Topical treatment for postinflammatory hyperpigmentation: a systematic review.

BACKGROUND: Topical measures are the mainstay treatment for postinflammatory hyperpigmentation (PIH). Numerous studies have assessed the efficacy of topical medications for the treatment of PIH, but few have evaluated the quality of evidence supporting these topical therapies. We performed a systematic review to evaluate the evidence of topical treatments for PIH. METHODS: We included English-language studies that evaluated topical medications for PIH. We searched PubMed, MEDLINE, and EMBASE from conception to March 29 2021. We used the modified Grading of Recommendations, Assessment, Development and Evaluation scale (GRADE) scale to assess quality of evidence. RESULTS: Forty-seven of 1,224 studies with 1,853 subjects were included. Topical agents with high-quality studies included retinoids, hydroxy acids, corticosteroids, thiamidol, niacinamide and plant-derived products. Sunscreens with SPF30 or greater was recommended in almost every study. Common side effects included desquamation, burning, stinging, dryness, and pruritus. CONCLUSIONS: Retinoids, hydroxy acids and broad-spectrum sunscreen were supported by the greatest number of high-quality studies. Ongoing inflammation may be subtle, especially in darker skin phenotypes. Herein, we proposed an evidence-based algorithm for PIH based on the high-quality studies. There is a need to adopt a validated outcome measure for PIH to better compare efficacy between various treatments in future studies.

Drug-Induced Intracranial Hypertension: A Systematic Review and Critical Assessment of Drug-Induced Causes.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a condition with increased intracranial pressure of unknown etiology. Its presenting symptoms include persistent headache, pulsatile tinnitus, and visual obscuration. It tends to occur in obese women of childbearing age, and its greatest risk is irreversible loss of vision. Some of the commonly used medications in dermatology, especially those for acne vulgaris, have been associated with IIH. However, the creation of specific risk categories for drugs as a guide for clinicians has never been performed. OBJECTIVE: The aim of this study was to critically assess all published cases of IIH and identify high-risk drugs associated with drug-induced intracranial hypertension (DIIH), to assist dermatologists and other physicians with patient education and monitoring of symptoms of secondary intracranial hypertension. METHODS: MEDLINE, EMBASE, and Cochrane Review Databases were searched for all cases of IIH thought to be drug-related between January 1900 and June 2019. A total of 5117 articles were identified, and 235 articles were found to be relevant. All cases were assessed to satisfy the modified Dandy criteria for diagnosis of IIH, and the likelihood of each case being a 'definite' adverse drug reaction (ADR) was determined using the Koh algorithm for ADR. An association category (from weakly associated [Category I] to strongly associated [Category V]) was assigned based on the number of cases meeting these two criteria. RESULTS: There were 259 verifiable cases of DIIH. Vitamin A derivatives, tetracycline-class antibiotics, recombinant growth hormone, and lithium were found to be most strongly associated with DIIH (Categories IV and V). Corticosteroids were moderately associated with DIIH (Category III). Drugs that were weakly associated with DIIH (Categories I and II) include cyclosporine, progestin-only contraceptives, combined oral contraceptives, second- and third-generation fluoroquinolones, sulfenazone, gonadotropin-releasing hormones and luteinizing hormone-releasing hormone agonist, nalidixic acid, amiodarone, stanozolol, danazol, divalproic acid, sulfasalazine, ketoconazole, and ustekinumab. CONCLUSION: We suggest using the term 'drug-induced intracranial hypertension' (DIIH) and propose a set of diagnostic criteria for DIIH. Our review attempts to identify DIIH-associated drugs based on a strict diagnostic and drug-causality algorithm, then stratify them into appropriate risks categories. This may ultimately assist physicians in counselling patients about the risk of DIIH when prescribing medications and recognizing this uncommon yet sight-threatening condition.

Survival rates of biological therapies for psoriasis treatment in real-world clinical practice: A Canadian multicentre retrospective study.

BACKGROUND/OBJECTIVES: Data on biologic drug survival in real-world psoriasis treatment are limited. There is a need to evaluate long-term trends of biologic use outside the realm of clinical trials. METHODS: A multicentre chart review was conducted with patients' data from September 2005 to September 2014. Kaplan-Meier plot analysis was used to determine 5-year drug survival rates. A log-rank test was used to compare the rates of drug survival between the studied biologics. RESULTS: For the 398 patients and 545 treatment series analysed, 1, 2, 3, 4 and 5-year survival rates were 0.826, 0.687, 0.563, 0.475 and 0.420 with etanercept; 0.804, 0.648, 0.553, 0.508 and 0.508 with adalimumab; 0.838, 0.664, 0.554, 0.485 and 0.382 with infliximab; and 0.914, 0.856, 0.800, 0.755 and 0.755 with ustekinumab, respectively. A statistically significant difference was seen between ustekinumab and the other three biologics. CONCLUSION: A progressive decrease in treatment adherence was seen with all four biologics, as expected, but the survival rate of ustekinumab was highest.

