Inpatient Management of Hidradenitis Suppurativa: A Delphi Consensus Study

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Inpatient Management of Hidradenitis Suppurativa: A Delphi Consensus Study

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that affects approximately 0.1% of the US population.1,2 Severe disease or HS flares can lead patients to seek care through the emergency department (ED), with some requiring inpatient admission. 3 Inpatient hospitalization of patients with HS has increased over the last 2 decades, and patients with HS utilize emergency and inpatient care more frequently than those with other dermatologic conditions.4,5 Minority patients and those of lower socioeconomic status are more likely to present to the ED for HS management due to limited access to care and other existing comorbid conditions. 4 In a 2022 study of the Nationwide Readmissions Database, the authors looked at hospital readmission rates of patients with HS compared with those with heart failure—both patient populations with chronic debilitating conditions. Results indicated that the hospital readmission rates for patients with HS surpassed those of patients with heart failure for that year, highlighting the need for improved inpatient management of HS.6

Patients with HS present to the ED with severe pain, fever, wound care, or the need for surgical intervention. The ED and inpatient hospital setting are locations in which physicians may not be as familiar with the diagnosis or treatment of HS, specifically flares or severe disease. 7 The inpatient care setting provides access to certain resources that can be challenging to obtain in the outpatient clinical setting, such as social workers and pain specialists, but also can prove challenging in obtaining other resources for HS management, such as advanced medical therapies. Given the increase in hospital- based care for HS and lack of widespread inpatient access to dermatology and HS experts, consensus recommendations for management of HS in the acute hospital setting would be beneficial. In our study, we sought to generate a collection of expert consensus statements providers can refer to when managing patients with HS in the inpatient setting.

Methods

The study team at the Wake Forest University School of Medicine (Winston-Salem, North Carolina)(M.N., R.P., L.C.S.) developed an initial set of consensus statements based on current published HS treatment guidelines,8,9 publications on management of inpatient HS,3 published supportive care guidelines for Stevens-Johnson syndrome, 10 and personal clinical experience in managing inpatient HS, which resulted in 50 statements organized into the following categories: overall care, wound care, genital care, pain management, infection control, medical management, surgical management, nutrition, and transitional care guidelines. This study was approved by the Wake Forest University institutional review board (IRB00084257).

Participant Recruitment—Dermatologists were identified for participation in the study based on membership in the Society of Dermatology Hospitalists and the Hidradenitis Suppurativa Foundation or authorship of publications relevant to HS or inpatient dermatology. Dermatologists from larger academic institutions with HS specialty clinics and inpatient dermatology services also were identified. Participants were invited via email and could suggest other experts for inclusion. A total of 31 dermatologists were invited to participate in the study, with 26 agreeing to participate. All participating dermatologists were practicing in the United States.

Delphi Study—In the first round of the Delphi study, the participants were sent an online survey via REDCap in which they were asked to rank the appropriateness of each of the proposed 50 guideline statements on a scale of 1 (very inappropriate) to 9 (very appropriate). Participants also were able to provide commentary and feedback on each of the statements. Survey results were analyzed using the RAND/ UCLA Appropriateness Method.11 For each statement, the median rating for appropriateness, interpercentile range (IPR), IPR adjusted for symmetry, and disagreement index (DI) were calculated (DI=IPR/IPR adjusted for symmetry). The 30th and 70th percentiles were used in the DI calculation as the upper and lower limits, respectively. A median rating for appropriateness of 1.0 to 3.9 was considered “inappropriate,” 4.0 to 6.9 was considered “uncertain appropriateness,” and 7.0 to 9.0 was “appropriate.” A DI value greater than or equal to 1 indicated a lack of consensus regarding the appropriateness of the statement. Following each round, participants received a copy of their responses along with the group median rank of each statement. Statements that did not reach consensus in the first Delphi round were revised based on feedback received by the participants, and a second survey with 14 statements was sent via REDCap 2 weeks later. The RAND/UCLA Appropriateness Method also was applied to this second Delphi round. After the second survey, participants received a copy of anonymized comments regarding the consensus statements and were allowed to provide additional final commentary to be included in the discussion of these recommendations.

Results

Twenty-six dermatologists completed the first-round survey, and 24 participants completed the second-round survey. All participants self-identified as having expertise in either HS (n=22 [85%]) or inpatient dermatology (n=17 [65%]), and 13 (50%) participants self-identified as experts in both HS and inpatient dermatology. All participants, except 1, were affiliated with an academic health system with inpatient dermatology services. The average length of time in practice as a dermatologist was 10 years (median, 9 years [range, 3–27 years]).

Of the 50 initial proposed consensus statements, 26 (52%) achieved consensus after the first round; 21 statements revealed DI calculations that did not achieve consensus. Two statements achieved consensus but received median ratings for appropriateness, indicating uncertain appropriateness; because of this, 1 statement was removed and 1 was revised based on participant feedback, resulting in 13 revised statements (eTable 1). Controversial topics in the consensus process included obtaining wound cultures and meaningful culture data interpretation, use of specific biologic medications in the inpatient setting, and use of intravenous ertapenem. Participant responses to these topics are discussed in detail below. Of these secondround statements, all achieved consensus. The final set of consensus statements can be found in eTable 2.

Comment

Our Delphi consensus study combined the expertise of both dermatologists who care for patients with HS and those with inpatient dermatology experience to produce a set of recommendations for the management of HS in the hospital care setting. A strength of this study is inclusion of many national leaders in both HS and inpatient dermatology, with some participants having developed the previously published HS treatment guidelines and others having participated in inpatient dermatology Delphi studies.8-10 The expertise is further strengthened by the geographically diverse institutional representation within the United States.

The final consensus recommendations included 40 statements covering a range of patient care issues, including use of appropriate inpatient subspecialists (care team), supportive care measures (wound care, pain control, genital care), disease-oriented treatment (medical management, surgical management), inpatient complications (infection control, nutrition), and successful transition back to outpatient management (transitional care). These recommendations are meant to serve as a resource for providers to consider when taking care of inpatient HS flares, recognizing that the complexity and individual circumstances of each patient are unique.

Delphi Consensus Recommendations Compared to Prior Guidelines—Several recommendations in the current study align with the previously published North American clinical management guidelines for HS.8,9 Our recommendations agree with prior guidelines on the importance of disease staging and pain assessment using validated assessment tools as well as screening for HS comorbidities. There also is agreement in the potential benefit of involving pain specialists in the development of a comprehensive pain management plan. The inpatient care setting provides a unique opportunity to engage multiple specialists and collaborate on patient care in a timely manner. Our recommendations regarding surgical care also align with established guidelines in recommending incision and drainage as an acute bedside procedure best utilized for symptom relief in inflamed abscesses and relegating most other surgical management to the outpatient setting. Wound care recommendations also are similar, with our expert participants agreeing on individualizing dressing choices based on wound characteristics. A benefit of inpatient wound care is access to skilled nursing for dressing changes and potentially improved access to more sophisticated dressing materials. Our recommendations differ from the prior guidelines in our focus on severe HS, HS flares, and HS complications, which constitute the majority of inpatient disease management. We provide additional guidance on management of secondary infections, perianal fistulous disease, and importantly transitional care to optimize discharge planning.

Differing Opinions in Our Analysis—Despite the success of our Delphi consensus process, there were some differing opinions regarding certain aspects of inpatient HS management, which is to be expected given the lack of strong evidence-based research to support some of the recommended practices. There were differing opinions on the utility of wound culture data, with some participants feeling culture data could help with antibiotic susceptibility and resistance patterns, while others felt wound cultures represent bacterial colonization or biofilm formation.

Initial consensus statements in the first Delphi round were created for individual biologic medications but did not achieve consensus, and feedback on the use of biologics in the inpatient environment was mixed, largely due to logistic and insurance issues. Many participants felt biologic medication cost, difficulty obtaining inpatient reimbursement, health care resource utilization, and availability of biologics in different hospital systems prevented recommending the use of specific biologics during hospitalization. The one exception was in the case of a hospitalized patient who was already receiving infliximab for HS: there was consensus on ensuring the patient dosing was maximized, if appropriate, to 10 mg/kg.12 Ertapenem use also was controversial, with some participants using it as a bridge therapy to either outpatient biologic use or surgery, while others felt it was onerous and difficult to establish reliable access to secure intravenous administration and regular dosing once the patient left the inpatient setting.13 Others said they have experienced objections from infectious disease colleagues on the use of intravenous antibiotics, citing antibiotic stewardship concerns.

Patient Care in the Inpatient Setting—Prior literature suggests patients admitted as inpatients for HS tend to be of lower socioeconomic status and are admitted to larger urban teaching hospitals.14,15 Patients with lower socioeconomic status have increased difficulty accessing health care resources; therefore, inpatient admission serves as an opportunity to provide a holistic HS assessment and coordinate resources for chronic outpatient management.

Study Limitations—This Delphi consensus study has some limitations. The existing literature on inpatient management of HS is limited, challenging our ability to assess the extent to which these published recommendations are already being implemented. Additionally, the study included HS and inpatient dermatology experts from the United States, which means the recommendations may not be generalizable to other countries. Most participants practiced dermatology at large tertiary care academic medical centers, which may limit the ability to implement recommendations in all US inpatient care settings such as small community-based hospitals; however, many of the supportive care guidelines such as pain control, wound care, nutritional support, and social work should be achievable in most inpatient care settings.

Conclusion

Given the increase in inpatient and ED health care utilization for HS, there is an urgent need for expert consensus recommendations on inpatient management of this unique patient population, which requires complex multidisciplinary care. Our recommendations are a resource for providers to utilize and potentially improve the standard of care we provide these patients.

Acknowledgment—We thank the Wake Forest University Clinical and Translational Science Institute (Winston- Salem, North Carolina) for providing statistical help.

