Guidelines of care for the management of acne vulgaris.

BACKGROUND: Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older. OBJECTIVE: The objective of this study was to provide evidence-based recommendations for the management of acne. METHODS: A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations. RESULTS: This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements. LIMITATIONS: Analysis is based on the best available evidence at the time of the systematic review. CONCLUSIONS: These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies.

BACKGROUND: For people with atopic dermatitis (AD) refractory to topical therapies, treatment with phototherapy and systemic therapies can be considered. Multiple biologic therapies and Janus kinase (JAK)inhibitors have been approved since 2014 to treat AD. These guidelines update the 2014 recommendations for management of AD with phototherapy and systemic therapies. OBJECTIVE: To provide evidence-based recommendations on the use of phototherapy and systemic therapies for AD in adults. METHODS: A multidisciplinary workgroup conducted a systematic review and applied the GRADE approach for assessing the certainty of evidence and formulating and grading recommendations. RESULTS: The workgroup developed 11 recommendations on the management of AD in adults with phototherapy and systemic agents, including biologics, oral JAK inhibitors, and other immunomodulatory medications. LIMITATIONS: Most randomized controlled trials of phototherapy and systemic therapies for AD are of short duration with subsequent extension studies, limiting comparative long-term efficacy and safety conclusions. CONCLUSIONS: We make strong recommendations for the use of dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib. We make conditional recommendations in favor of using phototherapy, azathioprine, cyclosporine, methotrexate, and mycophenolate, and against the use of systemic corticosteroids.

Executive summary: Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies.

BACKGROUND: The summarized guidelines update the 2014 recommendations for the management of AD with phototherapy and systemic therapies. METHODS: A multidisciplinary workgroup conducted a systematic review and applied the GRADE approach for assessing the certainty of the evidence and formulating and grading recommendations. RESULTS: The workgroup developed 11 recommendations on the management of AD in adults with phototherapy and systemic therapies, including biologics, oral Janus Kinase inhibitors, and other immunomodulatory medications. CONCLUSIONS: The evidence supported strong recommendations for the use of dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib and conditional recommendations in favor of using phototherapy, azathioprine, cyclosporine, methotrexate, and mycophenolate, and against the use of systemic corticosteroids.

Executive summary: American Academy of Dermatology guidelines of care for the management of atopic dermatitis in adults with topical therapies.

These guidelines update the 2014 recommendations for management of atopic dermatitis in adults with topical therapies. A multidisciplinary workgroup employed best practices for guideline development, including a systematic review of the evidence and application of the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading recommendations. The evidence on atopic dermatitis treatment supported strong recommendations for the use of nonprescription moisturizers, topical calcineurin inhibitors, topical corticosteroids, and topical PDE-4 and JAK inhibitors. Conditional recommendations are made for the use of bathing and wet wrap therapy and against the use of topical antimicrobials, antiseptics, and antihistamines.

Guidelines of care for the management of atopic dermatitis in adults with topical therapies.

BACKGROUND: New evidence has emerged since the 2014 guidelines that further informs the management of atopic dermatitis (AD) with topical therapies. These guidelines update the 2014 recommendations for management of AD with topical therapies. OBJECTIVE: To provide evidence-based recommendations related to management of AD in adults using topical treatments. METHODS: A multidisciplinary workgroup conducted a systematic review and applied the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach for assessing the certainty of evidence and formulating and grading recommendations. RESULTS: The workgroup developed 12 recommendations on the management of AD in adults with topical therapies, including nonprescription agents and prescription topical corticosteroids (TCS), calcineurin inhibitors (TCIs), Janus kinase (JAK) inhibitors, phosphodiesterase-4 inhibitors (PDE-4), antimicrobials, and antihistamines. LIMITATIONS: The pragmatic decision to limit the literature review to English-language randomized trials may have excluded data published in other languages and relevant long-term follow-up data. CONCLUSIONS: Strong recommendations are made for the use of moisturizers, TCIs, TCS, and topical PDE-4 and JAK inhibitors. Conditional recommendations are made for the use of bathing and wet wrap therapy and against the use of topical antimicrobials, antiseptics, and antihistamines.

