Postoperative Infections in Dermatologic Surgery: The Role of Wound Cultures.

BACKGROUND: Dermatologic surgery is associated with low postoperative infection rates, averaging from approximately 1% to 4.25%. Often, postoperative infections are treated empirically based on clinical diagnosis of infection, given it can take 48 to 72 hours for a wound culture to identify a pathogen. OBJECTIVE: We aimed to evaluate the efficacy of empiric antibiotics in dermatologic surgery postoperative infections and if wound cultures change postoperative antibiotic therapy. METHODS: A 7-center, retrospective analysis of postoperative infections, with culture data, in dermatologic surgery patients was performed. RESULTS: Of 91 cases of clinically diagnosed postoperative infection, 82.4% (n = 75) were successfully treated with empiric oral antibiotics (95% confidence interval [0.73-0.89], p < .0001). In 16 (17.6%) cases, initial empiric antibiotics were unsuccessful, and wound culture results altered antibiotic therapy in 9 cases (9.9%) with 6 (6.6%) of these cases requiring additional coverage for methicillin-resistant Staphylococcus aureus (MRSA). CONCLUSION: Empiric antibiotic treatment is usually appropriate for patients with postoperative surgical-site infections with wound cultures altering antibiotic management in a minority of cases. When empiric antibiotics fail, lack of MRSA coverage is usually the cause; therefore, providers should be aware of local MRSA prevalence and susceptibilities.

Horrendous, Treatment-resistant Pediatric Atopic Dermatitis Solved With a Change in Vehicle.

Severe atopic dermatitis can have an enormous impact on a child and the child's caregivers. Topical corticosteroids can be highly effective, but not all patients respond. If atopic dermatitis does not improve with a topical corticosteroid, poor adherence should be strongly considered as the cause of treatment failure. We report a child with horrendous atopic dermatitis whose disease resolved rapidly in the hospital when therapy was changed to a product that was easier to apply.

Ipilimumab Therapy in Patients With Advanced Melanoma and Preexisting Autoimmune Disorders.

IMPORTANCE: Ipilimumab and other immune therapies are effective treatment options for patients with advanced melanoma but cause frequent immune-related toxic effects. Autoimmune diseases are common, and the safety and efficacy of ipilimumab therapy in patients with preexisting autoimmune disorders is not known. OBJECTIVE: To determine the safety and efficacy of ipilimumab therapy in patients with advanced melanoma with preexisting autoimmune disorders. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of patients with advanced melanoma and preexisting autoimmune disorders who received ipilimumab at 9 academic tertiary referral centers from January 1, 2012, through August 1, 2015. The data analysis was performed on August 24, 2015. EXPOSURE: Ipilimumab therapy. MAIN OUTCOMES AND MEASURES: Safety, in terms of frequency of autoimmune flares and conventional immune-related adverse events (irAEs), and efficacy, in terms of response rates and overall survival, were evaluated descriptively. RESULTS: Of the 30 patients who received ipilimumab (17 [57%] male; median [range] age, 59.5 [30-80] y), 6 had rheumatoid arthritis, 5 had psoriasis, 6 had inflammatory bowel disease, 2 had systemic lupus erythematosus, 2 had multiple sclerosis, 2 had autoimmune thyroiditis, and 7 had other conditions. Thirteen patients (43%) were receiving immunosuppressive therapy at the time of initiation of ipilimumab therapy, most commonly low-dose prednisone or hydroxychloroquine. With ipilimumab treatment, 8 patients (27%) experienced exacerbations of their autoimmune condition necessitating systemic treatment; all were managed with corticosteroids. Conventional grade 3 to 5 irAEs occurred in 10 patients (33%) and were reversible with corticosteroids or with infliximab therapy in 2 cases. One patient with baseline psoriasis died of presumed immune-related colitis after a 1-week delay prior to reporting symptoms. Fifteen patients (50%) had neither autoimmune disease flares nor irAEs. Six patients experienced an objective response (20%), including 1 with a durable complete response. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the largest series of patients with preexisting autoimmune disease treated with immune checkpoint inhibitors. Ipilimumab was clinically active and was associated with exacerbations of autoimmune disease and conventional ipilimumab-induced irAEs that were readily manageable with standard therapies when started in a timely fashion. Ipilimumab therapy may be considered in this setting with vigilant clinical monitoring.

Incidence, risk factors, and preventative management of skin cancers in organ transplant recipients: a review of single- and multicenter retrospective studies from 2006 to 2010.