References
  1. Garg A, Kirby JS, Lavian J, et al. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States. JAMA Dermatol. 2017;153:760-764.
  2. Ingram JR. The epidemiology of hidradenitis suppurativa. Br J Dermatol. 2020;183:990-998. doi:10.1111/bjd.19435
  3. Charrow A, Savage KT, Flood K, et al. Hidradenitis suppurativa for the dermatologic hospitalist. Cutis. 2019;104:276-280.
  4. Anzaldi L, Perkins JA, Byrd AS, et al. Characterizing inpatient hospitalizations for hidradenitis suppurativa in the United States. J Am Acad Dermatol. 2020;82:510-513. doi:10.1016/j.jaad.2019.09.019
  5. Khalsa A, Liu G, Kirby JS. Increased utilization of emergency department and inpatient care by patients with hidradenitis suppurativa. J Am Acad Dermatol. 2015;73:609-614. doi:10.1016/j.jaad.2015.06.053
  6. Edigin E, Kaul S, Eseaton PO, et al. At 180 days hidradenitis suppurativa readmission rate is comparable to heart failure: analysis of the nationwide readmissions database. J Am Acad Dermatol. 2022;87:188-192. doi:10.1016/j.jaad.2021.06.894
  7. Kirby JS, Miller JJ, Adams DR, et al. Health care utilization patterns and costs for patients with hidradenitis suppurativa. JAMA Dermatol. 2014;150:937-944. doi:10.1001/jamadermatol.2014.691
  8. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part I: diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81:76-90. doi:10.1016/j .jaad.2019.02.067
  9. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part II: topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81:91-101. doi:10.1016/j.jaad.2019.02.068
  10. Seminario-Vidal L, Kroshinsky D, Malachowski SJ, et al. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol. 2020;82:1553-1567. doi:10.1016/j .jaad.2020.02.066
  11. Fitch K, Bernstein SJ, Burnand B, et al. The RAND/UCLA Appropriateness Method: User’s Manual. Rand; 2001.
  12. Oskardmay AN, Miles JA, Sayed CJ. Determining the optimal dose of infliximab for treatment of hidradenitis suppurativa. J Am Acad Dermatol. 2019;81:702-708. doi:10.1016/j.jaad.2019.05.022
  13. Join-Lambert O, Coignard-Biehler H, Jais JP, et al. Efficacy of ertapenem in severe hidradenitis suppurativa: a pilot study in a cohort of 30 consecutive patients. J Antimicrob Chemother. 2016;71:513-520. doi:10.1093/jac/dkv361
  14. Khanna R, Whang KA, Huang AH, et al. Inpatient burden of hidradenitis suppurativa in the United States: analysis of the 2016 National Inpatient Sample. J Dermatolog Treat. 2022;33:1150-1152. doi:10.1080/09 546634.2020.1773380
  15. Patel A, Patel A, Solanki D, et al. Hidradenitis suppurativa in the United States: insights from the national inpatient sample (2008-2017) on contemporary trends in demographics, hospitalization rates, chronic comorbid conditions, and mortality. Cureus. 2022;14:E24755. doi:10.7759/cureus.24755
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McKenzie Needham and Drs. Pichardo and Strowd are from the Wake Forest University School of Medicine, Winston-Salem, North Carolina. Drs. Pichardo and Strowd also are from the Department of Dermatology, Atrium Health Wake Forest Baptist, Winston-Salem. Dr. Alavi is from the Department of Dermatology, Mayo Clinic, Rochester, Minnesota. Drs. Chang and Fox are from the Department of Dermatology, School of Medicine, University of California San Francisco. Dr. Daveluy is from the School of Medicine, Wayne State University, Detroit, Michigan. Dr. DeNiro is from the Division of Dermatology, Department of Medicine, University of Washington, Seattle. Dr. Dewan is from Vanderbilt University Medical Center, Nashville, Tennessee. Drs. Eshaq and Manusco are from the Department of Dermatology, University of Michigan Medical School, Ann Arbor. Dr. Hsiao is from the Department of Dermatology, University of Southern California, Los Angeles. Dr. Kaffenberger is from the Department of Dermatology, Ohio State University, Columbus. Dr. Kirby is from the Department of Dermatology, Penn State Milton S. Hershey Medical Center, Pennsylvania, and Incyte Corporation, Wilmington, Delaware. Drs. Kroshinsky, Mostaghimi, and Porter are from the Department of Dermatology, Harvard Medical School, Boston, Massachusetts. Drs. Kroshinsky and Mostaghimi also are from the Department of Dermatology, Brigham & Women’s Hospital, Boston. Dr. Porter also is from the Department of Dermatology, Beth Israel Deaconess Medical Center, Boston. Dr. Ortega-Loayza is from the Department of Dermatology, Oregon Health & Science University, Portland. Dr. Micheletti is from the Departments of Dermatology and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Dr. Nelson is from the Department of Dermatology, Yale School of Medicine, New Haven, Connecticut. Dr. Pasieka is from the Department of Dermatology and Medicine, Uniformed Services University, Bethesda, Maryland. Dr. Resnik is from the Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Florida. Dr. Sayed is from the Department of Dermatology, University of North Carolina at Chapel Hill. Dr. Shi is from the Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock. Dr. Shields is from the Department of Dermatology, University of Wisconsin, Madison.

McKenzie Needham as well as Drs. Chang, DeNiro, Dewan, Eshaq, Kroshinsky, Manusco, and Pasieka report no conflicts of interest. Dr. Pichardo has been an advisor for Novartis and UCB. Dr. Alavi is a consultant for Almirall, Boehringer-Ingelheim, InflaRx, LEO Pharma, Novartis, and UCB; is on the board of editors for the Hidradenitis Suppurativa Foundation; has received a research grant from the National Institutes of Health; and has equity in Medical Dermatology. Dr. Daveluy is a speaker for AbbVie, Novartis, and UCB, and has received research grants from AbbVie, Novartis, Pfizer, Regeneron, Sanofi, and UCB. Dr. Fox is a co-founder of and holds equity in DermLab. Dr. Hsiao is on the Board of Directors for the Hidradenitis Suppurativa Foundation; is a speaker for AbbVie, Novartis, Regeneron, Sanofi, and UCB; has received research grants from Amgen, Boehringer-Ingelheim, and Incyte; and is an advisor for AbbVie, Aclaris, Boehringer-Ingelheim, Incyte, Novartis, and UCB. Dr. Kaffenberger is a consultant for ADC Therapeutics, Biogen, and Eli Lilly and Company; a speaker for Novartis and Novocure; and has received research grants from Biogen, InflaRx, Merck, and Target-Derm. Dr. Kirby is an employee of Incyte. Dr. Ortega-Loayza is an advisory board member and/or speaker for Biotech, Bristol Myers Squibb, Boehringer-Ingelheim, and Sanofi, and has received research grants and/or consulting fees from AbbVie, Boehringer-Ingelheim, Castle Biosciences, Clarivate, Corvus Pharmaceuticals, Eli Lilly and Company, Genentech, Guidepoint, Incyte, InflaRx, Janssen, National Institutes of Health, Otsuka, Pfizer, Sitala Bio Ltd, and TFS Health Science. Dr. Micheletti is a consultant for Vertex and has received research grants from Acelyrin, Amgen, Boehringer-Ingelheim, Cabaletta Bio, and InflaRx. Dr. Mostaghimi has received income from AbbVie, ASLAN, Boehringer-Ingelheim, Dermatheory, Digital Diagnostics, Eli Lilly and Company, Equillium, Figure 1 Inc, Hims & Hers Health, Inc, Legacy Healthcare, Olapex, Pfizer, and Sun Pharmaceuticals. Dr. Nelson is an advisory board member for and has received research grants from Boehringer-Ingelheim. Dr. Porter is a consultant for or has received research grants from AbbVie, Alumis, AnaptysBio, Avalo, Bayer, Bristol Myers Squibb, Eli Lilly and Company, Incyte, Janssen, Moonlake Therapeutics, Novartis, Oasis Pharmaceuticals, Pfizer, Prometheus Laboratories, Regeneron, Sanofi, Sonoma Biotherapeutics, Trifecta Clinical, and UCB. Dr. Resnik serves or served as a speaker for AbbVie and Novartis. Dr. Sayed serves or served as an advisor, consultant, director, employee, investigator, officer, partner, speaker, or trustee for AbbVie, AstraZeneca, Chemocentryx, Incyte, InflaRx, Logical Images, Novartis, Sandoz, Sanofi, and UCB. Dr. Shi is on the Board of Directors for the Hidradenitis Suppurativa Foundation and is an advisor for the National Eczema Association; is a consultant, investigator, and/or speaker for AbbVie, Almirall, Altus Lab/cQuell, Alumis, Aristea Therapeutics, ASLAN, Bain Capital, BoehringerIngelheim, Burt’s Bees, Castle Biosciences, Dermira, Eli Lilly and Company, Galderma, Genentech, GpSkin, Incyte, Kiniksa, LEO Pharma, Menlo Therapeutics, MYOR, Novartis, Pfizer, Polyfins Technology, Regeneron, Sanofi-Genzyme, Skin Actives Scientific, Sun Pharmaceuticals, Target Pharma Solutions, and UCB; has received research grants from Pfizer and Skin Actives Scientific; and is a stock shareholder in Learn Health. Dr. Shields is on the advisory board for Arcutis Therapeutics and has received income from UpToDate, Inc. Dr. Strowd is a speaker for and/or has received research grants or income from Galderma, Pfizer, Regeneron, and Sanofi. The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. This work was prepared by a military or civilian employee of the US Government as part of the individual’s official duties and therefore is in the public domain and does not possess copyright protection (public domain information may be freely distributed and copied; however, as a courtesy it is requested that the Uniformed Services University and the author be given an appropriate acknowledgment).

The eTables are available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Lindsay C. Strowd, MD (lchaney@wakehealth.edu).

