACKGROUND: Psoriasis patients with poor therapeutic response to multiple biologic agents are not well-characterized. OBJECTIVE: To describe the characteristics associated with development of multiple biologic failure (MBF) versus good clinical response (GR) to the first biologic. METHODS: This prospective cohort analysis evaluated patients in the multicenter CorEvitas Psoriasis Registry who initiated their first biologic between 2015 and 2020 and were followed for ≥24 months. Multivariable logistic regression identified sociodemographic, clinical, and patient-reported outcomes that differed between MBF (discontinued ≥2 biologics of different classes, each used for ≥90 days, due to inadequate efficacy) and GR (continued use of first biologic for ≥2 years) patients. RESULTS: One thousand thirty-nine patients were analyzed (490 GR [47.2%], 65 MBF [6.3%]). Female sex, shorter psoriasis duration, earlier year of biologic initiation, prior nonbiologic systemic therapy use, history of hyperlipidemia, and Medicaid insurance were significantly associated with MBF, though the latter 2 variables exhibited wider confidence intervals, indicating a lower level of support. The first-to-second biologic sequence most observed with MBF was Tumor necrosis factor-α inhibitor to IL-17 inhibitor use. LIMITATIONS: Biologic adherence between visits was not evaluated. CONCLUSION: Approximately 6% of psoriasis patients met MBF criteria. The results identify characteristics associated with MBF that may distinguish patients warranting more frequent follow-up.

Impact of Single Nucleotide Polymorphisms of the Promoter of the TNF Gene on Adalimumab Treatment Responses in Hidradenitis Suppurativa.

BACKGROUND: Results of randomized clinical trials show great variation in response to treatment with adalimumab (ADA) in hidradenitis suppurativa (HS). This varied response may be associated with genetic polymorphisms. OBJECTIVES: The aim of the study was to study the association between carriage of single nucleotide polymorphisms (SNPs) in the promoter of the tumor necrosis factor (TNF) gene and their response to ADA. METHODS: Patients with moderate to severe HS who received ADA treatment for at least 12 weeks were enrolled. SNPs were analyzed with PCR-restriction fragment length polymorphism. Hidradenitis Suppurativa Clinical Response (HiSCR) score, International Hidradenitis Suppurativa Severity Scoring System 4 (IHS4) score, inflammatory lesion (AN) count, and draining tunnel (dT) count were collected at weeks 0, 12, 24, 36, and 48. RESULTS: HiSCR response after 12 weeks of ADA treatment was 71.8% among carriers of the common GGG haplotype and 50.0% among carriers of minor frequency SNP haplotypes (p: 0.031; odds ratio: 0.39). This significant difference persisted until week 36. Carriers of minor frequency SNP haplotypes also had a lower relative decrease of the AN count at weeks 12 and 24; the dT count and IHS4 were not statistically different between the two groups. CONCLUSIONS: Carriage of at least one minor frequency SNP haplotype of the promoter of the TNF gene is associated with a decreased response to ADA. This association may have an impact on treatment decision-making.

Reddish-brown, papulonodular skin lesions in the periungual region.

Multicentric reticulohistiocytosis is a rare, non-Langerhans cell histiocytosis that most commonly presents in women in their fourth or fifth decades of life. Cutaneous involvement, characterized by reddish-brown papules in a "string of pearls" or "coral bead" linear formation, and joint involvement are the two most common manifestations at presentation. Histopathology demonstrates dermal proliferation of epithelioid histiocytic-appearing cells with ground glass cytoplasm. We report a 51-year-old woman who presented with ruddy, periungual papules and bilateral joint pain in the hands, consistent with multicentric reticulohistiocytosis. We describe the clinical and histopathologic presentation, therapeutic options, and differential diagnosis of this rare condition.

The epidemiology, impact, and diagnosis of micronutrient nutritional dermatoses. Part 2: B-complex vitamins.

Nutritional dermatoses are traditionally taught in the context of developing countries, famine, population displacement, and limited access to health care. In the United States, nutritional dermatoses may be underdiagnosed, leading to increased morbidity and utilization of hospital resources. These findings underscore the need for providers in developed nations to be able to identify these deficiencies. Dermatologists play a critical role in the diagnosis and management of patients with nutritional deficiencies, as they often present with cutaneous findings. Part 2 of this review series will focus on the epidemiology, impact, manifestations, and diagnosis of B-complex vitamins, which can present with cutaneous findings, including thiamine, riboflavin, niacin, pyridoxine, and biotin.

