Efficacy and Durability of Intravenous Ertapenem Therapy for Recalcitrant Hidradenitis Suppurativa.

Importance: Hidradenitis suppurativa (HS) is a debilitating follicular skin disorder in which bacterial colonization is typical. Oral antibiotic efficacy can be unreliable; however, selective intravenous antibiotics, specifically ertapenem, may provide favorable clinical outcomes. Objective: To explore optimal course duration, efficacy, and patient satisfaction associated with intravenous ertapenem for HS. Design, Setting, and Participants: This retrospective review of the medical records of 98 patients with HS between 2018 and 2022 measured and evaluated patient outcomes before and after treatment with intravenous ertapenem. Participants were followed up in a telephone survey assessing patient perspectives and satisfaction. All of those included in this study received medical care from the Albert Einstein College of Medicine's Montefiore HS Center. Exposures: Patients were treated with 1 g of ertapenem that was self-administered at home through a peripheral intravenous central catheter using an elastomeric pump for 12 to 16 weeks. Antiandrogens and immunomodulatory biologic therapies initiated prior to ertapenem were maintained throughout the treatment course. Main Outcomes and Measures: The primary outcomes, encompassing clinical severity (evaluated through the HS Physician Global Assessment score [a 6-point scale ranging from clear to very severe] and a numerical rating scale for pain [an 11-point scale in which a score of 0 indicates no pain and a score of 10 indicates the worst possible pain]) and markers of inflammation (such as leukocytes, erythrocyte sedimentation rate, C-reactive protein, and interleukin-6), were measured at baseline, the midcourse of intravenous ertapenem treatment, at the end of the course, and posttherapy. Bacterial abundance was also examined at these 4 points, and patient satisfaction was assessed during follow-up. Results: A total of 98 patients (mean [SD] age, 35.8 [13.0] years; 61 [62.2%] female) with HS were treated with intravenous ertapenem. The self-reported racial distribution included 3 individuals identifying as Asian (3.1%), 59 as Black/African American (60.2%), 13 as White (13.3%), and 23 as either other or unknown (23.5%). Additionally, 24 participants (24.5%) reported Spanish/Hispanic/Latino ethnicity. The mean (SD) treatment duration spanned 13.1 (4.0) weeks, with posttherapy follow-up occurring after 7.8 (3.6) weeks. From baseline to posttherapy follow-up, significant reductions were found in the mean (SD) HS Physician Global Assessment scores (3.9 [1.0] vs 2.7 [1.2]; P < .001) and the numerical rating scale for pain (4.2 [3.3] vs 1.8 [2.7]; P < .001), C-reactive protein (5.4 [11.4] vs 2.4 [2.0] mg/dL; P < .001), interleukin-6 (25.2 [21.1] vs 13.7 [13.9]; P < .001), and leukocytes (11.34 [3.9] vs 10.0 [3.4]; P < .001). At follow-up, 76 patients (78.0%) participated in the telephone survey, where 63 (80.3%) reported medium to high satisfaction; further, 69 (90.8%) would recommend ertapenem to other patients. Conclusions and Relevance: In this retrospective review of medical records and telephone survey, treating HS with intravenous ertapenem, administered for a mean of 13 weeks, was associated with improvement in clinical and inflammatory markers, as well as heightened patient satisfaction. Nonetheless, this approach should be monitored for the emergence of antimicrobial resistance given a longer than standard treatment course.

Efficacy and Patient Satisfaction Associated With Intramuscular Triamcinolone Therapy for Acute Flares of Hidradenitis Suppurativa.

BACKGROUND: A lack of consensus exists regarding acute flare management in hidradenitis suppurativa (HS). Intramuscular triamcinolone (IMTAC) therapy is useful in numerous inflammatory conditions; however, it has not been investigated for acute HS flares. OBJECTIVE: To evaluate the efficacy and patient experience associated with IMTAC therapy for acute, severe HS flares. METHODS: Retrospective analysis and surveys of 45 HS patients were conducted at Albert Einstein College of Medicine/ Montefiore HS Center, Bronx, NY, USA. RESULTS: Follow-up visits 6.77 (4.45) weeks after IMTAC therapy revealed significant reductions in mean HS-Physician Global Assessment (PGA) (P < .001), C-Reactive Protein (CRP) (P = .03), increased hemoglobin (P = .004), and improved pain scores (P < .001). Adjusting for age, sex and concomitant medications, multivariate analysis yielded significantly reduced pain (P = .02) and increased hemoglobin (P = .03). Patient surveys indicate that IMTAC was well-tolerated, as reflected in positive mean responses for satisfaction (29 [64%]) and willingness to receive IMTAC injections again (42 [93%]). CONCLUSIONS: These novel findings demonstrate that IMTAC is a safe, effective, and well accepted adjunct for acute HS management.