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McKenzie Needham and Drs. Pichardo and Strowd are from the Wake Forest University School of Medicine, Winston-Salem, North Carolina. Drs. Pichardo and Strowd also are from the Department of Dermatology, Atrium Health Wake Forest Baptist, Winston-Salem. Dr. Alavi is from the Department of Dermatology, Mayo Clinic, Rochester, Minnesota. Drs. Chang and Fox are from the Department of Dermatology, School of Medicine, University of California San Francisco. Dr. Daveluy is from the School of Medicine, Wayne State University, Detroit, Michigan. Dr. DeNiro is from the Division of Dermatology, Department of Medicine, University of Washington, Seattle. Dr. Dewan is from Vanderbilt University Medical Center, Nashville, Tennessee. Drs. Eshaq and Manusco are from the Department of Dermatology, University of Michigan Medical School, Ann Arbor. Dr. Hsiao is from the Department of Dermatology, University of Southern California, Los Angeles. Dr. Kaffenberger is from the Department of Dermatology, Ohio State University, Columbus. Dr. Kirby is from the Department of Dermatology, Penn State Milton S. Hershey Medical Center, Pennsylvania, and Incyte Corporation, Wilmington, Delaware. Drs. Kroshinsky, Mostaghimi, and Porter are from the Department of Dermatology, Harvard Medical School, Boston, Massachusetts. Drs. Kroshinsky and Mostaghimi also are from the Department of Dermatology, Brigham & Women’s Hospital, Boston. Dr. Porter also is from the Department of Dermatology, Beth Israel Deaconess Medical Center, Boston. Dr. Ortega-Loayza is from the Department of Dermatology, Oregon Health & Science University, Portland. Dr. Micheletti is from the Departments of Dermatology and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Dr. Nelson is from the Department of Dermatology, Yale School of Medicine, New Haven, Connecticut. Dr. Pasieka is from the Department of Dermatology and Medicine, Uniformed Services University, Bethesda, Maryland. Dr. Resnik is from the Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Florida. Dr. Sayed is from the Department of Dermatology, University of North Carolina at Chapel Hill. Dr. Shi is from the Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock. Dr. Shields is from the Department of Dermatology, University of Wisconsin, Madison.

McKenzie Needham as well as Drs. Chang, DeNiro, Dewan, Eshaq, Kroshinsky, Manusco, and Pasieka report no conflicts of interest. Dr. Pichardo has been an advisor for Novartis and UCB. Dr. Alavi is a consultant for Almirall, Boehringer-Ingelheim, InflaRx, LEO Pharma, Novartis, and UCB; is on the board of editors for the Hidradenitis Suppurativa Foundation; has received a research grant from the National Institutes of Health; and has equity in Medical Dermatology. Dr. Daveluy is a speaker for AbbVie, Novartis, and UCB, and has received research grants from AbbVie, Novartis, Pfizer, Regeneron, Sanofi, and UCB. Dr. Fox is a co-founder of and holds equity in DermLab. Dr. Hsiao is on the Board of Directors for the Hidradenitis Suppurativa Foundation; is a speaker for AbbVie, Novartis, Regeneron, Sanofi, and UCB; has received research grants from Amgen, Boehringer-Ingelheim, and Incyte; and is an advisor for AbbVie, Aclaris, Boehringer-Ingelheim, Incyte, Novartis, and UCB. Dr. Kaffenberger is a consultant for ADC Therapeutics, Biogen, and Eli Lilly and Company; a speaker for Novartis and Novocure; and has received research grants from Biogen, InflaRx, Merck, and Target-Derm. Dr. Kirby is an employee of Incyte. Dr. Ortega-Loayza is an advisory board member and/or speaker for Biotech, Bristol Myers Squibb, Boehringer-Ingelheim, and Sanofi, and has received research grants and/or consulting fees from AbbVie, Boehringer-Ingelheim, Castle Biosciences, Clarivate, Corvus Pharmaceuticals, Eli Lilly and Company, Genentech, Guidepoint, Incyte, InflaRx, Janssen, National Institutes of Health, Otsuka, Pfizer, Sitala Bio Ltd, and TFS Health Science. Dr. Micheletti is a consultant for Vertex and has received research grants from Acelyrin, Amgen, Boehringer-Ingelheim, Cabaletta Bio, and InflaRx. Dr. Mostaghimi has received income from AbbVie, ASLAN, Boehringer-Ingelheim, Dermatheory, Digital Diagnostics, Eli Lilly and Company, Equillium, Figure 1 Inc, Hims & Hers Health, Inc, Legacy Healthcare, Olapex, Pfizer, and Sun Pharmaceuticals. Dr. Nelson is an advisory board member for and has received research grants from Boehringer-Ingelheim. Dr. Porter is a consultant for or has received research grants from AbbVie, Alumis, AnaptysBio, Avalo, Bayer, Bristol Myers Squibb, Eli Lilly and Company, Incyte, Janssen, Moonlake Therapeutics, Novartis, Oasis Pharmaceuticals, Pfizer, Prometheus Laboratories, Regeneron, Sanofi, Sonoma Biotherapeutics, Trifecta Clinical, and UCB. Dr. Resnik serves or served as a speaker for AbbVie and Novartis. Dr. Sayed serves or served as an advisor, consultant, director, employee, investigator, officer, partner, speaker, or trustee for AbbVie, AstraZeneca, Chemocentryx, Incyte, InflaRx, Logical Images, Novartis, Sandoz, Sanofi, and UCB. Dr. Shi is on the Board of Directors for the Hidradenitis Suppurativa Foundation and is an advisor for the National Eczema Association; is a consultant, investigator, and/or speaker for AbbVie, Almirall, Altus Lab/cQuell, Alumis, Aristea Therapeutics, ASLAN, Bain Capital, BoehringerIngelheim, Burt’s Bees, Castle Biosciences, Dermira, Eli Lilly and Company, Galderma, Genentech, GpSkin, Incyte, Kiniksa, LEO Pharma, Menlo Therapeutics, MYOR, Novartis, Pfizer, Polyfins Technology, Regeneron, Sanofi-Genzyme, Skin Actives Scientific, Sun Pharmaceuticals, Target Pharma Solutions, and UCB; has received research grants from Pfizer and Skin Actives Scientific; and is a stock shareholder in Learn Health. Dr. Shields is on the advisory board for Arcutis Therapeutics and has received income from UpToDate, Inc. Dr. Strowd is a speaker for and/or has received research grants or income from Galderma, Pfizer, Regeneron, and Sanofi. The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. This work was prepared by a military or civilian employee of the US Government as part of the individual’s official duties and therefore is in the public domain and does not possess copyright protection (public domain information may be freely distributed and copied; however, as a courtesy it is requested that the Uniformed Services University and the author be given an appropriate acknowledgment).

The eTables are available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Lindsay C. Strowd, MD (lchaney@wakehealth.edu).

Author and Disclosure Information

McKenzie Needham and Drs. Pichardo and Strowd are from the Wake Forest University School of Medicine, Winston-Salem, North Carolina. Drs. Pichardo and Strowd also are from the Department of Dermatology, Atrium Health Wake Forest Baptist, Winston-Salem. Dr. Alavi is from the Department of Dermatology, Mayo Clinic, Rochester, Minnesota. Drs. Chang and Fox are from the Department of Dermatology, School of Medicine, University of California San Francisco. Dr. Daveluy is from the School of Medicine, Wayne State University, Detroit, Michigan. Dr. DeNiro is from the Division of Dermatology, Department of Medicine, University of Washington, Seattle. Dr. Dewan is from Vanderbilt University Medical Center, Nashville, Tennessee. Drs. Eshaq and Manusco are from the Department of Dermatology, University of Michigan Medical School, Ann Arbor. Dr. Hsiao is from the Department of Dermatology, University of Southern California, Los Angeles. Dr. Kaffenberger is from the Department of Dermatology, Ohio State University, Columbus. Dr. Kirby is from the Department of Dermatology, Penn State Milton S. Hershey Medical Center, Pennsylvania, and Incyte Corporation, Wilmington, Delaware. Drs. Kroshinsky, Mostaghimi, and Porter are from the Department of Dermatology, Harvard Medical School, Boston, Massachusetts. Drs. Kroshinsky and Mostaghimi also are from the Department of Dermatology, Brigham & Women’s Hospital, Boston. Dr. Porter also is from the Department of Dermatology, Beth Israel Deaconess Medical Center, Boston. Dr. Ortega-Loayza is from the Department of Dermatology, Oregon Health & Science University, Portland. Dr. Micheletti is from the Departments of Dermatology and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Dr. Nelson is from the Department of Dermatology, Yale School of Medicine, New Haven, Connecticut. Dr. Pasieka is from the Department of Dermatology and Medicine, Uniformed Services University, Bethesda, Maryland. Dr. Resnik is from the Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Florida. Dr. Sayed is from the Department of Dermatology, University of North Carolina at Chapel Hill. Dr. Shi is from the Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock. Dr. Shields is from the Department of Dermatology, University of Wisconsin, Madison.