Potential Allergens in Wound Care Products.

Background: Patients with chronic wounds have an increased risk of developing allergic contact dermatitis (ACD). Reports of ACD to wound care products are not uncommon. To minimize contact sensitization in patients with chronic wounds, allergenic ingredients should be avoided when possible. Objective: With more than 5000 wound care products available in the United States, it is essential to understand which products can be chosen to minimize allergen exposures. Methods: Ingredients in wound care products in 5 wound care clinics across 2 institutions were cross-referenced with the American Contact Dermatitis Society core allergen series 2020. Results: Of the 267 wound care products included, 97 (36.3%) contained at least one allergen, including 31 dressings/wraps (22.3%), 25 medications (69.4%), 12 cleaning supplies (36.3%), 16 tapes/glues (80%), 2 instruments (14.3%), 8 emollients and vehicles (61.5%), 1 ostomy product (11.1%), and 2 odor-eliminating products (66.7%). Thirty-four different allergens were identified across all products. The most common allergens present in the included items were acrylates and propylene glycol, followed by parabens, cetyl stearyl alcohol, tocopherol, fragrance, and phenoxyethanol. Conclusions: Many wound care products contain at least one contact allergen, highlighting the importance of clinician education on ACD in the context of wound care product selection.

Primary Sarcoidosis of the Temporal Bone a Clinical Pathologic Correlation.

Objective: This report describes a case of sarcoidosis that presented as a lytic bone lesion in the squamous part of the temporal bone. Patients: A 64-year-old woman presented with right-sided aural fullness, pulsatile tinnitus, and intermittent otalgia. Interventions: CT and MRI were performed without contrast and suggested an osseodestructive, lytic bone lesion. An excisional biopsy was performed, showing granulomatous infiltration suggestive of osseous sarcoidosis. Main Outcome Measures: Removal of mass and resolution of symptoms. Results: Initial findings from patient imaging suggested a lytic bone lesion. An excisional biopsy was required for diagnosis and was performed with little patient morbidity. Biopsy findings showed granulomatous infiltration suggestive of osseous sarcoidosis. Osseous involvement of sarcoidosis is a rare manifestation and typically occurs secondary to other disease manifestations. After the removal of the mass and a short unrelated course of steroids, the patient's symptoms resolved. Conclusions: Sarcoidosis should be added to the differential diagnosis of lytic bone lesions in the temporal bone.

Systematic Review of Systemic Corticosteroid Effects on Patch Testing.

ABSTRACT: Systemic corticosteroids are commonly used as a short-term management option for inflammatory skin conditions, such as contact dermatitis. The purpose of our systematic review was to compare presence and degree of patch test reactions with or without different doses of systemic corticosteroid therapy. The relationship between 20, 30, and 40 mg daily doses of prednisone and retained, diminished, and negated reactions was not linear, whereas the reaction ratings for all patches placed with or without corticosteroid therapy revealed trends toward lower intensity reactions while receiving prednisone ( P < 0.0001, χ 2 , for all doses of prednisone). Our review provides insight into directions for future studies that examine the effect of corticosteroids on patch testing.

Potential Allergens in Wound Care Products.

BACKGROUND: Patients with chronic wounds have an increased risk of developing allergic contact dermatitis (ACD). Reports of ACD to wound care products are not uncommon. To minimize contact sensitization in patients with chronic wounds, allergenic ingredients should be avoided when possible. OBJECTIVE: With more than 5000 wound care products available in the United States, it is essential to understand which products can be chosen to minimize allergen exposures. METHODS: Ingredients in wound care products in 5 wound care clinics across 2 institutions were cross-referenced with the American Contact Dermatitis Society core allergen series 2020. RESULTS: Of the 267 wound care products included, 97 (36.3%) contained at least one allergen, including 31 dressings/wraps (22.3%), 25 medications (69.4%), 12 cleaning supplies (36.3%), 16 tapes/glues (80%), 2 instruments (14.3%), 8 emollients and vehicles (61.5%), 1 ostomy product (11.1%), and 2 odor-eliminating products (66.7%). Thirty-four different allergens were identified across all products. The most common allergens present in the included items were acrylates and propylene glycol, followed by parabens, cetyl stearyl alcohol, tocopherol, fragrance, and phenoxyethanol. CONCLUSIONS: Many wound care products contain at least one contact allergen, highlighting the importance of clinician education on ACD in the context of wound care product selection.