Diversifying the Mohs Workforce: Understanding Barriers of Applicants to Mohs Micrographic Surgery Fellowship.

BACKGROUND: The population of the United States is becoming increasingly diverse, yet dermatology, especially Mohs micrographic surgery (MMS), lags behind. OBJECTIVE: This survey study investigates perceived barriers of underrepresented groups in medicine (URM) who are pursuing fellowship in Mohs micrographic surgery and dermatologic oncology (MSDO). METHODS AND MATERIALS: An IRB-approved survey was distributed electronically to accredited dermatology residencies between December 2020 and April 2021. RESULTS: One hundred and thirty-three dermatology residents responded to the survey and of the participants, 21% identified as a URM. There was no significant difference in those interested in applying for MSDO fellowship between URMs and non-URMs. URMs rated the following factors significantly higher when deciding to pursue MSDO fellowship: lack of perceived diversity in target patient population (mean 3.61, SD 1.66), race/ethnicity/gender of past MSDO fellows (mean 3.25, SD 1.71), perceived attitudes of MSDO fellowships towards an applicant’s race or ethnicity (mean 3.25, 1.65 SD), and lack of diversity of trainees and faculty in MMS (mean 3.61, SD 1.47). CONCLUSION: This study is one of the first to evaluate perceived barriers to diversifying the MMS workforce. The perceived barriers we have identified are complex and require concerted efforts for improvement. J Drugs Dermatol. 2023;22(5): doi:10.36849/JDD.7083.

Importance of a multi-tiered treatment approach for intellectually and developmentally disabled patients with hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic, debilitating skin condition that is characterized by painful pustules, nodules, abscesses, and sinus tracts. The complicated and fast-evolving treatment of HS consists of a multi-tiered approach that includes, antibacterial, antihormonal, anti-inflammatory, and surgical options. Studies have demonstrated an earlier age of onset and increased prevalence of HS in patients with intellectual and developmental disability (IDD) compared to patients without IDD. To explore the use of an intensive multi-tiered HS management algorithm that requires monthly office visits, monthly intravenous therapy, and several daily treatment modalities in an HS population with IDD, we conducted an IRB-approved retrospective chart review of HS patients treated at the Albert Einstein College of Medicine-Montefiore HS Center (HSC) with diagnoses of concurrent IDD to investigate their demographic and diagnostic characteristics, as well as the spectrum of therapies employed in this cohort. A total of 22 HS patients with concomitant IDD, including trisomy 21, unspecified intellectual disability, autism spectrum disorder, and trisomy 13 were identified. Therapies utilized in this cohort for HS included topical and oral antibiotics, spironolactone, finasteride, oral contraceptive pills, infliximab, adalimumab, isotretinoin, intralesional and intramuscular triamcinolone injections, and excisional surgery. In conclusion, our findings indicate that despite the practical challenges, daily oral antibiotic regimens, anti-androgen combinations, oral retinoids, infliximab, adalimumab, and surgery collectively play important roles in treating HS patients with IDD. Our cases underscore the importance of utilizing the full range of modalities as the HS treatment algorithm continues to evolve.

Adalimumab efficacy is inversely correlated with body mass index (BMI) in hidradenitis suppurativa.

