Treatment of severe psoriasis and psoriatic arthritis with adalimumab in an HIV-positive patient.

Psoriasis in HIV-infected patients poses a distinct challenge to the dermatologist due to its increased severity, tendency to be refractory to common treatment modalities, and necessity for cautious use of immunosuppressive agents. Tumor necrosis factor-α inhibitors have been shown to be safe and effective for the treatment of psoriasis in the general population, but their role in the treatment of HIV-positive patients is still unclear. The use of the tumor necrosis factor-α inhibitor adalimumab for the treatment of psoriasis in HIV-positive patients has yet to be reported. We present the case of a 49-year-old HIV-positive man with severe plaque psoriasis who has been successfully treated with adalimumab for the past 30 months with no adverse events related to treatment.

Delusional infestations: clinical presentation, diagnosis and treatment.

Patients with delusional infestations (DI), previously named delusions of parasitosis, have a fixed, false belief that they are infested with living or non-living pathogens. Patients have abnormal cutaneous symptoms such as itching, biting, or crawling sensations. They often demonstrate self-destructive behavior in an effort to rid the pathogens from under their skin, leading to excoriations, ulcerations, and serious secondary infections. This review article aims to provide an overview of DI including its clinical presentation, diagnosis, and treatment. Strategies on how to establish a strong therapeutic alliance with DI patients are discussed. In addition, antipsychotic medications used in the treatment of DI are described.

The impact of emollients on phototherapy: a review.

When treating psoriasis, various topical emollients exist that can affect the penetration of ultraviolet radiation in phototherapy. Compared with normal-appearing skin with a reflectance of 4% to 5%, psoriatic skin has higher reflectance as a result of its increased air-to-corneocyte interfaces. Studies have tested the effect of emollients on light penetration by assessing psoriatic plaque clearance, differences in minimal erythema dose, and physical properties of the emollient (eg, monochromatic protection factor and absorbance). Psoriatic plaque clearance was found to improve with serous (thin liquid)-based emollients (eg, Vaseline oil [Unilever, Blackfriars, London, UK], mineral oil, and glycerol), whereas clearance decreased with salicylic acid and viscous-based emollients (eg, petrolatum). Emollients with high ultraviolet absorbance properties increased minimal erythema dose, and those with low absorbance properties decreased minimal erythema dose. Interestingly, when a liquid emollient with a refractive index close to that of normal-appearing skin was applied, there was a net increase in light absorption, or a reduction in reflection that exceeded the emollient's innate ability to absorb light.

The role of tumor necrosis factor-alpha and other cytokines in depression: what dermatologists should know.

Recent studies have suggested that inflammatory responses may play an important role in the pathophysiology of depression. In fact, depressed individuals have been found to have higher levels of pro-inflammatory cytokines, especially tumor necrosis factor-alpha (TNF-α) and interleukin-6. This appears to be independent of any pre-existing chronic inflammatory disorders. In this article, various studies correlating increased levels of cytokines to depression are reviewed. As much as 60% of individuals with psoriasis also suffer from clinical depression. TNF-α antagonists, frequently used in the treatment of psoriasis, may be helpful in directly reducing depressive symptoms for patients with psoriasis and other chronic inflammatory conditions.

Goeckerman therapy: a very effective, yet often forgotten treatment for severe generalized psoriasis.

As early as 1925, patients suffering from psoriasis have been effectively treated with combination crude coal tar and ultraviolet B radiation, commonly known as Goeckerman therapy. Even though the efficacy of Goeckerman therapy is as good as, if not better than, other more recently available treatment options, its use virtually disappeared after extended inpatient therapies became no longer feasible in the USA. Our clinic at the University of California San Francisco is one of the few outpatient dermatologic clinics that still offer Goeckerman therapy. We present a case report of a patient with severe generalized plaque-type psoriasis, who demonstrated dramatic improvement within 28 days of Goeckerman therapy. It is our hope that this case report serves to remind physicians that Goeckerman therapy is viable treatment option for patients with severe psoriasis, especially those with treatment-resistant psoriasis.

How psoriasis patients perceive, obtain, and use biologic agents: Survey from an academic medical center.