Focused update: Guidelines of care for the management of actinic keratosis.

BACKGROUND: Actinic keratoses (AKs) are rough scaly patches that arise on chronically UV-exposed skin and can progress to keratinocyte carcinoma. OBJECTIVE: In 2021, the American Academy of Dermatology published guidelines to assist in clinical decision-making for the management of AK. The purpose of this focused guideline update is to incorporate recently available evidence on the use of topical tirbanibulin to treat AK. METHODS: A multidisciplinary work group conducted a systematic review to evaluate data on the use of tirbanibulin for AK and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading a clinical recommendation. The graded recommendation was voted on to achieve consensus. RESULTS: Two trials were identified, and analysis of the evidence resulted in 1 recommendation. LIMITATIONS: This analysis is based on the best available evidence at the time it was conducted. Long-term efficacy and safety data are not currently available. CONCLUSIONS: A strong recommendation for the use of topical tirbanibulin to join the currently recommended list of topical therapies for AK was made on the basis of the available evidence.

T-Cell Lymphomas, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology.

Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of lymphoproliferative disorders arising from mature T cells, accounting for about 10% of non-Hodgkin lymphomas. PTCL-not otherwise specified is the most common subtype, followed by angioimmunoblastic T-cell lymphoma, anaplastic large cell lymphoma, anaplastic lymphoma kinase-positive, anaplastic large cell lymphoma, anaplastic lymphoma kinase-negative, and enteropathy-associated T-cell lymphoma. This discussion section focuses on the diagnosis and treatment of PTCLs as outlined in the NCCN Guidelines for T-Cell Lymphomas.

Risk factors for changes in carotid intima media thickness and plaque over 5 years in women with systemic lupus erythematosus.

OBJECTIVE: To investigate the occurrence of and risk factors for progression of carotid intima media thickness (IMT) and plaque in women with and without SLE. METHODS: A cohort of 149 women with SLE and 126 controls participated in SOLVABLE (Study of Lupus Vascular and Bone Long-term Endpoints). Demographics, cardiovascular and SLE factors, and laboratory assessments were collected at baseline. Carotid IMT and plaque were measured using B-mode ultrasound at baseline and at 5-year follow-up. Regression models were used to identify predictors of progression in carotid IMT and plaque; multivariate models were adjusted for age, hypertension and total cholesterol to high-density lipoprotein ratio. RESULTS: The mean±SD follow-up time was 5.35±0.60 years in cases and 5.62±0.66 years in controls. The mean IMT change per year was 0.008±0.015 mm in cases and 0.005±0.019 mm in controls (p=0.24). At follow-up, 31.5% of cases and 15% of controls had plaque progression, with a relative risk for plaque progression of 2.09 (95% CI 1.30 to 3.37). In SLE cases, higher fasting glucose and lower fibrinogen were associated with IMT progression after adjustment. Larger waist circumference and non-use of hydroxychloroquine were associated with plaque progression after adjustment. CONCLUSION: Potential modifiable risk factors for carotid IMT and plaque progression in women with SLE were identified, suggesting that monitoring of glucose and waist circumference and use of hydroxychloroquine may be beneficial.

Topical treatments for early-stage mycosis fungoides using Grading Recommendations Assessment, Development and Evaluation (GRADE) criteria: A systematic review.

