Once-daily omeprazole/sodium bicarbonate heals severe refractory reflux esophagitis with morning or nighttime dosing.

BACKGROUND: Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe reflux esophagitis. AIM: Compare the effect of single dose morning (control arm) versus nighttime (experimental arm) omeprazole/sodium bicarbonate (Zegerid(®)) (IR-OME) on esophagitis and gastroesophageal reflux symptoms. METHODS: Adult outpatients with Los Angeles grade C or D esophagitis were allocated to open-label 40 mg IR-OME once a day for 8 weeks in a prospective, randomized, parallel design, single center study. Esophagogastroduodenoscopy (EGD) and validated self-report symptom questionnaires were completed at baseline and follow-up. Intention-to-treat and per-protocol analyses were performed. RESULTS: Ninety-two of 128 (72 %) eligible subjects participated [64 (70 %) male, mean age 58 (range 19-86), median BMI 29 (range 21-51), 58 C:34 D]. Overall, 81 (88 %) subjects healed [n = 70 (76 %)] or improved [n = 11 (12 %)] erosions. There was no significant difference (morning vs. night) in mucosal healing [81 vs. 71 %, (p = 0.44)] or symptom resolution [heartburn (77 vs. 65 %, p = 0.12), acid regurgitation (82 vs. 73 %, p = 0.28)]. Prevalence of newly identified Barrett's esophagus was 14 % with half diagnosed only after treatment. CONCLUSIONS: Once-daily IR-OME (taken morning or night) effectively heals severe reflux esophagitis and improves GERD symptoms. Results support the clinical practice recommendation to repeat EGD after 8 weeks PPI therapy in severe esophagitis patients to assure healing and exclude Barrett's esophagus.

Repigmentation of hair following adalimumab therapy.

Repigmentation of canities, or age-related grey or white hair, is a rare occurrence. Generalized repigmentation of grey-white hair has been reported following inflammatory processes, and heterochromia (localized patches of hair repigmentation) is even more unusual, reported in association with medication use and malignancy. Tumor necrosis factor (TNF) inhibitors are increasingly utilized medications for inflammatory disorders, including psoriasis, rheumatoid arthritis, and inflammatory bowel disease. Hair loss, or alopecia, has been described among the side effects of these medications, but changes in hair pigmentation in association with this class of drugs have not previously been reported. We describe a patient with hair repigmentation associated with adalimumab therapy.

Diagnosing oral ulcers.

Oral ulcers are common and can have many causes, making diagnosis challenging. This article provides an overview of common oral ulcers and an algorithmic approach to establishing the correct diagnosis. Factors such as duration, pattern of recurrence, clinical appearance, mucosal location, and presence or absence of systemic symptoms are useful clues to determining an ulcer's cause.

Cosmetic procedures performed in the United States: a 16-year analysis.

BACKGROUND: Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well-characterized. OBJECTIVE: To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them. METHODS: The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010. RESULTS: Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p < .001). Botulinum toxin injections were the most frequently performed cosmetic procedure and increased at the greatest rate over time. Plastic surgeons performed the largest proportion of cosmetic procedures (36.1%), followed by dermatologists (33.7%), but other specialties have been performing an increasing proportion of cosmetic procedures. This study was limited to the provision of outpatient procedures, and the nationally representative data of the NAMCS is subject to sample bias. CONCLUSIONS: Plastic surgeons and other physicians performed the majority of outpatient cosmetic procedures. Dermatologists performed one-third of ambulatory cosmetic procedures from 1995 to 2010. This broadening spectrum of physicians and nonphysicians providing cosmetic procedures may have important implications for patient safety.

Noncosmetic skin-related procedures performed in the United States: an analysis of national ambulatory medical care survey data from 1995 to 2010.

BACKGROUND: Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin-related procedural care are not well characterized. OBJECTIVE: To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time. METHODS: The annual volume of skin-related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010. RESULTS: Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively). CONCLUSIONS: Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin-related procedures to meet increasing demand.

Patterns of vitamin D analog use for the treatment of psoriasis.