Diagnosis and management of psoriasis.

OBJECTIVE: To provide primary care clinicians with an up-to-date and practical overview of the diagnosis and management of psoriasis. QUALITY OF EVIDENCE: PubMed, MEDLINE, EMBASE, and Cochrane databases were searched for relevant meta-analyses, randomized controlled trials, systematic reviews, and observational studies about the diagnosis and management of psoriasis. MAIN MESSAGE: Psoriasis is a chronic, multisystem inflammatory disease with predominantly skin and joint involvement. Beyond the physical dimensions of disease, psoriasis has an extensive emotional and psychosocial effect on patients, affecting social functioning and interpersonal relationships. As a disease of systemic inflammation, psoriasis is associated with multiple comorbidities, including cardiovascular disease and malignancy. The diagnosis is primarily clinical and a skin biopsy is seldom required. Depending on the severity of disease, appropriate treatment can be initiated. For mild to moderate disease, first-line treatment involves topical therapies including corticosteroids, vitamin D3 analogues, and combination products. These topical treatments are efficacious and can be safely initiated and prescribed by primary care physicians. Patients with more severe and refractory symptoms might require further evaluation by a dermatologist for systemic therapy. CONCLUSION: Many patients with psoriasis seek initial evaluation and treatment from their primary care providers. Recognition of psoriasis, as well as its associated medical and psychiatric comorbidities, would facilitate timely diagnosis and appropriate management with effective and safe topical therapies and other medical and psychological interventions, as needed. More severe and refractory cases might warrant referral to a dermatologist for further evaluation and possible systemic therapy.

Risk of Malignancy in Dermatomyositis and Polymyositis.

BACKGROUND: There is variation in the risk of malignancy in dermatomyositis (DM) and polymyositis (PM) in the existing literature. OBJECTIVE: To conduct a meta-analysis to estimate the risk of malignancy in DM and PM as compared with the general population. METHODS: Medline and Embase Database abstracts were searched through August 2014 using the search terms myositis, neoplasms, and paraneoplastic syndromes. Population-based, observational studies in English were included. Meta-analyses were conducted using random-effects models. RESULTS: A total of 5 studies with 4538 DM or PM patients were included in the analysis. The overall relative risk was 4.66 for DM and 1.75 for PM. By gender, the standardized incidence ratio (SIR) of malignancy among DM patients was 5.29 for males and 4.56 for females; the SIR of malignancy among PM patients was 1.62 for males and 2.02 for females. By time since diagnosis, the SIR of malignancy among DM patients was 17.29 in the first year, 2.7 between 1 and 5 years, and 1.37 after 5 years. By age group, the SIR among DM patients was 2.79 for patients between 15 and 44 years and 3.13 beyond 45 years. CONCLUSIONS: Both DM and PM are associated with increased risk of malignancy, but the risk is higher in DM. The risk of malignancy is present in both genders and all age groups and is highest in the first year after diagnosis but persists beyond the fifth year in DM. Adults should be evaluated for malignancy at diagnosis, followed by long-term surveillance.

MACEs Not Associated With the Use of Biologic Therapy for Psoriasis in Real-World Clinical Practice: A Canadian Multicenter Retrospective Study.

INTRODUCTION: Previous reports have shown inconsistent findings with regard to the relationship between biologic therapy and risk for major adverse cardiovascular events (MACEs). OBJECTIVES: The aim of this study was to determine the overall rate of MACEs in a cohort of 398 patients. METHODS: All patients treated with biologics for psoriasis at 2 academic centers in Toronto, Ontario, between September 2005 and September 2014 were considered for inclusion. Medical records were reviewed to identify MACEs. RESULTS: A total of 398 patients were included. The median duration of disease was 19.8 years. Median time to biologic therapy withdrawal because of an adverse event was 23.5 months. In this cohort, no MACEs were identified in patients treated with biologic therapy. CONCLUSIONS: Biologic treatment for psoriasis was not associated with increased cardiovascular risk in this cohort. These results require validation in larger studies.

Clinical Features and Patient Outcomes of Hidradenitis Suppurativa: A Cross-Sectional Retrospective Study.