BACKGROUND: Organ transplant recipients (OTRs) taking immunosuppressants are at high risk of skin cancer, which is the most common malignant condition in OTRs, so dermatologic surveillance is important for OTRs. OBJECTIVES: To characterize the most common skin cancers arising from chronic immunosuppression in OTRs. METHODS: A PubMed search for retrospective single- and multicenter studies reporting skin cancer incidence from 2006 to 2010 was undertaken. Data regarding each study's immunosuppressive regimen, affected skin cancer cohort, and associated risk factors were extracted. RESULTS: Thirty-six articles that met our inclusion criteria reported incidences of nonmelanoma skin cancer (NMSC), Kaposi's sarcoma, melanoma, and Merkel cell carcinoma. NMSC was the most commonly reported cancer of all skin cancers after transplantation. Common risk factors were sex, age, sunlight exposure, and immunosuppressive agent-related (duration, type). CONCLUSION: Sun education programs and frequent screenings in organ transplant clinics have provided the best preventative strategies after transplantation, although the characteristics of the immunosuppressive regimen also play an important role. Thus, the adjuvant strategy of modifying immunosuppression may be effective when confronting severe transplant-associated skin cancer. Although the decision-making process for curbing levels of immunosuppression is difficult, further long-term, randomized controlled studies should assess the effect of using less immunosuppressant medication while preserving graft function.

Interleukin-23 and interleukin-17: importance in pathogenesis and therapy of psoriasis.

Emerging data in mice and humans reveals a critical contribution of Th17-associated cytokines, particularly interleukin-(IL)-23 and IL-17, in the pathogenesis of psoriasis. The IL-23/Th17 pathway is a therapeutic target for biologic agents and systemic therapies in psoriasis treatment. A literature search was performed to review and summarize the current evidence on IL-17 and IL-23 as a basis for understanding the use of anti-IL-17 and anti-IL-23 agents for psoriasis therapy. Using PubMed, recent articles were identified pertaining to IL-17, IL-23, and psoriasis. Signaling via the heterodimeric IL-23 receptor induces production of IL-17, which stimulates production of proinflammatory keratinocyte cytokines that mediate the psoriatic response. An overexpression of IL-23, IL-17, or Th17 cells in transgenic mice is associated with the development of inflammatory disease. Both IL-17 knockout mice and humans with a genetic IL-17 deficiency are susceptible to extracellular and intracellular pathogens. This suggests a potential for adverse effects from clinical administration of anti IL-23-p40/IL-17 therapies. Anti-p40 antibodies, briakinumab and ustekinumab, were tolerated in clinical trials and substantially improved psoriasis. Further trials of anti IL-17 therapies are needed to assess their clinical use and potential for infection and other adverse events.

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.

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.

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.

The economic impact of non-melanoma skin cancer: a review.

Non-melanoma skin cancer (NMSC) is the most common cancer in the United States. Cost of NMSC care primarily depends on 2 factors: care settings and treatment modalities. However, the cost efficacy of NMSC care has been insufficiently addressed in previous literature. Therefore, this article evaluates available research on the cost implications to compare the costs associated with treatment within different care settings and specialties involved, and to assess the costs of different treatment modalities with respect to procedure type, tumor size, and tumor location. This evaluation showed that physician-office settings provided the lowest cost per episode of care ($492) and were the dominant setting for NMSC care; dermatologists managed most NMSC episodes and used a wider range of treatment options than other specialists. Regarding treatment modalities, Mohs micrographic surgery was shown to be similar in cost to traditional surgical excision with permanent sections and was less costly than excision with frozen sections. Electrodessication and curettage and imiquimod were also reported to be inexpensive treatments. Furthermore, a positive correlation was seen between cost and tumor size for any particular treatment modality. Given these comparisons, and the rising incidence of NMSC and potential legislative measures to regulate office-based procedures, it is important to preserve the low-cost management of this disease.

Palliative cancer care ethics: principles and challenges in the Indian setting.

Palliative cancer treatment is a system of care that seeks to relieve suffering in patients with progressive cancer. Given the intractable symptoms with which certain malignancies manifest, palliative care offers a practical approach towards improving the patient's quality of life. However, there are an array of ethical issues associated with this treatment strategy such as particular methods of pain relief, a reliable assessment of suffering, autonomy, and multi-specialist care. While these principles are important to increase and improve the network of palliative care, the resource-poor Indian environments present numerous barriers for these principles to be practically applied. As the infrastructure of comprehensive cancer centers develop, paralleled with an increase in training of palliative care professionals, significant improvements need to be made in order to elevate the status of palliative cancer care in India.