McKenzie Needham as well as Drs. Chang, DeNiro, Dewan, Eshaq, Kroshinsky, Manusco, and Pasieka report no conflicts of interest. Dr. Pichardo has been an advisor for Novartis and UCB. Dr. Alavi is a consultant for Almirall, Boehringer-Ingelheim, InflaRx, LEO Pharma, Novartis, and UCB; is on the board of editors for the Hidradenitis Suppurativa Foundation; has received a research grant from the National Institutes of Health; and has equity in Medical Dermatology. Dr. Daveluy is a speaker for AbbVie, Novartis, and UCB, and has received research grants from AbbVie, Novartis, Pfizer, Regeneron, Sanofi, and UCB. Dr. Fox is a co-founder of and holds equity in DermLab. Dr. Hsiao is on the Board of Directors for the Hidradenitis Suppurativa Foundation; is a speaker for AbbVie, Novartis, Regeneron, Sanofi, and UCB; has received research grants from Amgen, Boehringer-Ingelheim, and Incyte; and is an advisor for AbbVie, Aclaris, Boehringer-Ingelheim, Incyte, Novartis, and UCB. Dr. Kaffenberger is a consultant for ADC Therapeutics, Biogen, and Eli Lilly and Company; a speaker for Novartis and Novocure; and has received research grants from Biogen, InflaRx, Merck, and Target-Derm. Dr. Kirby is an employee of Incyte. Dr. Ortega-Loayza is an advisory board member and/or speaker for Biotech, Bristol Myers Squibb, Boehringer-Ingelheim, and Sanofi, and has received research grants and/or consulting fees from AbbVie, Boehringer-Ingelheim, Castle Biosciences, Clarivate, Corvus Pharmaceuticals, Eli Lilly and Company, Genentech, Guidepoint, Incyte, InflaRx, Janssen, National Institutes of Health, Otsuka, Pfizer, Sitala Bio Ltd, and TFS Health Science. Dr. Micheletti is a consultant for Vertex and has received research grants from Acelyrin, Amgen, Boehringer-Ingelheim, Cabaletta Bio, and InflaRx. Dr. Mostaghimi has received income from AbbVie, ASLAN, Boehringer-Ingelheim, Dermatheory, Digital Diagnostics, Eli Lilly and Company, Equillium, Figure 1 Inc, Hims & Hers Health, Inc, Legacy Healthcare, Olapex, Pfizer, and Sun Pharmaceuticals. Dr. Nelson is an advisory board member for and has received research grants from Boehringer-Ingelheim. Dr. Porter is a consultant for or has received research grants from AbbVie, Alumis, AnaptysBio, Avalo, Bayer, Bristol Myers Squibb, Eli Lilly and Company, Incyte, Janssen, Moonlake Therapeutics, Novartis, Oasis Pharmaceuticals, Pfizer, Prometheus Laboratories, Regeneron, Sanofi, Sonoma Biotherapeutics, Trifecta Clinical, and UCB. Dr. Resnik serves or served as a speaker for AbbVie and Novartis. Dr. Sayed serves or served as an advisor, consultant, director, employee, investigator, officer, partner, speaker, or trustee for AbbVie, AstraZeneca, Chemocentryx, Incyte, InflaRx, Logical Images, Novartis, Sandoz, Sanofi, and UCB. Dr. Shi is on the Board of Directors for the Hidradenitis Suppurativa Foundation and is an advisor for the National Eczema Association; is a consultant, investigator, and/or speaker for AbbVie, Almirall, Altus Lab/cQuell, Alumis, Aristea Therapeutics, ASLAN, Bain Capital, BoehringerIngelheim, Burt’s Bees, Castle Biosciences, Dermira, Eli Lilly and Company, Galderma, Genentech, GpSkin, Incyte, Kiniksa, LEO Pharma, Menlo Therapeutics, MYOR, Novartis, Pfizer, Polyfins Technology, Regeneron, Sanofi-Genzyme, Skin Actives Scientific, Sun Pharmaceuticals, Target Pharma Solutions, and UCB; has received research grants from Pfizer and Skin Actives Scientific; and is a stock shareholder in Learn Health. Dr. Shields is on the advisory board for Arcutis Therapeutics and has received income from UpToDate, Inc. Dr. Strowd is a speaker for and/or has received research grants or income from Galderma, Pfizer, Regeneron, and Sanofi. The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. This work was prepared by a military or civilian employee of the US Government as part of the individual’s official duties and therefore is in the public domain and does not possess copyright protection (public domain information may be freely distributed and copied; however, as a courtesy it is requested that the Uniformed Services University and the author be given an appropriate acknowledgment).

The eTables are available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Lindsay C. Strowd, MD (lchaney@wakehealth.edu).

Article PDF
Article PDF

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that affects approximately 0.1% of the US population.1,2 Severe disease or HS flares can lead patients to seek care through the emergency department (ED), with some requiring inpatient admission. 3 Inpatient hospitalization of patients with HS has increased over the last 2 decades, and patients with HS utilize emergency and inpatient care more frequently than those with other dermatologic conditions.4,5 Minority patients and those of lower socioeconomic status are more likely to present to the ED for HS management due to limited access to care and other existing comorbid conditions. 4 In a 2022 study of the Nationwide Readmissions Database, the authors looked at hospital readmission rates of patients with HS compared with those with heart failure—both patient populations with chronic debilitating conditions. Results indicated that the hospital readmission rates for patients with HS surpassed those of patients with heart failure for that year, highlighting the need for improved inpatient management of HS.6

Patients with HS present to the ED with severe pain, fever, wound care, or the need for surgical intervention. The ED and inpatient hospital setting are locations in which physicians may not be as familiar with the diagnosis or treatment of HS, specifically flares or severe disease. 7 The inpatient care setting provides access to certain resources that can be challenging to obtain in the outpatient clinical setting, such as social workers and pain specialists, but also can prove challenging in obtaining other resources for HS management, such as advanced medical therapies. Given the increase in hospital- based care for HS and lack of widespread inpatient access to dermatology and HS experts, consensus recommendations for management of HS in the acute hospital setting would be beneficial. In our study, we sought to generate a collection of expert consensus statements providers can refer to when managing patients with HS in the inpatient setting.

Methods

The study team at the Wake Forest University School of Medicine (Winston-Salem, North Carolina)(M.N., R.P., L.C.S.) developed an initial set of consensus statements based on current published HS treatment guidelines,8,9 publications on management of inpatient HS,3 published supportive care guidelines for Stevens-Johnson syndrome, 10 and personal clinical experience in managing inpatient HS, which resulted in 50 statements organized into the following categories: overall care, wound care, genital care, pain management, infection control, medical management, surgical management, nutrition, and transitional care guidelines. This study was approved by the Wake Forest University institutional review board (IRB00084257).

Participant Recruitment—Dermatologists were identified for participation in the study based on membership in the Society of Dermatology Hospitalists and the Hidradenitis Suppurativa Foundation or authorship of publications relevant to HS or inpatient dermatology. Dermatologists from larger academic institutions with HS specialty clinics and inpatient dermatology services also were identified. Participants were invited via email and could suggest other experts for inclusion. A total of 31 dermatologists were invited to participate in the study, with 26 agreeing to participate. All participating dermatologists were practicing in the United States.

Delphi Study—In the first round of the Delphi study, the participants were sent an online survey via REDCap in which they were asked to rank the appropriateness of each of the proposed 50 guideline statements on a scale of 1 (very inappropriate) to 9 (very appropriate). Participants also were able to provide commentary and feedback on each of the statements. Survey results were analyzed using the RAND/ UCLA Appropriateness Method.11 For each statement, the median rating for appropriateness, interpercentile range (IPR), IPR adjusted for symmetry, and disagreement index (DI) were calculated (DI=IPR/IPR adjusted for symmetry). The 30th and 70th percentiles were used in the DI calculation as the upper and lower limits, respectively. A median rating for appropriateness of 1.0 to 3.9 was considered “inappropriate,” 4.0 to 6.9 was considered “uncertain appropriateness,” and 7.0 to 9.0 was “appropriate.” A DI value greater than or equal to 1 indicated a lack of consensus regarding the appropriateness of the statement. Following each round, participants received a copy of their responses along with the group median rank of each statement. Statements that did not reach consensus in the first Delphi round were revised based on feedback received by the participants, and a second survey with 14 statements was sent via REDCap 2 weeks later. The RAND/UCLA Appropriateness Method also was applied to this second Delphi round. After the second survey, participants received a copy of anonymized comments regarding the consensus statements and were allowed to provide additional final commentary to be included in the discussion of these recommendations.

Results

Twenty-six dermatologists completed the first-round survey, and 24 participants completed the second-round survey. All participants self-identified as having expertise in either HS (n=22 [85%]) or inpatient dermatology (n=17 [65%]), and 13 (50%) participants self-identified as experts in both HS and inpatient dermatology. All participants, except 1, were affiliated with an academic health system with inpatient dermatology services. The average length of time in practice as a dermatologist was 10 years (median, 9 years [range, 3–27 years]).

Of the 50 initial proposed consensus statements, 26 (52%) achieved consensus after the first round; 21 statements revealed DI calculations that did not achieve consensus. Two statements achieved consensus but received median ratings for appropriateness, indicating uncertain appropriateness; because of this, 1 statement was removed and 1 was revised based on participant feedback, resulting in 13 revised statements (eTable 1). Controversial topics in the consensus process included obtaining wound cultures and meaningful culture data interpretation, use of specific biologic medications in the inpatient setting, and use of intravenous ertapenem. Participant responses to these topics are discussed in detail below. Of these secondround statements, all achieved consensus. The final set of consensus statements can be found in eTable 2.

Comment

Our Delphi consensus study combined the expertise of both dermatologists who care for patients with HS and those with inpatient dermatology experience to produce a set of recommendations for the management of HS in the hospital care setting. A strength of this study is inclusion of many national leaders in both HS and inpatient dermatology, with some participants having developed the previously published HS treatment guidelines and others having participated in inpatient dermatology Delphi studies.8-10 The expertise is further strengthened by the geographically diverse institutional representation within the United States.

The final consensus recommendations included 40 statements covering a range of patient care issues, including use of appropriate inpatient subspecialists (care team), supportive care measures (wound care, pain control, genital care), disease-oriented treatment (medical management, surgical management), inpatient complications (infection control, nutrition), and successful transition back to outpatient management (transitional care). These recommendations are meant to serve as a resource for providers to consider when taking care of inpatient HS flares, recognizing that the complexity and individual circumstances of each patient are unique.

