Validation of actinic keratosis diagnosis and treatment codes among veterans living with HIV.

PURPOSE: Actinic keratoses (AK) diagnosis, billing, and pharmacy codes have not been validated among people living with human immunodeficiency virus (HIV), preventing use in epidemiologic and clinical research. We aimed to calculate the positive predictive value (PPV) of AK diagnosis codes, procedural codes for destruction of pre-malignant lesions, and pharmacy codes for topical 5-fluorouracil. METHODS: Patients diagnosed with HIV within the Infectious Disease clinic at the Atlanta Veterans Affairs Medical Center from 1/1/2002 to 8/5/2017 were eligible. Patients were included if they had any of the following: encounters with a diagnosis for AK (International Classification of Diseases [ICD]-9: 702.0; ICD-10: L57.0), procedural codes for destruction of premalignant lesions (Current Procedural Terminology [CPT]: 17000, 17003, and 17004), and prescriptions for topical 5-fluorouracil. PPV and binomial 95% confidence intervals were calculated. RESULTS: PPV was 91.9% (89.1-94.7) for 369 encounters with an AK diagnosis. For procedural codes, PPV was 52.6% (48.1-57.2) for 454 encounters with destruction of 1 pre-malignant lesion, 63.7% (58.4-68.9) for 322 encounters with destruction of 2-14 lesions, and 57.7% (38.7-76.7) for 26 encounters with destruction of 15+ lesions. PPV was 72.9% (63.5-82.4) for 85 encounters with a prescription of topical 5-fluorouracil. CONCLUSION: AK diagnosis codes are appropriate to use in epidemiologic and health policy research among people living with HIV and may be more reliable than destruction of pre-malignant lesion CPT codes.

Severe atopic dermatitis: Therapeutic update.

Background: Atopic dermatitis (AD) is a common inflammatory skin disorder with a multitude of highly characterized comorbidities that affect infants, children, and adults worldwide. Despite its high prevalence and health burden, our armamentarium to treat AD in its severe form has remained lacking. For decades, the only Food and Drug Administration approved systemic treatment options for AD had been limited to corticosteroids. Methods: We conducted a nonsystematic review of the new and emerging drugs for the treatment of AD. Results: The recent emergence of dupilumab, a monoclonal antibody that selectively inhibits the type 2 cytokines that are integral to the pathogenesis of AD has provided dermatologists and allergists with a safe and effective targeted therapy to manage patients with moderate-to-severe disease. Numerous other drugs, both topical and systemic, are currently in development for the treatment of AD and have shown promise in their early phase trials. These agents include monoclonal antibodies that target various mediators relevant for a type 2 immune response, small-molecule inhibitors that block signaling through the Janus kinase pathway, and other agents that are aimed at addressing the symptomatology of itch. Conclusion: When anticipating the successful development and release of these drugs in the near future, it will be imperative for providers to review the available data, including the efficacy and adverse effects profile of each agent to determine the best treatment approach for each individual patient with AD.

Psoriasis: Psychosomatic, somatopsychic, or both?

Psoriasis is a chronic inflammatory disorder characterized by substantial psychiatric comorbidity. Historically, anecdotal observations have suggested that psychosocial distress can trigger flares of psoriasis, but over the past several decades, high-quality data from experimental studies support the assertion that stress plays a critical role in the pathogenesis of psoriasis. There may be a subset of patients unable to elicit an appropriate immunosuppressive response to stress through upregulation of cortisol, with resultant exacerbation of their psoriasis. Other notable studies revealed that key neuromodulators, including substance P, calcitonin gene-related peptide, vasoactive intestinal peptide, and nerve growth factor may be potent regulators of neurogenic inflammation that induce psoriasis flares through a stress-mediated mechanism. Preliminary trials in humans that examine psychosocial interventions to reduce stress, as well as animal studies targeting specific neuropeptides, provide support for the concept that alteration of pathways mediated by the stress response represents novel forms of therapy in the management of psoriasis.