BACKGROUND: Adalimumab is the only FDA-approved biologic for hidradenitis suppurativa (HS). In the setting of increasing obesity rates worldwide, the relationship between adalimumab efficacy for HS and BMI is essential to understand. We assessed this relationship through markers of disease severity and inflammation. METHODS: Institutional review board-approved retrospective chart review of Montefiore/Einstein HS Center (HSC) patients (n = 57) treated with adalimumab. The relationship between BMI and adalimumab efficacy was assessed through disease severity (HS-Physician Global Assessment [HS-PGA] 0 and Numerical Rating Scale Pain [NRS-Pain]) and inflammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and interleukin-6 [IL-6]). A BMI ≥ 30 is defined as obese; BMI < 30 is defined as non-obese. RESULTS: The mean age was 35.8 ± 13.0 years. After adalimumab therapy, those with BMI < 30 experienced significant reductions in HS-PGA (-1.5 ± 0.9; P < 0.0001) and NRS-Pain (-1.6 ± 2.1; P < 0.0001), as well as mean decreases in inflammatory markers ESR, CRP, and IL-6 (-17.90 ± 23.6, -0.71 ± 1.4, -5.88 ± 7.9, respectively; P > 0.05). Obese patients (BMI ≥ 30) experienced mean increases in HS-PGA (+0.22 ± 0.8; P > 0.05) and NRS-Pain scores (+1.41 ± 3.5; P > 0.05) as well as mean increases in ESR, CRP, and IL-6 (+2.62 ± 28.3, +0.44 ± 3.0, +2.35 ± 6.9, respectively; P > 0.05). Comparing the cohorts, differences in changes in HS-PGA, NRS-Pain, ESR, and IL-6 after therapy are significantly different (P < 0.05). CONCLUSIONS: We identified significantly lower efficacy of adalimumab in HS patients with BMI ≥ 30 compared to those with BMI < 30. Those with BMI ≥ 30 demonstrated signs of both clinical and physiological deterioration while on adalimumab. Future studies are needed to examine adalimumab dosing for HS patients with high BMI, as well as a critical reconsideration of weight-based therapies.

Serum inflammatory markers and leukocyte profiles accurately describe hidradenitis suppurativa disease severity.

BACKGROUND: Inflammatory markers and leukocyte profiles have not been longitudinally evaluated as objective signs of hidradenitis suppurativa (HS) severity. We sought to assess C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), and leukocyte profiles as reliable indicators of HS severity. METHODS: Retrospective cohort study of 404 patients seen at the Einstein/Montefiore HS Center, Bronx, New York, between March 2019 and November 2020. Associations of disease severity (HS-Physician Global Assessment) with inflammatory markers and leukocyte profiles were assessed by odds ratios (OR) and 95% confidence intervals (95% CI) incorporating up to four visits per patient, adjusting for baseline gender, age, BMI, and smoking status. RESULTS: Patients with severe disease had elevated CRP (OR 1.87; 95% CI 1.49, 2.34), ESR (OR 1.04; 95% CI 1.03, 1.04), IL-6 (OR 1.08; 95% CI 1.00, 1.16), leukocytes (OR 1.22; 95% CI 1.14, 1.31), neutrophils (OR 1.31; 95% CI 1.20, 1.42), eosinophils (OR 14.40; 95% CI 2.97, 69.74), basophils (OR 2.53; 95% CI 1.09, 5.85), monocytes (OR 5.36; 95% CI 2.49, 11.53), and neutrophil-lymphocyte ratios (OR 1.63; 95% CI 1.35, 1.96) but decreased lymphocytes (OR 0.86; 95% CI 0.68, 1.10). CONCLUSIONS: This novel longitudinal study of inflammatory markers and leukocyte profiles offers critical laboratory measures to confirm clinically determined disease severity over time.

Epicardial Fat: A New Therapeutic Target in Psoriasis.

Psoriasis is a chronic inflammatory disease affecting over 8 million Americans. Importantly, patients with psoriasis are at an increased risk of developing atherosclerosis, coronary artery disease, and myocardial infarctions. Several studies have suggested that psoriasis may be an independent risk factor for cardiovascular disease given their shared inflammatory properties and pathogenic similarities. Epicardial fat is also linked to cardiovascular disease and may be an independent risk factor for atherosclerosis. It has been proposed that measuring epicardial fat tissue may serve as a useful subclinical measure of cardiovascular disease in psoriasis patients. Echocardiography has been increasingly adopted as an accurate, minimally invasive, and cost-effective measure of determining the volume and thickness of epicardial fat. Using echocardiographic measures of epicardial fat thickness as a marker of cardiovascular disease and therapeutic target in psoriasis patients may provide clinicians with a means to better manage and hopefully prevent deleterious downstream effects.