Delphi Consensus Recommendations Compared to Prior Guidelines—Several recommendations in the current study align with the previously published North American clinical management guidelines for HS.8,9 Our recommendations agree with prior guidelines on the importance of disease staging and pain assessment using validated assessment tools as well as screening for HS comorbidities. There also is agreement in the potential benefit of involving pain specialists in the development of a comprehensive pain management plan. The inpatient care setting provides a unique opportunity to engage multiple specialists and collaborate on patient care in a timely manner. Our recommendations regarding surgical care also align with established guidelines in recommending incision and drainage as an acute bedside procedure best utilized for symptom relief in inflamed abscesses and relegating most other surgical management to the outpatient setting. Wound care recommendations also are similar, with our expert participants agreeing on individualizing dressing choices based on wound characteristics. A benefit of inpatient wound care is access to skilled nursing for dressing changes and potentially improved access to more sophisticated dressing materials. Our recommendations differ from the prior guidelines in our focus on severe HS, HS flares, and HS complications, which constitute the majority of inpatient disease management. We provide additional guidance on management of secondary infections, perianal fistulous disease, and importantly transitional care to optimize discharge planning.

Differing Opinions in Our Analysis—Despite the success of our Delphi consensus process, there were some differing opinions regarding certain aspects of inpatient HS management, which is to be expected given the lack of strong evidence-based research to support some of the recommended practices. There were differing opinions on the utility of wound culture data, with some participants feeling culture data could help with antibiotic susceptibility and resistance patterns, while others felt wound cultures represent bacterial colonization or biofilm formation.

Initial consensus statements in the first Delphi round were created for individual biologic medications but did not achieve consensus, and feedback on the use of biologics in the inpatient environment was mixed, largely due to logistic and insurance issues. Many participants felt biologic medication cost, difficulty obtaining inpatient reimbursement, health care resource utilization, and availability of biologics in different hospital systems prevented recommending the use of specific biologics during hospitalization. The one exception was in the case of a hospitalized patient who was already receiving infliximab for HS: there was consensus on ensuring the patient dosing was maximized, if appropriate, to 10 mg/kg.12 Ertapenem use also was controversial, with some participants using it as a bridge therapy to either outpatient biologic use or surgery, while others felt it was onerous and difficult to establish reliable access to secure intravenous administration and regular dosing once the patient left the inpatient setting.13 Others said they have experienced objections from infectious disease colleagues on the use of intravenous antibiotics, citing antibiotic stewardship concerns.

Patient Care in the Inpatient Setting—Prior literature suggests patients admitted as inpatients for HS tend to be of lower socioeconomic status and are admitted to larger urban teaching hospitals.14,15 Patients with lower socioeconomic status have increased difficulty accessing health care resources; therefore, inpatient admission serves as an opportunity to provide a holistic HS assessment and coordinate resources for chronic outpatient management.

Study Limitations—This Delphi consensus study has some limitations. The existing literature on inpatient management of HS is limited, challenging our ability to assess the extent to which these published recommendations are already being implemented. Additionally, the study included HS and inpatient dermatology experts from the United States, which means the recommendations may not be generalizable to other countries. Most participants practiced dermatology at large tertiary care academic medical centers, which may limit the ability to implement recommendations in all US inpatient care settings such as small community-based hospitals; however, many of the supportive care guidelines such as pain control, wound care, nutritional support, and social work should be achievable in most inpatient care settings.

Conclusion

Given the increase in inpatient and ED health care utilization for HS, there is an urgent need for expert consensus recommendations on inpatient management of this unique patient population, which requires complex multidisciplinary care. Our recommendations are a resource for providers to utilize and potentially improve the standard of care we provide these patients.

Acknowledgment—We thank the Wake Forest University Clinical and Translational Science Institute (Winston- Salem, North Carolina) for providing statistical help.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that affects approximately 0.1% of the US population.1,2 Severe disease or HS flares can lead patients to seek care through the emergency department (ED), with some requiring inpatient admission. 3 Inpatient hospitalization of patients with HS has increased over the last 2 decades, and patients with HS utilize emergency and inpatient care more frequently than those with other dermatologic conditions.4,5 Minority patients and those of lower socioeconomic status are more likely to present to the ED for HS management due to limited access to care and other existing comorbid conditions. 4 In a 2022 study of the Nationwide Readmissions Database, the authors looked at hospital readmission rates of patients with HS compared with those with heart failure—both patient populations with chronic debilitating conditions. Results indicated that the hospital readmission rates for patients with HS surpassed those of patients with heart failure for that year, highlighting the need for improved inpatient management of HS.6

Patients with HS present to the ED with severe pain, fever, wound care, or the need for surgical intervention. The ED and inpatient hospital setting are locations in which physicians may not be as familiar with the diagnosis or treatment of HS, specifically flares or severe disease. 7 The inpatient care setting provides access to certain resources that can be challenging to obtain in the outpatient clinical setting, such as social workers and pain specialists, but also can prove challenging in obtaining other resources for HS management, such as advanced medical therapies. Given the increase in hospital- based care for HS and lack of widespread inpatient access to dermatology and HS experts, consensus recommendations for management of HS in the acute hospital setting would be beneficial. In our study, we sought to generate a collection of expert consensus statements providers can refer to when managing patients with HS in the inpatient setting.

Methods

The study team at the Wake Forest University School of Medicine (Winston-Salem, North Carolina)(M.N., R.P., L.C.S.) developed an initial set of consensus statements based on current published HS treatment guidelines,8,9 publications on management of inpatient HS,3 published supportive care guidelines for Stevens-Johnson syndrome, 10 and personal clinical experience in managing inpatient HS, which resulted in 50 statements organized into the following categories: overall care, wound care, genital care, pain management, infection control, medical management, surgical management, nutrition, and transitional care guidelines. This study was approved by the Wake Forest University institutional review board (IRB00084257).

Participant Recruitment—Dermatologists were identified for participation in the study based on membership in the Society of Dermatology Hospitalists and the Hidradenitis Suppurativa Foundation or authorship of publications relevant to HS or inpatient dermatology. Dermatologists from larger academic institutions with HS specialty clinics and inpatient dermatology services also were identified. Participants were invited via email and could suggest other experts for inclusion. A total of 31 dermatologists were invited to participate in the study, with 26 agreeing to participate. All participating dermatologists were practicing in the United States.

Delphi Study—In the first round of the Delphi study, the participants were sent an online survey via REDCap in which they were asked to rank the appropriateness of each of the proposed 50 guideline statements on a scale of 1 (very inappropriate) to 9 (very appropriate). Participants also were able to provide commentary and feedback on each of the statements. Survey results were analyzed using the RAND/ UCLA Appropriateness Method.11 For each statement, the median rating for appropriateness, interpercentile range (IPR), IPR adjusted for symmetry, and disagreement index (DI) were calculated (DI=IPR/IPR adjusted for symmetry). The 30th and 70th percentiles were used in the DI calculation as the upper and lower limits, respectively. A median rating for appropriateness of 1.0 to 3.9 was considered “inappropriate,” 4.0 to 6.9 was considered “uncertain appropriateness,” and 7.0 to 9.0 was “appropriate.” A DI value greater than or equal to 1 indicated a lack of consensus regarding the appropriateness of the statement. Following each round, participants received a copy of their responses along with the group median rank of each statement. Statements that did not reach consensus in the first Delphi round were revised based on feedback received by the participants, and a second survey with 14 statements was sent via REDCap 2 weeks later. The RAND/UCLA Appropriateness Method also was applied to this second Delphi round. After the second survey, participants received a copy of anonymized comments regarding the consensus statements and were allowed to provide additional final commentary to be included in the discussion of these recommendations.

Results

Twenty-six dermatologists completed the first-round survey, and 24 participants completed the second-round survey. All participants self-identified as having expertise in either HS (n=22 [85%]) or inpatient dermatology (n=17 [65%]), and 13 (50%) participants self-identified as experts in both HS and inpatient dermatology. All participants, except 1, were affiliated with an academic health system with inpatient dermatology services. The average length of time in practice as a dermatologist was 10 years (median, 9 years [range, 3–27 years]).

Of the 50 initial proposed consensus statements, 26 (52%) achieved consensus after the first round; 21 statements revealed DI calculations that did not achieve consensus. Two statements achieved consensus but received median ratings for appropriateness, indicating uncertain appropriateness; because of this, 1 statement was removed and 1 was revised based on participant feedback, resulting in 13 revised statements (eTable 1). Controversial topics in the consensus process included obtaining wound cultures and meaningful culture data interpretation, use of specific biologic medications in the inpatient setting, and use of intravenous ertapenem. Participant responses to these topics are discussed in detail below. Of these secondround statements, all achieved consensus. The final set of consensus statements can be found in eTable 2.

Comment

Our Delphi consensus study combined the expertise of both dermatologists who care for patients with HS and those with inpatient dermatology experience to produce a set of recommendations for the management of HS in the hospital care setting. A strength of this study is inclusion of many national leaders in both HS and inpatient dermatology, with some participants having developed the previously published HS treatment guidelines and others having participated in inpatient dermatology Delphi studies.8-10 The expertise is further strengthened by the geographically diverse institutional representation within the United States.

The final consensus recommendations included 40 statements covering a range of patient care issues, including use of appropriate inpatient subspecialists (care team), supportive care measures (wound care, pain control, genital care), disease-oriented treatment (medical management, surgical management), inpatient complications (infection control, nutrition), and successful transition back to outpatient management (transitional care). These recommendations are meant to serve as a resource for providers to consider when taking care of inpatient HS flares, recognizing that the complexity and individual circumstances of each patient are unique.

