Comparing demographic characteristics and adverse event rates at two dermatologic surgery practices.

BACKGROUND: Patient demographics and operative techniques may contribute to adverse events after surgeries. OBJECTIVE: To identify differences in adverse event rates between different dermatologic surgery centers and potential contributing features affecting these rates. METHODS: Data regarding demographics, procedure type, and adverse events were collected at two dermatologic surgery centers. RESULTS: The most common adverse event at both sites was infection: 2.1% at site 1 versus 0.5% at site 2 (p < .001). Using multivariate logistic regression, procedure type (Mohs surgery), geographic location (being at site 1), older age, and anatomic location of surgery were associated with a higher risk of infection. CONCLUSION: Adverse event rate appears to correlate with patient demographics, procedure type, and setting of surgery more than use of prophylactic antibiotics. Identification of differences in adverse event rates and potential contributing variables at different practices may allow for identification of opportunities to prevent adverse events.

Insect repellents and contact urticaria: differential response to DEET and picaridin.

Topical insect repellent is commonly used throughout the world. Active ingredients typically include N,N-diethyl-meta-toluamide (DEET) or picaridin. Reactions to topical repellents have ranged from contact dermatitis to urticaria. Exposure to DEET can produce contact urticaria; however, it is unknown if patients with a sensitivity to DEET can tolerate picaridin. We report the case of a 22-year-old man who presented for evaluation of contact urticaria that had developed immediately after the application of insect repellent and contact with individuals who had used DEET-containing repellents. No systemic manifestations were noted. Commercially available products containing DEET or picaridin were used for open patch testing. The patient showed immediate urticarial responses to 7% DEET and 7% DEET in ethanol, but patch tests for 5% picaridin and 5% picaridin in ethanol were negative. Based on these results, we conclude that insect repellents containing picaridin may be acceptable alternatives in patients who demonstrate sensitivity to products containing DEET.

Quantifying and characterizing adverse events in dermatologic surgery.

BACKGROUND: Although office-based dermatologic procedures are generally considered safe, there is a lack of prospective data on the rate of adverse events (AEs) associated with these procedures. OBJECTIVE: To determine the frequency of AEs after dermatologic surgery and to characterize the most commonly encountered AEs. METHODS: A web-based interface was designed to track AEs with the input of four dermatologic surgeons. Patient demographic and operative data were collected at the time of the dermatologic surgery procedure. AEs occurring at any time during the data collection period were logged according to an a priori categorization scheme. RESULTS: The AE rate was 2.0% in this series of 2,418 subjects undergoing dermatologic surgery from February 1 through December 14, 2010. The most commonly reported AEs were suspicion of infection (64%), postoperative hemorrhage (20%), and wound dehiscence (8%). Suspicion of infection was slightly less frequent in subjects who received prophylactic preoperative antibiotics (0.4%) than in those who did not (1.5%, p = .07). There were no serious AEs and no deaths. CONCLUSION: AEs are uncommon after office-based dermatologic surgery procedures. Preoperative antibiotics may further decrease the infection rate after dermatologic surgery, but the risks and benefits must be weighed given the already low AE rate.

Sleep disturbances in psoriasis.

BACKGROUND: Psoriasis negatively impacts sleep, but the factors that cause this sleep disturbance are not well characterized. PURPOSE: To assess sleep quality in subjects with psoriasis. METHODS: 35 outpatients diagnosed with chronic plaque psoriasis affecting at least 10 percent BSA and 44 controls completed the Pittsburgh Sleep Quality Index, Patient Health Questionnaire, Itch Severity Scale, Insomnia Severity Index, and Epworth Sleepiness Scale. For multiple testing, alpha was set at 0.008. RESULTS: Adjusting for age, BMI, and gender, patients with psoriasis had 4.3 times the odds to score in a higher insomnia category (OR 95% CI: 1.7, 11.2; p=0.01), a trend toward experiencing "poor sleep" (p=0.04), and no difference in odds to be "sleepy" (p=0.83). Patients with psoriasis had greater itch than those without psoriasis (mean ISS 8.5 vs. 2.0; p<0.0001). When adjusting for age, BMI, gender, and depression, those with psoriasis were not more likely to experience poor sleep quality (p=0.25), nor to score in a higher insomnia category (p=0.20) or be more "sleepy" (p=0.53). CONCLUSIONS: Patients with psoriasis suffer from sleep disturbances and pruritus more than those without psoriasis. Although sleep disturbances are more prevalent, this may be secondary to depression rather than related to a direct effect of psoriasis.

The safety of immunosuppressants in the treatment of psoriasis patients: is there concern regarding those with familial lymphoproliferative disease?

Immunosuppressant drugs may increase the risk of lymphoproliferative disease (LPD) states, and additionally, the diagnosis of psoriasis may predispose to lymphoma. It is important to educate patients regarding the side effects of any treatment regimen. A positive family history of LPD disease may increase the risk of personal acquisition of LPD disease in those patients with psoriasis additionally making use of immunosuppressant therapy, such as the biologics. It is currently recommended to employ caution in those being treated with biologics who carry a high risk of developing malignancy. Those with a positive family history may fit into this category.

Apremilast as a treatment for psoriasis.

INTRODUCTION: Psoriasis is a common skin disorder characterized by chronic inflammatory lesions that are frequently vexing for patients and difficult for physicians to treat. Although multiple therapeutic options are available, all have limitations. Topical preparations have issues with patient adherence, as compared to oral routes of administration. Currently available oral medications, such as methotrexate, possess unfavorable toxicity profiles that limit use. There is a large unmet need for an effective, safe oral treatment for psoriasis. Apremilast is an oral medication that inhibits the activity of multiple inflammatory markers involved in the pathogenesis of psoriasis. AREAS COVERED: The present review article presents the pharmacokinetic properties of apremilast, as well as available preliminary pre-clinical and clinical trial data, and gives an overview of its safety and efficacy. EXPERT OPINION: Apremilast has been well tolerated in phase I and II clinical trials. It has favorable safety and toxicity profiles at doses that are also effective for the treatment of plaque psoriasis. Phase III clinical trials are currently underway and will better elucidate appropriate dosing of apremilast and further illuminate its side effect profile. In future studies, a comparison of apremilast to other psoriasis medications administered through different routes would be beneficial, to document whether patient adherence is better with an oral medication. Depending on the price of the agent, efficacy and perhaps most importantly its safety profile, apremilast may fill a key need as a safe, first-line oral treatment for patients with psoriasis.

Development of low blood glucose readings in nine non-diabetic patients treated with tumor necrosis factor-alpha inhibitors: a case series.

INTRODUCTION: Treatment with various biological agents in disease states such as rheumatoid arthritis has been associated with multiple side effects. Whereas many of these are frequently reported in the literature, hypoglycemia, a possible side effect of tumor necrosis factor-alpha inhibitors, may be underpublicized. CASE PRESENTATION: We report nine cases of non-diabetic Caucasian women who were between 29 and 68 years of age and who developed low glucose readings after treatment with tumor necrosis factor-alpha inhibitors. We provide a more detailed discussion of existing evidence of the role of tumor necrosis factor-alpha in the pathogenesis of inflammation and its impact on glycemic equilibrium. CONCLUSIONS: Physicians using tumor necrosis factor-alpha inhibitors in the treatment of various rheumatic and other autoimmune diseases should be aware of the potential for the development of glycemic disturbance in these patients. A further role of tumor necrosis factor-alpha inhibitors in the glycemic equilibrium warrants larger controlled trials in patients with and those without a history of diabetes.