BACKGROUND: Despite the high burden of disease associated with hidradenitis suppurativa (HS), epidemiologic data are scarce. OBJECTIVE: The objective was to review demographic features and clinical findings in 80 HS patients from 2 referral centres in Ontario, Canada, from October 2013 to September 2014, and to assess for factors that are associated with more advanced disease. METHODS: Multicentre cross-sectional study. The data on demographic and clinical features were obtained by questionnaires and chart review. RESULTS: Of a total of 80 patients (67.5% females), percentages of patients in Hurley stages I, II, and III were 15.4%, 55.8%, and 28.9%, respectively. Most patients were not diagnosed for more than 1 year (70.1%). Patients with more severe disease were more likely to be females and to have a greater number of lesions and were less likely to be diagnosed initially by a dermatologist. CONCLUSIONS: This study documents the common demographic and clinical features of HS to optimize resource allocation and patient outcomes.

Adverse events resulting in withdrawal of biologic therapy for psoriasis in real-world clinical practice: A Canadian multicenter retrospective study.

BACKGROUND: Safety profiles of biologics for treatment of psoriasis are limited to data from randomized controlled trials. There is a need for comparative safety reports of biologics based on data from clinical practice. OBJECTIVE: We sought to estimate and compare the incidence of adverse events (AEs) leading to withdrawal of biologics (etanercept, infliximab, adalimumab, and ustekinumab) in the treatment of psoriasis. METHODS: We conducted a multicenter retrospective chart review from September 2005 to September 2014. Incidence proportion and rate of AEs leading to withdrawal by biologic agent and AE were calculated. RESULTS: For 545 treatments administered in 398 patients, 22 (4.04%) AEs were associated with withdrawal, for a rate of 1.97/100 patient-years (95% confidence interval [CI] 1.32-2.94). Common AEs were injection-/infusion-site reactions (0.55%, 0.92%, 0%, and 0% for etanercept, infliximab, adalimumab, and ustekinumab, respectively); infections (0%, 0.18%, 0.55%, 0.18%); and malignancies (0.18%, 0.18%, 0%, 0.37%). LIMITATIONS: Possible incompleteness of chart details and small study population limit the conclusiveness of findings. CONCLUSION: Biologic agents for treatment of psoriasis are safe; AEs associated with withdrawal occurred in 4% of all administered biologic therapies. It does not appear that real-world patients encounter more AEs with biologics than patients in clinical trials.

Skin Necrosis from Intra-articular Hyaluronic Acid Injection.

BACKGROUND: Tissue necrosis is a rare yet potentially serious complication of intra-articular (IA) hyaluronic acid (HA) injections for treatment of knee osteoarthritis. OBJECTIVE: To report a case of a patient with cutaneous necrosis after IA HA injection for treatment of knee osteoarthritis, presenting as a livedoid violaceous patch on the right knee. METHOD: We report a case of cutaneous necrosis as a rare complication of IA HA injection for treatment of knee osteoarthritis. A literature review was undertaken of similar cases. RESULTS: Use of HA IA injections in the treatment of osteoarthritis can result in similar skin necrosis at uncommon anatomic locations corresponding to the site of HA injection. CONCLUSION: Although tissue necrosis is a rare complication, physicians need to be aware of this possibility as a complication of HA IA injections in the treatment of osteoarthritis and should be mindful of potential treatment options to manage this adverse event.

Public Engagement with Dermatology Contents on Facebook.

BACKGROUND: The gtring presence of dermatology platforms on Facebook has been acknowledged; however, little is known about the extent to which different types of content influence the level of engagement with online users. OBJECTIVE: To assess the level of public engagement with different types of content posted on Facebook pages devoted to dermatology. METHODS: A search on Facebook identified existing pages for dermatology academic journals, professional societies, and patient-centered groups. Then the engagement rate was calculated for each content type published on the selected pages. RESULTS: The median engagement rates were 63.8% for educational posts, 41.3% for interactive posts, 27.4% for news articles, 11.8% for academic articles, and 9.3% for others. CONCLUSION: Educational posts engaged with online users the most effectively. The level of engagement is a key determinant of knowledge dissemination via online tools, and the type of content may influence the level of engagement.

Epidermolysis Bullosa Pruriginosa: Case Series and Review of the Literature.

Epidermolysis bullosa (EB) pruriginosa is a rare clinical subtype of dystrophic epidermolysis bullosa (DEB) that is characterized by intense pruritus resulting in hypertrophic, lichenified, prurigo-like plaques and nodules secondary to scratching. The variability in the age of onset, rarity of intact bullae, histologic ambiguities, and close resemblance to other conditions such as acquired inflammatory dermatoses may make diagnosis difficult for this unusual condition, for which fewer than 100 cases have been documented. In this report, we describe 3 cases of EB pruriginosa and review the current literature.