BACKGROUND: Psoriasis is a chronic disease that significantly impacts patients' quality of life. It most commonly manifests as localized disease, for which there are various treatment options. OBJECTIVE: To determine the prescription patterns of topical corticosteroids and vitamin D analogs for the treatment of psoriasis in the United States and how their use has changed over time. METHODS: Data from the National Ambulatory Medical Care Survey (NAMCS) from 1994 to 2010 were queried for visits linked with a psoriasis diagnosis. Prescriptions for topical corticosteroids and vitamin D analogs were described. Vitamin D analogs usage was compared across physician specialties. For each sampled visit reported in the NAMCS, visits meeting our inclusion criteria that also mentioned the following medications were identified: topical calcipotriene, topical calcipotriene/betamethasone or any topical corticosteroid indicated for the treatment of psoriasis. RESULTS: There were an estimated 2.05 million psoriasis visits per year over the 1994-2010 interval. Dermatologists were responsible for 67% of these encounters followed by family practice (14%) and internal medicine (11%). Dermatologists prescribed a vitamin D product at 15% of psoriasis visits, followed by family physicians at 12%, and internists at 5%. Dermatologists prescribed calcipotriene, calcipotriene/betamethasone, and topical corticosteroids in 15%, 4% and 59% of psoriasis visits, respectively. Over time, there was no significant change in the use of topical steroids or vitamin D products by physicians.This study is limited by the inability to determine the severity of psoriasis from the data collected, and the lack of data on the length of treatment with different medications. CONCLUSIONS: Despite their demonstrated efficacy and safer side effect profile, vitamin D analogs are used less often than topical corticosteroids for the treatment of psoriasis. These findings suggest that vitamin D products may not be utilized to their fullest potential as effective topical therapy or adjuncts to therapy for localized plaque psoriasis.

A review of targeted ultraviolet B phototherapy for psoriasis.

Targeted ultraviolet (UV) B phototherapy devices provide a practical means to treat localized psoriasis while sparing harmful effects to unaffected skin. The objective of this study was to characterize the efficacy and safety of targeted phototherapy devices for psoriasis. We conducted a PubMed search for broadband UVB, narrowband UVB, and localized phototherapy, and a Google search for handheld phototherapy. The most common targeted phototherapy devices were characterized as 308-nm excimer laser, 308-nm excimer nonlaser, or nonexcimer light subtypes. Nine clinical trials met inclusion criteria and all found targeted phototherapy efficacious. In a nonexcimer light study, high doses cleared the most plaques. The 308-nm excimer laser had long-term clearance in 13 of 26 patients. The mean number of UVB treatments in all 9 studies and highest cumulative dose was less than those same parameters in nontargeted phototherapies. Common adverse effects included erythema, blisters, hyperpigmentation, erosion, mild burning, and itching. The predominant setting for excimer units is the office; however, the majority of nonexcimer light devices can also be used at home. Targeted phototherapy should be considered among the treatment options for localized variants of psoriasis.

Wet dressing therapy in conjunction with topical corticosteroids is effective for rapid control of severe pediatric atopic dermatitis: experience with 218 patients over 30 years at Mayo Clinic.

BACKGROUND: At our institution, hospitalization for intensive treatment (combining wet dressings and topical corticosteroids) is a primary intervention for severe pediatric atopic dermatitis. Prior reports of this treatment are limited. OBJECTIVE: We sought to review the efficacy of wet dressings for pediatric atopic dermatitis. METHODS: We reviewed records of pediatric patients hospitalized from January 1, 1980, through April 20, 2010, who received intensive topical treatments for atopic dermatitis. RESULTS: In total, 218 pediatric patients had widespread atopic dermatitis severe enough to warrant hospitalization, despite prior outpatient topical treatments and other interventions such as immunomodulating agents, phototherapy, dietary manipulation, or contact allergen avoidance. Mean (SD) age was 5.97 (4.91) years (range, 2 months-17 years); 141 patients (65%) were female. There were 266 hospitalizations: 192 patients (72%) had one admission, 15 (6%) had two admissions, and 11 (4%) had 3 or more admissions. Mean (SD) duration of hospitalization was 3.61 (2.23) days (range, 1-16 days). Upon discharge, all patients showed improvement. In 239 of 266 hospitalizations, patient records showed quantification of improvement (global assessment): 121 (45%) had 75% to 100% improvement, 102 (38%) had 50% to 75% improvement, and 16 (6%) had 25% to 50% improvement. LIMITATIONS: This was a retrospective study. CONCLUSION: Intensive inpatient treatment (with wet dressings and topical corticosteroids) was highly effective in controlling severe and recalcitrant atopic dermatitis. Intensive topical treatment, although underused, is an effective first-line approach for patients with severe atopic dermatitis.

A review of protocols for 308 nm excimer laser phototherapy in psoriasis.