The evaluation and management of macronutrient deficiency dermatoses.

In industrialized countries, nutritional dermatoses are likely underdiagnosed and result in increased disease morbidity and utilization of hospital resources. These findings underscore the need for physicians to be able to correctly identify these deficiencies. Nutritional dermatoses may be split into micronutrient deficiencies and macronutrient deficiencies. This article is intended to serve as a supplement to a 2-part review of micronutrient deficiency dermatoses and highlights cutaneous findings in patients with protein-energy malnutrition and essential fatty acid deficiency. This article reviews the evaluation, cutaneous manifestations, and management of macronutrient deficiencies.

The epidemiology, impact, and diagnosis of micronutrient nutritional dermatoses part 1: Zinc, selenium, copper, vitamin A, and vitamin C.

Dermatologists play a critical role in diagnosing and managing nutritional deficiencies as they often present with cutaneous findings. Traditionally, nutritional dermatoses are taught in the context of developing countries, famine, population displacement, and poor health care access; however, in the United States, common risk factors include chronic liver disease, alcoholism, psychiatric disease, bariatric surgery, inflammatory bowel disease, and hemodialysis. Additionally, nutritional dermatoses may be underdiagnosed in the United States and result in increased morbidity and utilization of hospital resources. There is a need for providers in developed nations to identify these deficiencies, and this review aims to meet that practice gap and provide relevant context to these diseases for dermatologists. This 2-part review series will focus on the epidemiology, impact, appearance, and diagnostic modalities for micronutrient deficiencies, including zinc, selenium, copper, and vitamins A and C in part 1. The companion review will focus on the B-complex vitamins.

Dermatologic complications of orthopedic casts in pediatric patients.

Cast immobilization is performed in pediatric patients to support fracture healing, provide post-operative protection, or correct congenital deformities. Pediatric dermatologists will likely encounter the casted patients in their practice. These patients may present with cast-related complications that can arise due to the cast application or removal process, the inner cast environment, direct physical effects of the cast, or other external factors. This article provides a review of the dermatologic complications of cast immobilization, as well as useful recommendations for patients and their families.

In vitro diagnostics for the medical dermatologist. Part I: Autoimmune tests.

Despite the expansion of available in vitro laboratory tests at a rate far exceeding that of dermatologic pharmaceuticals, the existing literature is dominated by discussion of the latter. With the advent of numerous new tests, it can be difficult for practicing dermatologists to stay up-to-date on the available options, methodologies, and recommendations for when to order one test over another. Understanding the inherent strengths and weaknesses of these options is necessary to inform appropriate ordering and proper interpretation of the results. The first article in this continuing medical education series summarizes information on methodology, test characteristics, and limitations of several in vitro laboratory tests used for the work up of undifferentiated patients suspected of having dermatologic autoimmune diseases and it provides a general guide to ordering these tests.

In vitro diagnostics for the medical dermatologist. Part II: Hypercoagulability tests.

The skin often provides initial clues of hypercoagulability with features such as livedo reticularis, livedo racemosa, retiform purpura, necrosis, and ulcerations. Because these cutaneous manifestations are nonspecific, laboratory testing is often needed to evaluate for underlying causes of hypercoagulability. Importantly, these disorders are reported to be the most common mimicker, resulting in an erroneous diagnosis of pyoderma gangrenosum. Understanding inherent properties of, and indications for, available tests is necessary for appropriate ordering and interpretation of results. Additionally, ordering of these tests in an indiscriminate manner may lead to inaccurate results, complicating the interpretation and approach to management. This second article in this continuing medical education series summarizes information on methodology, test characteristics, and limitations of several in vitro laboratory tests used for the work up of hypercoagulability and vasculopathic disease as it pertains to dermatologic disease.

Interstitial granuloma annulare triggered by Lyme disease.

Granuloma annulare is a non-infectious granulomatous skin condition with multiple different associations. We present a case of a man in his 60s with a three-week history of progressive targetoid plaques on his arms, legs, and trunk. Skin biopsy demonstrated interstitial granuloma annulare. Additional testing revealed IgM antibodies to Borrelia burgdorferi on western blot suggesting interstitial granuloma annulare was precipitated by the recent infection. Lyme disease is an uncommonly reported association with interstitial granuloma annulare.