BACKGROUND: Mycosis fungoides (MF) is a cutaneous lymphoma; most patients present with early, skin-limited disease and are managed by dermatologists. OBJECTIVE: The purpose of this study was to systematically review and assess the evidence on topical treatments for early-stage (IA, IB, IIA) MF. METHODS: We performed a literature search via MEDLINE, Embase, Web of Science, and Cochrane databases. Grading Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to assess the certainty of the data. RESULTS: Two searches yielded 1252 references; 26 met the inclusion criteria and included literature on nitrogen mustard, retinoids, corticosteroids, carmustine, fluorouracil, methotrexate-laurocapram, hexadecylphosphocholine, peldesine, ingenol mebutate, topical methotrexate with oxygen flow-assisted LP3 carrier, and resiquimod. Most studies were single intervention, observational series. Nitrogen mustard, with the most published reports, was effective with 12%-82% early-stage MF patients (total n > 1000) achieving complete remission (CR) (low certainty evidence). Clinical CR was achieved among 10%-60% treated with topical retinoids (low certainty evidence). Two moderate-sized retrospective case series on topical steroids had 18%-63% CR (low certainty evidence). Only single studies were available for the other therapies. CONCLUSIONS: For most outcomes of interest, the GRADE certainty for topical therapies for early-stage MF was low. Further randomized controlled trials and inclusion of quality of life indicators are needed.

Guidelines of care for the management of actinic keratosis: Executive summary.

BACKGROUND: Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma. Treatment options for AK include topical medications, photodynamic therapy, cryosurgery, and laser ablation. OBJECTIVE: This executive summary provides a synopsis of the 18 evidence-based recommendations for the treatment of AK detailed in the Guidelines of Care for the Management of Actinic Keratosis. METHODS: A multidisciplinary workgroup conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations Assessment, Development and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus. RESULTS: Analysis of the evidence resulted in 18 recommendations, suggesting there are several effective treatments available for AK. LIMITATIONS: The analysis informing the recommendations was based on the best available evidence at the time it was conducted. The results of future studies may necessitate a revision of current recommendations. CONCLUSIONS: Strong recommendations are presented for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are presented for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Guidelines of care for the management of actinic keratosis.

BACKGROUND: Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma. OBJECTIVE: This analysis examined the literature related to the management of AK to provide evidence-based recommendations for treatment. Grading, histologic classification, natural history, risk of progression, and dermatologic surveillance of AKs are also discussed. METHODS: A multidisciplinary Work Group conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus. RESULTS: Analysis of the evidence resulted in 18 recommendations. LIMITATIONS: This analysis is based on the best available evidence at the time it was conducted. The pragmatic decision to limit the literature review to English language randomized trials may have excluded data published in other languages or limited identification of relevant long-term follow-up data. CONCLUSIONS: Strong recommendations are made for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are made for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Lower vitamin D is associated with metabolic syndrome and insulin resistance in systemic lupus: data from an international inception cohort.

OBJECTIVES: Vitamin D (25(OH)D) deficiency and metabolic syndrome (MetS) may both contribute to increased cardiovascular risk in SLE. We aimed to examine the association of demographic factors, SLE phenotype, therapy and vitamin D levels with MetS and insulin resistance. METHODS: The Systemic Lupus International Collaborating Clinics (SLICC) enrolled patients recently diagnosed with SLE (<15 months) from 33 centres across 11 countries from 2000. Clinical, laboratory and therapeutic data were collected. Vitamin D level was defined according to tertiles based on distribution across this cohort, which were set at T1 (10-36 nmol/l), T2 (37-60 nmol/l) and T3 (61-174 nmol/l). MetS was defined according to the 2009 consensus statement from the International Diabetes Federation. Insulin resistance was determined using the HOMA-IR model. Linear and logistic regressions were used to assess the association of variables with vitamin D levels. RESULTS: Of the 1847 patients, 1163 (63%) had vitamin D measured and 398 (34.2%) subjects were in the lowest 25(OH)D tertile. MetS was present in 286 of 860 (33%) patients whose status could be determined. Patients with lower 25(OH)D were more likely to have MetS and higher HOMA-IR. The MetS components, hypertension, hypertriglyceridemia and decreased high-density lipoprotein (HDL) were all significantly associated with lower 25(OH)D. Increased average glucocorticoid exposure was associated with higher insulin resistance. CONCLUSIONS: MetS and insulin resistance are associated with lower vitamin D in patients with SLE. Further studies could determine whether vitamin D repletion confers better control of these cardiovascular risk factors and improve long-term outcomes in SLE.