Delphi Consensus Recommendations Compared to Prior Guidelines—Several recommendations in the current study align with the previously published North American clinical management guidelines for HS.8,9 Our recommendations agree with prior guidelines on the importance of disease staging and pain assessment using validated assessment tools as well as screening for HS comorbidities. There also is agreement in the potential benefit of involving pain specialists in the development of a comprehensive pain management plan. The inpatient care setting provides a unique opportunity to engage multiple specialists and collaborate on patient care in a timely manner. Our recommendations regarding surgical care also align with established guidelines in recommending incision and drainage as an acute bedside procedure best utilized for symptom relief in inflamed abscesses and relegating most other surgical management to the outpatient setting. Wound care recommendations also are similar, with our expert participants agreeing on individualizing dressing choices based on wound characteristics. A benefit of inpatient wound care is access to skilled nursing for dressing changes and potentially improved access to more sophisticated dressing materials. Our recommendations differ from the prior guidelines in our focus on severe HS, HS flares, and HS complications, which constitute the majority of inpatient disease management. We provide additional guidance on management of secondary infections, perianal fistulous disease, and importantly transitional care to optimize discharge planning.

Differing Opinions in Our Analysis—Despite the success of our Delphi consensus process, there were some differing opinions regarding certain aspects of inpatient HS management, which is to be expected given the lack of strong evidence-based research to support some of the recommended practices. There were differing opinions on the utility of wound culture data, with some participants feeling culture data could help with antibiotic susceptibility and resistance patterns, while others felt wound cultures represent bacterial colonization or biofilm formation.

Initial consensus statements in the first Delphi round were created for individual biologic medications but did not achieve consensus, and feedback on the use of biologics in the inpatient environment was mixed, largely due to logistic and insurance issues. Many participants felt biologic medication cost, difficulty obtaining inpatient reimbursement, health care resource utilization, and availability of biologics in different hospital systems prevented recommending the use of specific biologics during hospitalization. The one exception was in the case of a hospitalized patient who was already receiving infliximab for HS: there was consensus on ensuring the patient dosing was maximized, if appropriate, to 10 mg/kg.12 Ertapenem use also was controversial, with some participants using it as a bridge therapy to either outpatient biologic use or surgery, while others felt it was onerous and difficult to establish reliable access to secure intravenous administration and regular dosing once the patient left the inpatient setting.13 Others said they have experienced objections from infectious disease colleagues on the use of intravenous antibiotics, citing antibiotic stewardship concerns.

Patient Care in the Inpatient Setting—Prior literature suggests patients admitted as inpatients for HS tend to be of lower socioeconomic status and are admitted to larger urban teaching hospitals.14,15 Patients with lower socioeconomic status have increased difficulty accessing health care resources; therefore, inpatient admission serves as an opportunity to provide a holistic HS assessment and coordinate resources for chronic outpatient management.

Study Limitations—This Delphi consensus study has some limitations. The existing literature on inpatient management of HS is limited, challenging our ability to assess the extent to which these published recommendations are already being implemented. Additionally, the study included HS and inpatient dermatology experts from the United States, which means the recommendations may not be generalizable to other countries. Most participants practiced dermatology at large tertiary care academic medical centers, which may limit the ability to implement recommendations in all US inpatient care settings such as small community-based hospitals; however, many of the supportive care guidelines such as pain control, wound care, nutritional support, and social work should be achievable in most inpatient care settings.

Conclusion

Given the increase in inpatient and ED health care utilization for HS, there is an urgent need for expert consensus recommendations on inpatient management of this unique patient population, which requires complex multidisciplinary care. Our recommendations are a resource for providers to utilize and potentially improve the standard of care we provide these patients.

Acknowledgment—We thank the Wake Forest University Clinical and Translational Science Institute (Winston- Salem, North Carolina) for providing statistical help.

References
  1. Garg A, Kirby JS, Lavian J, et al. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States. JAMA Dermatol. 2017;153:760-764.
  2. Ingram JR. The epidemiology of hidradenitis suppurativa. Br J Dermatol. 2020;183:990-998. doi:10.1111/bjd.19435
  3. Charrow A, Savage KT, Flood K, et al. Hidradenitis suppurativa for the dermatologic hospitalist. Cutis. 2019;104:276-280.
  4. Anzaldi L, Perkins JA, Byrd AS, et al. Characterizing inpatient hospitalizations for hidradenitis suppurativa in the United States. J Am Acad Dermatol. 2020;82:510-513. doi:10.1016/j.jaad.2019.09.019
  5. Khalsa A, Liu G, Kirby JS. Increased utilization of emergency department and inpatient care by patients with hidradenitis suppurativa. J Am Acad Dermatol. 2015;73:609-614. doi:10.1016/j.jaad.2015.06.053
  6. Edigin E, Kaul S, Eseaton PO, et al. At 180 days hidradenitis suppurativa readmission rate is comparable to heart failure: analysis of the nationwide readmissions database. J Am Acad Dermatol. 2022;87:188-192. doi:10.1016/j.jaad.2021.06.894
  7. Kirby JS, Miller JJ, Adams DR, et al. Health care utilization patterns and costs for patients with hidradenitis suppurativa. JAMA Dermatol. 2014;150:937-944. doi:10.1001/jamadermatol.2014.691
  8. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part I: diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81:76-90. doi:10.1016/j .jaad.2019.02.067
  9. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part II: topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81:91-101. doi:10.1016/j.jaad.2019.02.068
  10. Seminario-Vidal L, Kroshinsky D, Malachowski SJ, et al. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol. 2020;82:1553-1567. doi:10.1016/j .jaad.2020.02.066
  11. Fitch K, Bernstein SJ, Burnand B, et al. The RAND/UCLA Appropriateness Method: User’s Manual. Rand; 2001.
  12. Oskardmay AN, Miles JA, Sayed CJ. Determining the optimal dose of infliximab for treatment of hidradenitis suppurativa. J Am Acad Dermatol. 2019;81:702-708. doi:10.1016/j.jaad.2019.05.022
  13. Join-Lambert O, Coignard-Biehler H, Jais JP, et al. Efficacy of ertapenem in severe hidradenitis suppurativa: a pilot study in a cohort of 30 consecutive patients. J Antimicrob Chemother. 2016;71:513-520. doi:10.1093/jac/dkv361
  14. Khanna R, Whang KA, Huang AH, et al. Inpatient burden of hidradenitis suppurativa in the United States: analysis of the 2016 National Inpatient Sample. J Dermatolog Treat. 2022;33:1150-1152. doi:10.1080/09 546634.2020.1773380
  15. Patel A, Patel A, Solanki D, et al. Hidradenitis suppurativa in the United States: insights from the national inpatient sample (2008-2017) on contemporary trends in demographics, hospitalization rates, chronic comorbid conditions, and mortality. Cureus. 2022;14:E24755. doi:10.7759/cureus.24755
References
  1. Garg A, Kirby JS, Lavian J, et al. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States. JAMA Dermatol. 2017;153:760-764.
  2. Ingram JR. The epidemiology of hidradenitis suppurativa. Br J Dermatol. 2020;183:990-998. doi:10.1111/bjd.19435
  3. Charrow A, Savage KT, Flood K, et al. Hidradenitis suppurativa for the dermatologic hospitalist. Cutis. 2019;104:276-280.
  4. Anzaldi L, Perkins JA, Byrd AS, et al. Characterizing inpatient hospitalizations for hidradenitis suppurativa in the United States. J Am Acad Dermatol. 2020;82:510-513. doi:10.1016/j.jaad.2019.09.019
  5. Khalsa A, Liu G, Kirby JS. Increased utilization of emergency department and inpatient care by patients with hidradenitis suppurativa. J Am Acad Dermatol. 2015;73:609-614. doi:10.1016/j.jaad.2015.06.053
  6. Edigin E, Kaul S, Eseaton PO, et al. At 180 days hidradenitis suppurativa readmission rate is comparable to heart failure: analysis of the nationwide readmissions database. J Am Acad Dermatol. 2022;87:188-192. doi:10.1016/j.jaad.2021.06.894
  7. Kirby JS, Miller JJ, Adams DR, et al. Health care utilization patterns and costs for patients with hidradenitis suppurativa. JAMA Dermatol. 2014;150:937-944. doi:10.1001/jamadermatol.2014.691
  8. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part I: diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81:76-90. doi:10.1016/j .jaad.2019.02.067
  9. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part II: topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81:91-101. doi:10.1016/j.jaad.2019.02.068
  10. Seminario-Vidal L, Kroshinsky D, Malachowski SJ, et al. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol. 2020;82:1553-1567. doi:10.1016/j .jaad.2020.02.066
  11. Fitch K, Bernstein SJ, Burnand B, et al. The RAND/UCLA Appropriateness Method: User’s Manual. Rand; 2001.
  12. Oskardmay AN, Miles JA, Sayed CJ. Determining the optimal dose of infliximab for treatment of hidradenitis suppurativa. J Am Acad Dermatol. 2019;81:702-708. doi:10.1016/j.jaad.2019.05.022
  13. Join-Lambert O, Coignard-Biehler H, Jais JP, et al. Efficacy of ertapenem in severe hidradenitis suppurativa: a pilot study in a cohort of 30 consecutive patients. J Antimicrob Chemother. 2016;71:513-520. doi:10.1093/jac/dkv361
  14. Khanna R, Whang KA, Huang AH, et al. Inpatient burden of hidradenitis suppurativa in the United States: analysis of the 2016 National Inpatient Sample. J Dermatolog Treat. 2022;33:1150-1152. doi:10.1080/09 546634.2020.1773380
  15. Patel A, Patel A, Solanki D, et al. Hidradenitis suppurativa in the United States: insights from the national inpatient sample (2008-2017) on contemporary trends in demographics, hospitalization rates, chronic comorbid conditions, and mortality. Cureus. 2022;14:E24755. doi:10.7759/cureus.24755
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Inpatient Management of Hidradenitis Suppurativa: A Delphi Consensus Study
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Practice Points