Epidermolysis bullosa pruriginosa: a systematic review exploring genotype-phenotype correlation.

INTRODUCTION: Epidermolysis bullosa pruriginosa (EBP) is a clinical variant of dystrophic epidermolysis bullosa (DEB), characterized by intense pruritus and hypertrophic, lichenified, prurigo-like papules, plaques, and nodules secondary to scratching. These clinical findings have been attributed to various mutations in the COL7A1 gene. Previous reports have yielded inconsistent findings regarding a possible genotype-phenotype relationship in EBP. OBJECTIVE: Our aim was to conduct a systematic review aimed at assessing the genotype-phenotype correlation in EBP. METHODS: A systematic review was conducted using PubMed, Medline, EMBASE, and Cochrane databases for all reports of mutation-verified EBP, published from 1946 to September 2014. Statistical comparison of clinical findings between mutation types was performed using logistic regression analysis. RESULTS: The review included a total of 28 articles with 74 individuals, which consisted of level 4 non-controlled case series (grade C) and level 5 case reports (grade D). Previous reported mutation types included glycine substitution (GS, 52.7%), in-frame skipping (IFS, 33.8%), non-glycine substitution (NGS, 8.1%), and premature termination codon (PTC, 5.4%). The most common clinical findings were extremities involvement, linear configuration, and nail dystrophy. In comparison with GS mutation carriers, IFS carriers had a higher likelihood of (1) being male (OR 2.99; p = 0.043; 95% CI 1.27-11.4) and (2) presenting with blisters (OR 4.10; p = 0.013; 95% CI 1.34-12.5). CONCLUSIONS: To our knowledge, this study is the first systematic review examining the relationship between mutation type and clinical presentation in EBP. The findings in this review (1) identify common clinical characteristics of EBP that may help in the assessment of patients with possible EBP; and (2) indicate that certain mutation carriers may have a higher likelihood of exhibiting particular phenotypes. In the case of potential diagnostic challenge, assessment for presence of common clinical findings as well as molecular testing may facilitate correct identification and prognostication.

Quality-of-life impairment in patients with hidradenitis suppurativa: a Canadian study.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic relapsing condition with a clinical picture that includes solitary nodules; diffuse, painful abscesses; malodorous drainage; sinus tract formation; and scarring. Treatment options are often unsatisfactory. The adverse effects of this disease on quality of life (QoL) is not extensively studied, especially in the Canadian population. OBJECTIVES: The objectives of this study were to (1) identify the impairment of QoL in patients with HS and the aspects that are most affected, and (2) assess the correlation between disease severity (based on Hurley's staging) and QoL impairment. METHODS: This prospective case series studied 55 patients (38 females and 17 males) from community dermatology clinics in Ontario. All patients filled out the questionnaires for QoL data using the Dermatology Life Quality Index (DLQI) and the Short Form 36 Version 2 (SF-36v2) health survey, either in the clinic or over the telephone. RESULTS: The mean DLQI score was 10 ± 8.8, indicating a moderate effect on patients' lives. In keeping with this, SF-36v2 scores were significantly reduced with respect to both physical and mental health. The severity of disease, as measured by Hurley staging, the number of lesions, and patient-reported QoL were significantly correlated with the DLQI score (ß = 0.549, 0.285, 0.390, respectively; p = 0.000, 0.045, 0.004, respectively; α = 0.05). CONCLUSIONS: The impact on QoL for patients with HS is extensive yet underestimated; quantifying and assessing the burden of disease for the individual and society will lead to establishment of funding priorities and greater awareness of this condition.

Pretibial Myxedema: Case Presentation and Review of Treatment Options.

Pretibial myxedema (PM) is a rare autoimmune manifestation of Graves' disease, which commonly presents as diffuse, nonpitting edema of shins and less often as plaques, nodules, or elephantiasis lesions mimicking lymphedema. We present a 57-year-old woman with 12-month history of PM, which occurred a year after treatment of Graves' disease and improved with topical corticosteroids, support stockings, and intralesional steroid injections until recurrence with local erythema and woody edema. A literature review was undertaken of the evidence-based treatment modalities for symptomatic PM: although commonly asymptomatic and self-limited, severe cases of PM may be treated with topical corticosteroid, compressive therapy, and intralesional corticosteroid injections.