BACKGROUND: 308 nm excimer laser phototherapy is efficacious in the treatment of localized psoriasis. Different approaches regarding dose fluency, number of treatments, and maintenance have been utilized, and there is yet to be a consensus on standard protocol. OBJECTIVE: To characterize treatment parameters for 308 nm excimer laser phototherapy. METHODS: We performed a PubMed search for studies describing excimer laser treatment protocol with particular attention to dosage determination, dose adjustment, dose fluency, number of treatments, and maintenance. RESULTS: Seven prospective studies were found describing the excimer efficacy for psoriasis. All studies determined the initial treatment dose using either the minimal erythema dose (MED) or induration. Fluency ranged from 0.5 MED (low) to 16 MED (high); one study demonstrated that medium to high fluencies yielded better improvement in fewer number of treatments. Fluency adjustments during the course of treatment were important to minimize phototherapy-associated side effects. The use of higher fluencies was reported to result in higher occurrences of blistering. One study implemented a maintenance tapering of dose-frequency phase to better manage psoriasis flare-ups. CONCLUSION: The 308 nm excimer laser is an effective therapy for psoriasis regardless of the method used to determine initial dosage, dose fluency, or number of treatments. As its usage as a targeted monotherapy increases, future trials should consider evaluating and modifying these parameters to determine the most optimal management of localized psoriasis. Based on our reviewed studies, there is no consensus for a single excimer laser therapy protocol and as a result, patient preferences should continue to be an important consideration for phototherapy regimen planning.

JAK inhibitors in psoriasis: a promising new treatment modality.

BACKGROUND: Inflammatory cytokines play a crucial role in the pathophysiology of psoriasis. New therapies are targeting Janus kinases (JAKs), enzymes involved with transduction of cytokine receptor signaling. OBJECTIVE: Review the utility of JAK inhibitors in the treatment of psoriasis. METHODS: A review was performed using PubMed and Google to identify research relevant to the treatment of psoriasis using JAK inhibitors. RESULTS: In a CD18 mutant PL/J mouse model with T-cell dependent psoriasiform skin disease, the JAK inhibitor R348 reduced skin inflammation, with reductions in CD4+, CD8+, and CD25+ T-cell infiltration and systemic decreases of IL-17, IL-19, IL-22, IL-23 and TNF-α. Two JAK inhibitors, CP-690,550 (tasocitinib) and INCB018424 (ruxolitinib), were effective in psoriasis clinical trials. In a phase 1, randomized, double-blind, dose escalation trial for plaque psoriasis, CP-690,050 led to improvements in Psoriatic Lesion Severity Sum score at doses greater than 5 mg. A phase 2 trial showed CP-690,050 administered at 2, 5, and 15 mg twice daily resulted in a 75% reduction in Psoriasis Area and Severity Index (PASI) in 25%, 40.8%, and 66.7% of patients, respectively, for moderate to severe psoriasis. A phase 3 study of CP-690,550 for plaque psoriasis was begun in September 2010 (NCT01163253). INCB018424, another JAK inhibitor, was used topically at 3 doses (0.5%, 1%, 1.5%) in a phase 2B, double-blind, placebo-controlled trial, resulting in improved total lesion score, global assessment, and PASI for all doses. CONCLUSION: Janus Kinase inhibitors are promising potential therapeutic options for psoriasis.

Treatment of impetigo: oral antibiotics most commonly prescribed.

BACKGROUND: Impetigo is a highly contagious, superficial skin disease that is frequently seen in children. While data support the use of topical antibiotics for treatment, the medications actually prescribed in practice are not well documented. OBJECTIVES: To determine the prescribing pattern of dermatologists and nondermatologists when treating impetigo and the demographics of the patients treated. METHODS: National Ambulatory Medical Care Survey data on office visits for impetigo were analyzed from 1997 to 2007. Patient demographics and the treatments for impetigo were recorded. RESULTS: During this 10-year period, dermatologists managed an estimated 274,815 impetigo visits and nondermatologists an estimated 3,722,462 visits. Both dermatologists and nondermatologists most frequently prescribed oral antibiotics to treat impetigo. Topical antibiotics were second most common, and a variety of combination treatments were used. CONCLUSIONS: Oral antibiotics are the most common class of medications used to treat impetigo. There is an opportunity for physicians to take advantage of the equally efficacious topical antibiotics for treating impetigo. A shift towards topical antibiotics would likely decrease morbidity (resulting from adverse effects) associated with use of oral agents.

Therapeutic modalities for localized psoriasis: 308-nm UVB excimer laser versus nontargeted phototherapy.