  • Given the increase in hospital-based care for hidradenitis suppurativa (HS) and the lack of widespread inpatient access to dermatology and HS experts, consensus recommendations for management of HS in the acute hospital setting would be beneficial.
  • Our Delphi study yielded 40 statements that reached consensus covering a range of patient care issues (eg, appropriate inpatient subspecialists [care team]), supportive care measures (wound care, pain control, genital care), disease-oriented treatment (medical management, surgical management), inpatient complications (infection control, nutrition), and successful transition to outpatient management (transitional care).
  • These recommendations serve as an important resource for providers caring for inpatients with HS and represent a successful collaboration between inpatient dermatology and HS experts.
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E-Consults in Dermatology: A Retrospective Analysis

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E-Consults in Dermatology: A Retrospective Analysis
IN PARTNERSHIP WITH THE SOCIETY OF DERMATOLOGY HOSPITALISTS

Dermatologic conditions affect approximately one-third of individuals in the United States.1,2 Nearly 1 in 4 physician office visits in the United States are for skin conditions, and less than one-third of these visits are with dermatologists. Although many of these patients may prefer to see a dermatologist for their concerns, they may not be able to access specialist care.3 The limited supply and urban-focused distribution of dermatologists along with reduced acceptance of state-funded insurance plans and long appointment wait times all pose considerable challenges to individuals seeking dermatologic care.2 Electronic consultations (e-consults) have emerged as a promising solution to overcoming these barriers while providing high-quality dermatologic care to a large diverse patient population.2,4 Although e-consults can be of service to all dermatology patients, this modality may be especially beneficial to underserved populations, such as the uninsured and Medicaid patients—groups that historically have experienced limited access to dermatology care due to the low reimbursement rates and high administrative burdens accompanying care delivery.4 This limited access leads to inequity in care, as timely access to dermatology is associated with improved diagnostic accuracy and disease outcomes.3 E-consult implementation can facilitate timely access for these underserved populations and bypass additional barriers to care such as lack of transportation or time off work. Prior e-consult studies have demonstrated relatively high numbers of Medicaid patients utilizing e-consult services.3,5

Although in-person visits remain the gold standard for diagnosis and treatment of dermatologic conditions, e-consults placed by primary care providers (PCPs) can improve access and help triage patients who require in-person dermatology visits.6 In this study, we conducted a retrospective chart review to characterize the e-consults requested of the dermatology department at a large tertiary care medical center in Winston-Salem, North Carolina.

Methods

The electronic health record (EHR) of Atrium Health Wake Forest Baptist (Winston-Salem, North Carolina) was screened for eligible patients from January 1, 2020, to May 31, 2021. Patients—both adult (aged ≥18 years) and pediatric (aged <18 years)—were included if they underwent a dermatology e-consult within this time frame. Provider notes in the medical records were reviewed to determine the nature of the lesion, how long the dermatologist took to complete the e-consult, whether an in-person appointment was recommended, and whether the patient was seen by dermatology within 90 days of the e-consult. Institutional review board approval was obtained.

For each e-consult, the PCP obtained clinical photographs of the lesion in question either through the EHR mobile application or by having patients upload their own photographs directly to their medical records. The referring PCP then completed a brief template regarding the patient’s clinical question and medical history and then sent the completed information to the consulting dermatologist’s EHR inbox. From there, the dermatologist could view the clinical question, documented photographs, and patient medical record to create a brief consult note with recommendations. The note was then sent back via EHR to the PCP to follow up with the patient. Patients were not charged for the e-consult.

Characteristics of Adult and Pediatric E-consult Patients

Results

Two hundred fifty-four dermatology e-consults were requested by providers at the study center (eTable), which included 252 unique patients (2 patients had 2 separate e-consults regarding different clinical questions). The median time for completion of the e-consult—from submission of the PCP’s e-consult request to dermatologist completion—was 0.37 days. Fifty-six patients (22.0%) were recommended for an in-person appointment (Figure), 33 (58.9%) of whom ultimately scheduled the in-person appointment, and the median length of time between the completion of the e-consult and the in-person appointment was 16.5 days. The remaining 198 patients (78.0%) were not triaged to receive an in-person appointment following the e-consult,but 2 patients (8.7%) were ultimately seen in-person anyway via other referral pathways, with a median length of 33 days between e-consult completion and the in-person appointment. One hundred seventy-six patients (69.8%) avoided an in-person dermatology visit, although 38 (21.6%) of those patients were fewer than 90 days out from their e-consults at the time of data collection. The 254 e-consults included patients from 50 different zip codes, 49 (98.0%) of which were in North Carolina.

Adult and pediatric electronic consultations (e-consults) resulted in reduced frequencies of in-person dermatology appointments.
Adult and pediatric electronic consultations (e-consults) resulted in reduced frequencies of in-person dermatology appointments.a2 patients had 2 separate e-consults regarding different clinical questions.

Comment

An e-consult is an asynchronous telehealth modality through which PCPs can request specialty evaluation to provide diagnostic and therapeutic guidance, facilitate PCP-specialist coordination of care, and increase access to specialty care with reduced wait times.7,8 Increased care access is especially important, as specialty referral can decrease overall health care expenditure; however, the demand for specialists often exceeds the availability.8 Our e-consult program drastically reduced the time from patients’ initial presentation at their PCP’s office to dermatologist recommendations for treatment or need for in-person dermatology follow-up.

In our analysis, patients were of different racial, ethnic, and socioeconomic backgrounds and lived across a variety of zip codes, predominantly in central and western North Carolina. Almost three-quarters of the patients resided in zip codes where the average income was less than the North Carolina median household income ($66,196).9 Additionally, 82 patients (32.3%) were uninsured or on Medicaid (eTable). These economically disadvantaged patient populations historically have had limited access to dermatologic care.4 One study showed that privately insured individuals were accepted as new patients by dermatologists 91% of the time compared to a 29.8% acceptance rate for publicly insured individuals.10 Uninsured and Medicaid patients also have to wait 34% longer for an appointment compared to individuals with Medicare or private insurance.2 Considering these patients may already be at an economic disadvantage when it comes to seeing and paying for dermatologic services, e-consults may reduce patient travel and appointment expenses while increasing access to specialty care. Based on a 2020 study, each e-consult generates an estimated savings of $80 out-of-pocket per patient per avoided in-person visit.11

 

 

In our study, the most common condition for an e-consult in both adult and pediatric patients was rash, which is consistent with prior e-consult studies.5,11 We found that most e-consult patients were not recommended for an in-person dermatology visit, and for those who were recommended to have an in-person visit, the wait time was reduced (Figure). These results corroborate that e-consults may be used as an important triage tool for determining whether a specialist appointment is indicated as well as a public health tool, as timely evaluation is associated with better dermatologic health care outcomes.3 However, the number of patients who did not present for an in-person appointment in our study may be overestimated, as 38 patients’ (21.6%) e-consults were conducted fewer than 90 days before our data collection. Although none of these patients had been seen in person, it is possible they requested an in-person visit after their medical records were reviewed for this study. Additionally, it is possible patients sought care from outside providers not documented in the EHR.

With regard to the payment model for the e-consult program, Atrium Health Wake Forest Baptist initially piloted the e-consult system through a partnership with the American Academy of Medical Colleges’ Project CORE: Coordinating Optimal Referral Experiences (https://www.aamc.org/what-we-do/mission-areas/health-care/project-core). Grant funding through Project CORE allowed both the referring PCP and the specialist completing the e-consult to each receive approximately 0.5 relative value units in payment for each consult completed. Based on early adoption successes, the institution has created additional internal funding to support the continued expansion of the e-consult system and is incentivized to continue funding, as proper utilization of e-consults improves patient access to timely specialist care, avoids no-shows or last-minute cancellations for specialist appointments, and decreases back-door access to specialist care through the emergency department and urgent care facilities.5 Although 0.5 relative value units is not equivalent compensation to an in-person office visit, our study showed that e-consults can be completed much more quickly and efficiently and do not utilize nursing staff or other office resources.

Conclusion

E-consults are an effective telehealth modality that can increase patients’ access to dermatologic specialty care. Patients who typically are underrepresented in dermatology practices especially may benefit from increased accessibility, and all patients requiring in-person visits may benefit from reduced appointment wait times. The savings generated by in-person appointment avoidance reduce overall health care expenditure as well as the burden of individual expenses. The short turnaround time for e-consults also allows PCPs to better manage dermatologic issues in a timely manner. Integrating and expanding e-consult programs into everyday practice would extend specialty care to broader populations and help reduce barriers to access to dermatologic care.

Acknowledgments—The authors thank the Wake Forest University School of Medicine Department of Medical Education and Department of Dermatology (Winston-Salem, North Carolina) for their contributions to this research study as well as the Wake Forest Clinical and Translational Science Institute (Winston-Salem, North Carolina) for their help extracting EHR data.

References
  1. Hay RJ, Johns NE, Williams HC, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol. 2014;134:1527-1534.
  2. Naka F, Lu J, Porto A, et al. Impact of dermatology econsults on access to care and skin cancer screening in underserved populations: a model for teledermatology services in community health centers. J Am Acad Dermatol. 2018;78:293-302.
  3. Mulcahy A, Mehrotra A, Edison K, et al. Variation in dermatologist visits by sociodemographic characteristics. J Am Acad Dermatol. 2017;76:918-924.
  4. Yang X, Barbieri JS, Kovarik CL. Cost analysis of a store-and-forward teledermatology consult system in Philadelphia. J Am Acad Dermatol. 2019;81:758-764.
  5. Wang RF, Trinidad J, Lawrence J, et al. Improved patient access and outcomes with the integration of an econsult program (teledermatology) within a large academic medical center. J Am Acad Dermatol. 2020;83:1633-1638.
  6. Lee KJ, Finnane A, Soyer HP. Recent trends in teledermatology and teledermoscopy. Dermatol Pract Concept. 2018;8:214-223.
  7. Parikh PJ, Mowrey C, Gallimore J, et al. Evaluating e-consultation implementations based on use and time-line across various specialties. Int J Med Inform. 2017;108:42-48.
  8. Wasfy JH, Rao SK, Kalwani N, et al. Longer-term impact of cardiology e-consults. Am Heart J. 2016;173:86-93.
  9. United States Census Bureau. QuickFacts: North Carolina; United States. Accessed February 26, 2024. https://www.census.gov/quickfacts/fact/table/NC,US/PST045222
  10. Alghothani L, Jacks SK, Vander Horst A, et al. Disparities in access to dermatologic care according to insurance type. Arch Dermatol. 2012;148:956-957.
  11. Seiger K, Hawryluk EB, Kroshinsky D, et al. Pediatric dermatology econsults: reduced wait times and dermatology office visits. Pediatr Dermatol. 2020;37:804-810.
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From the Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Katherine R. Salisbury and Drs. Porter and Ali report no conflict of interest. Dr. Strowd has received grants or support from AbbVie, Galderma, Pfizer, and Sanofi-Regeneron.