Erosive pustular dermatosis of the scalp.

Erosive pustular dermatosis of the scalp (EPDS) is a rare inflammatory condition commonly associated with antecedent iatrogenic insult. EPDS may be diagnostically challenging owing to a lack of pathognomonic histologic findings and cutaneous manifestations that overlap with alternative dermatologic conditions. Therefore, EPDS may be more common than previously recognized. We present a 60-year-old woman with a four-year history of non-healing scalp erosions, progressive skin atrophy, and scarring alopecia despite intravenous antibiotics and intraoperative debridement who improved with systemic glucocorticoids. Our report emphasizes the importance of early recognition of EPDS when delayed wound healing and erosive disease occur in the setting of iatrogenic injury to the scalp. Timely treatment with systemic anti-inflammatory agents is paramount to prevent cicatricial alopecia and mitigate further scalp insult in EPDS.

Treatment of Recalcitrant Acrodermatitis Continua of Hallopeau With Brodalumab

To the Editor: Acrodermatitis continua of Hallopeau (ACH) is a relatively rare chronic disorder with clinical findings of pustules and erythematous plaques on the digits.1 Although it is a variant of pustular psoriasis, it can be resistant to multiple lines of therapy. We describe for the first time a patient with recalcitrant ACH successfully treated with brodalumab, an interleukin-17 receptor A (IL-17RA) blocking antibody.

The impacts of oral health symptoms, hygiene, and diet on the development and severity of psoriasis.

Numerous studies have suggested a correlation between oral health, the oral microbiome, and various dermatologic conditions, particularly psoriasis. In this study, we utilize a specially designed questionnaire administered to 265 patients at The Ohio State University's dermatology clinics to explore the relationship between psoriasis and a combination of factors that included dietary habits, oral health, and oral hygiene practices. Age, family history of psoriasis, previous diagnosis of strep throat or rheumatoid arthritis, and oral pain or discomfort experienced within the last 12 months were all found to be significant predictors of psoriasis. Additionally, higher body mass index scores, poor gum health, and speech difficulties related to dental problems were all correlated with more severe psoriasis symptoms. Conversely, patients who reported consuming fresh fruit at least once a day experienced milder symptoms. Our goal is to develop a better understanding of how and why psoriasis incidence is correlated with some of the oral health factors under review.

A case of segmental Darier disease treated with doxycycline monotherapy.

Darier disease is a rare autosomal dominant disorder that results from a mutation in the gene coding for the endoplasmic reticulum membrane calcium pump Ca2+-ATPase type 2 (SERCA2), leading to compromised intercellular adhesion. Patients typically present in the first two decades of life with keratotic, greasy papules in a seborrheic distribution. Segmental Darier disease is a variant with localized disease that follows Blaschko lines. Treatment options include topical and systemic agents including corticosteroids, retinoids, and antibiotics. We present a 67-year-old woman who came to our clinic with segmental Darier disease recalcitrant to topical therapy. Owing to cost and side effect profile, the patient declined treatment with oral retinoids. Doxycycline 100mg daily was started with significant improvement. Tetracyclines both chelate and assist calcium to cross membranes. This mechanism may correct the cellular calcium imbalance present in Darier disease. In addition, tetracyclines have been shown to inhibit metalloproteinase 9, an important part of Darier disease pathogenesis. Owing to its favorable side effect profile, further investigation is warranted to establish doxycycline as a more widely utilized treatment option for Darier disease.

Xanthomatized Neutrophilic Dermatosis in a Patient With Myelodysplastic Syndrome.

We present an original case report of a 58-year-old man with a history of histiocytoid Sweet and myelodysplastic syndrome who presented with a new onset of tender plaques on his oral commissures. A biopsy revealed a dense dermal neutrophilic infiltrate, leukocytoclasis without frank vasculitis, and, most notably, the presence of many xanthomatized cells. Clinical presentation and histologic features were most consistent with an acute neutrophilic dermatosis, which we believe to be a xanthomized variant of Sweet syndrome. Recent cases have described patients with similar clinical features and neutrophilic dermatosis in the setting of a normolipemic xanthomatosis. These cases were ultimately diagnosed as neutrophilic xanthoma, suggesting a possible histologic overlap between neutrophilic xanthoma and Sweet syndrome. Given these findings, we propose xanthomatized Sweet syndrome as a new histologic variant.