UVB phototherapy is an effective treatment modality for psoriasis. For patients with localized plaque-type lesions, 308-nm excimer laser phototherapy offers rapidly delivered, targeted, high UVB doses, while sparing adjacent healthy skin. We aimed to compare the advantages and disadvantages of the 308-nm xenon chloride (XeCI) UVB excimer laser with nontargeted broadband UVB (BB-UVB), narrowband UVB (NB-UVB), and psoralen plus UVA (PUVA) phototherapies. A PubMed search for studies evaluating the efficacy and safety of the laser versus nontargeted phototherapeutic modalities was conducted. Three prospective nonrandomized studies compared NB-UVB with excimer laser phototherapy. No head-to-head studies were found for BB-UVB or PUVA compared to excimer laser. Both the 308-nm excimer laser and nontargeted phototherapies were found to effectively clear localized psoriasis. Although it is proposed that excimer laser exclusively treats diseased skin with better response rates, split-body trials revealed no differences. Long-term studies are necessary to compare the effects of high-dose excimer laser regimens with nontargeted phototherapies.

Diagnosis and treatment of the neutrophilic dermatoses (pyoderma gangrenosum, Sweet's syndrome).

Neutrophilic dermatoses include a spectrum of disorders with similar histologic appearance and pathologic processes. Clinically, however, they have different physical manifestations and associations. This group includes two diseases for which dermatologists are commonly consulted in the hospital, namely pyoderma gangrenosum and acute febrile neutrophilic dermatosis, or Sweet's syndrome. Evaluation is challenging, and many therapeutic approaches have been described for both. The previously reported diagnostic criteria, physical descriptions, differential diagnosis, workup, and treatment options are reviewed. A practical approach to pyoderma gangrenosum and Sweet's syndrome for the provider is described.

Acitretin for the treatment of psoriasis: an assessment of national trends.

BACKGROUND: Combination therapy is a common and appropriate treatment strategy for moderate-to-severe psoriasis, as it provides for enhanced efficacy and decreased toxicity compared to the use of a single agent. Acitretin is an effective oral retinoid for psoriasis that seems to find its greatest value when complemented by other topical and systemic treatments. OBJECTIVE: The primary aim of this study is to assess the use of acitretin in combination with other treatments for psoriasis. METHODS: We assessed the use of acitretin for the treatment of psoriasis using nationally representative survey data from the National Ambulatory Medical Care Survey (NAMCS). RESULTS: Among visits where acitretin was listed in the NAMCS, other psoriasis medications were co-prescribed in 62 percent of visits. The co-prescribed medications included topical corticosteroids (51%), calcipotriene (31%), biologics (6%), cyclosporine (5%), methotrexate (5%) and tazarotene (2%). CONCLUSION: The use of acitretin in combination with other psoriasis treatments, particularly topical corticosteroids and calcipotriene, is a common practice. Acitretin is co-prescribed with the biologics, likely because of the relative lack of overlapping effects on immune function. The immune-sparing method of action of acitretin makes combination treatment with the systemic agents an attractive treatment option, especially in patients where further immunosuppression is unwarranted.

Changing age of acne vulgaris visits: another sign of earlier puberty?

The objective of the current study was to assess changes in the onset of pubertal maturation by determining whether acne is occurring at an earlier age. We assessed the age at which acne is occurring by assessing trends in the age of people seeking medical attention for acne. The National Ambulatory Medical Care Survey database was used to analyze physician visits for acne vulgaris in children aged 6 to 18 from 1979 to 2007. The data were used to assess trends in the mean age of children with acne and to compare these trends according to race and sex. Regression analysis revealed a significant decrease in the mean age of children seeking treatment for acne over this 28-year period (p < 0.001). There was no significant change in the mean age of black children seeking treatment for acne. Black girls had the lowest mean age whereas white boys had the highest mean age. There has been a decrease in the average age of children seeking treatment for acne that may be indicative of earlier acne onset. This finding provides supporting evidence of the increasingly earlier onset of puberty in girls.

Phototherapy trends in dermatology.

BACKGROUND: Use of phototherapy in the United States declined during the 1990s, largely due to unfavorable economic incentives. The trends in phototherapy since then are not well characterized. METHODS: We analyzed the National Ambulatory Medical Care Survey (NAMCS) data on quantity of phototherapy visits and associated diagnoses and payment sources. Trends were assessed by linear regression. RESULTS: There were an estimated 230 000 outpatient phototherapy visits per year, with an increasing trend over time (p = 0.03). Dermatologists managed 87% of the visits. Leading diagnoses associated with phototherapy included psoriasis (25%), dermatitis NOS (6%), vitiligo (6%), other dyschromia (6%), and actinic keratosis (5%). CONCLUSIONS: Use of phototherapy for psoriasis has remained relatively low up to 2010. However, phototherapy may be becoming more frequent for conditions other than psoriasis.