The availability of new biologic agents for the treatment of psoriasis provides hope for improved quality of life outcomes. However, the way patients come to use biologics, the potential barriers they encounter, and their attitudes towards using these medications are still not well studied. Here, we conducted a survey of 106 psoriasis patients at an academic medical center to discern patient attitudes towards biologics. We found that most patients learn of biologics through their physician and perform follow-up research using the Internet. Most patients did not find it difficult to make the decision to start a biologic. Difficulty in obtaining biologics was associated with age less than 55 (p = 0.01), lower income level (p = 0.007), and lack of insurance (p = 0.04). Patients were found to have high satisfaction and compliance rates on biologics. Of patients who missed a dose of their biologic, this was mainly due to logistical reasons such as not having the medication or forgetting to take it, rather than being depressed or overwhelmed. Patients with lower income levels had increased cut backs in personal expenses due to co-payments (p = 0.001). Among respondents, the mean annual out-of-pocket expense for a biologic was $557.12 per year, with a range of $0-7000.

Long-term etanercept use for severe generalized psoriasis in an HIV-infected individual: a case study.

The treatment options for psoriasis in HIV-infected individuals are limited due to the immunosuppressive nature of the therapeutic modalities and the patient's immunocompromised state. Etanercept has been shown to be safe and effective in the non-HIV psoriasis population with nearly 20 years of experience. However, there is limited data on the safety of etanercept use in the HIV patient population. The authors report a case of an HIV-infected patient with psoriasis who has remained mostly clear on continuous, uninterrupted etanercept use for over six years.

Quality-of-life instruments: evaluation of the impact of psoriasis on patients.

The negative impact of psoriasis on a patient's quality of life (QoL) is well documented in the literature. Patients often suffer poor self-esteem, difficulties in social interactions, and significant psychological distress. It is, therefore, critically important that a clinician evaluate the extent to which the disease impacts a patient's QoL. This chapter reviews several validated and reliable generic, dermatology-specific, and disease-specific QoL instruments useful in measuring the impact of psoriasis on patient's QoL. These QoL instruments can be especially helpful in identifying those patients who would most benefit from systemic or biologic therapy.

Hydroxyurea for the Treatment of Psoriasis including in HIV-infected Individuals: A Review.

Hydroxyurea is a drug that has been long forgotten for the treatment of psoriasis. In addition to its anti-psoriatic effects, it has also been shown to have antiviral effects. This dual effect makes it a drug that dermatologists may want to consider when treating psoriasis in HIV-infected individuals. There are currently no studies that discuss the safety and efficacy of hydroxyurea in the treatment of psoriasis in this immunocompromised group; however, there are multiple reports that discuss the safety and efficacy of hydroxyurea in psoriasis and HIV separately. This review suggests that hydroxyurea is generally safe and effective. The main risk involves the hematologic adverse events (anemia, leukopenia, thrombocytopenia, and macrocytosis) which appear to be dose-dependent. Because of the common hematologic adverse events, hydroxyurea may be considered as a viable therapeutic option for patients with generalized psoriasis inadequately responsive to other safer options, whether the patient is HIV-positive or not.

Thermophilic anaerobic digestion to increase the net energy balance of corn grain ethanol.

U.S. production of fuel ethanol from corn grain has increased considerably over the last 10 years. Intense debate regarding the true environmental impact of the overall production process has been ongoing. The present study evaluated the utilization of thin stillage (a major byproduct of the dry-mill corn grain-to-ethanol process) in laboratory-scale thermophilic anaerobic sequencing batch reactors for conversion to methane. We found that augmentation of cobalt as a growth factor to the thermophilic anaerobic digestion process is required. After reaching sustainable operating performances, the methane potential in the reactors was 0.254 L CH4/g total chemical oxygen demand (TCOD) fed. Together with a reduction in the mass of solids that needs drying, methane generation translates to a 51% reduction of natural gas consumption at a conventional dry mill, which improves the net energy balance ratio from 1.26 to 1.70. At the design hydraulic retention time of 10 days, the digesters achieved TCOD, biodegradable COD, volatile solids, and total solids removal efficiencies of 90%, 75%, 89%, and 81%, respectively. We also found that struvite precipitation occurred in the thermophilic digesters during the course of the study, resulting in possibilities for nutrient recovery.