The eTable is available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Katherine R. Salisbury, BS, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (ksalisbu@wakehealth.edu).

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From the Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Katherine R. Salisbury and Drs. Porter and Ali report no conflict of interest. Dr. Strowd has received grants or support from AbbVie, Galderma, Pfizer, and Sanofi-Regeneron.

The eTable is available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Katherine R. Salisbury, BS, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (ksalisbu@wakehealth.edu).

Author and Disclosure Information

From the Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Katherine R. Salisbury and Drs. Porter and Ali report no conflict of interest. Dr. Strowd has received grants or support from AbbVie, Galderma, Pfizer, and Sanofi-Regeneron.

The eTable is available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Katherine R. Salisbury, BS, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (ksalisbu@wakehealth.edu).

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Article PDF
IN PARTNERSHIP WITH THE SOCIETY OF DERMATOLOGY HOSPITALISTS
IN PARTNERSHIP WITH THE SOCIETY OF DERMATOLOGY HOSPITALISTS

Dermatologic conditions affect approximately one-third of individuals in the United States.1,2 Nearly 1 in 4 physician office visits in the United States are for skin conditions, and less than one-third of these visits are with dermatologists. Although many of these patients may prefer to see a dermatologist for their concerns, they may not be able to access specialist care.3 The limited supply and urban-focused distribution of dermatologists along with reduced acceptance of state-funded insurance plans and long appointment wait times all pose considerable challenges to individuals seeking dermatologic care.2 Electronic consultations (e-consults) have emerged as a promising solution to overcoming these barriers while providing high-quality dermatologic care to a large diverse patient population.2,4 Although e-consults can be of service to all dermatology patients, this modality may be especially beneficial to underserved populations, such as the uninsured and Medicaid patients—groups that historically have experienced limited access to dermatology care due to the low reimbursement rates and high administrative burdens accompanying care delivery.4 This limited access leads to inequity in care, as timely access to dermatology is associated with improved diagnostic accuracy and disease outcomes.3 E-consult implementation can facilitate timely access for these underserved populations and bypass additional barriers to care such as lack of transportation or time off work. Prior e-consult studies have demonstrated relatively high numbers of Medicaid patients utilizing e-consult services.3,5

Although in-person visits remain the gold standard for diagnosis and treatment of dermatologic conditions, e-consults placed by primary care providers (PCPs) can improve access and help triage patients who require in-person dermatology visits.6 In this study, we conducted a retrospective chart review to characterize the e-consults requested of the dermatology department at a large tertiary care medical center in Winston-Salem, North Carolina.

Methods

The electronic health record (EHR) of Atrium Health Wake Forest Baptist (Winston-Salem, North Carolina) was screened for eligible patients from January 1, 2020, to May 31, 2021. Patients—both adult (aged ≥18 years) and pediatric (aged <18 years)—were included if they underwent a dermatology e-consult within this time frame. Provider notes in the medical records were reviewed to determine the nature of the lesion, how long the dermatologist took to complete the e-consult, whether an in-person appointment was recommended, and whether the patient was seen by dermatology within 90 days of the e-consult. Institutional review board approval was obtained.

For each e-consult, the PCP obtained clinical photographs of the lesion in question either through the EHR mobile application or by having patients upload their own photographs directly to their medical records. The referring PCP then completed a brief template regarding the patient’s clinical question and medical history and then sent the completed information to the consulting dermatologist’s EHR inbox. From there, the dermatologist could view the clinical question, documented photographs, and patient medical record to create a brief consult note with recommendations. The note was then sent back via EHR to the PCP to follow up with the patient. Patients were not charged for the e-consult.

Characteristics of Adult and Pediatric E-consult Patients

Results

Two hundred fifty-four dermatology e-consults were requested by providers at the study center (eTable), which included 252 unique patients (2 patients had 2 separate e-consults regarding different clinical questions). The median time for completion of the e-consult—from submission of the PCP’s e-consult request to dermatologist completion—was 0.37 days. Fifty-six patients (22.0%) were recommended for an in-person appointment (Figure), 33 (58.9%) of whom ultimately scheduled the in-person appointment, and the median length of time between the completion of the e-consult and the in-person appointment was 16.5 days. The remaining 198 patients (78.0%) were not triaged to receive an in-person appointment following the e-consult,but 2 patients (8.7%) were ultimately seen in-person anyway via other referral pathways, with a median length of 33 days between e-consult completion and the in-person appointment. One hundred seventy-six patients (69.8%) avoided an in-person dermatology visit, although 38 (21.6%) of those patients were fewer than 90 days out from their e-consults at the time of data collection. The 254 e-consults included patients from 50 different zip codes, 49 (98.0%) of which were in North Carolina.

Adult and pediatric electronic consultations (e-consults) resulted in reduced frequencies of in-person dermatology appointments.
Adult and pediatric electronic consultations (e-consults) resulted in reduced frequencies of in-person dermatology appointments.a2 patients had 2 separate e-consults regarding different clinical questions.

Comment

An e-consult is an asynchronous telehealth modality through which PCPs can request specialty evaluation to provide diagnostic and therapeutic guidance, facilitate PCP-specialist coordination of care, and increase access to specialty care with reduced wait times.7,8 Increased care access is especially important, as specialty referral can decrease overall health care expenditure; however, the demand for specialists often exceeds the availability.8 Our e-consult program drastically reduced the time from patients’ initial presentation at their PCP’s office to dermatologist recommendations for treatment or need for in-person dermatology follow-up.

In our analysis, patients were of different racial, ethnic, and socioeconomic backgrounds and lived across a variety of zip codes, predominantly in central and western North Carolina. Almost three-quarters of the patients resided in zip codes where the average income was less than the North Carolina median household income ($66,196).9 Additionally, 82 patients (32.3%) were uninsured or on Medicaid (eTable). These economically disadvantaged patient populations historically have had limited access to dermatologic care.4 One study showed that privately insured individuals were accepted as new patients by dermatologists 91% of the time compared to a 29.8% acceptance rate for publicly insured individuals.10 Uninsured and Medicaid patients also have to wait 34% longer for an appointment compared to individuals with Medicare or private insurance.2 Considering these patients may already be at an economic disadvantage when it comes to seeing and paying for dermatologic services, e-consults may reduce patient travel and appointment expenses while increasing access to specialty care. Based on a 2020 study, each e-consult generates an estimated savings of $80 out-of-pocket per patient per avoided in-person visit.11

 

 

In our study, the most common condition for an e-consult in both adult and pediatric patients was rash, which is consistent with prior e-consult studies.5,11 We found that most e-consult patients were not recommended for an in-person dermatology visit, and for those who were recommended to have an in-person visit, the wait time was reduced (Figure). These results corroborate that e-consults may be used as an important triage tool for determining whether a specialist appointment is indicated as well as a public health tool, as timely evaluation is associated with better dermatologic health care outcomes.3 However, the number of patients who did not present for an in-person appointment in our study may be overestimated, as 38 patients’ (21.6%) e-consults were conducted fewer than 90 days before our data collection. Although none of these patients had been seen in person, it is possible they requested an in-person visit after their medical records were reviewed for this study. Additionally, it is possible patients sought care from outside providers not documented in the EHR.

With regard to the payment model for the e-consult program, Atrium Health Wake Forest Baptist initially piloted the e-consult system through a partnership with the American Academy of Medical Colleges’ Project CORE: Coordinating Optimal Referral Experiences (https://www.aamc.org/what-we-do/mission-areas/health-care/project-core). Grant funding through Project CORE allowed both the referring PCP and the specialist completing the e-consult to each receive approximately 0.5 relative value units in payment for each consult completed. Based on early adoption successes, the institution has created additional internal funding to support the continued expansion of the e-consult system and is incentivized to continue funding, as proper utilization of e-consults improves patient access to timely specialist care, avoids no-shows or last-minute cancellations for specialist appointments, and decreases back-door access to specialist care through the emergency department and urgent care facilities.5 Although 0.5 relative value units is not equivalent compensation to an in-person office visit, our study showed that e-consults can be completed much more quickly and efficiently and do not utilize nursing staff or other office resources.

Conclusion

E-consults are an effective telehealth modality that can increase patients’ access to dermatologic specialty care. Patients who typically are underrepresented in dermatology practices especially may benefit from increased accessibility, and all patients requiring in-person visits may benefit from reduced appointment wait times. The savings generated by in-person appointment avoidance reduce overall health care expenditure as well as the burden of individual expenses. The short turnaround time for e-consults also allows PCPs to better manage dermatologic issues in a timely manner. Integrating and expanding e-consult programs into everyday practice would extend specialty care to broader populations and help reduce barriers to access to dermatologic care.

Acknowledgments—The authors thank the Wake Forest University School of Medicine Department of Medical Education and Department of Dermatology (Winston-Salem, North Carolina) for their contributions to this research study as well as the Wake Forest Clinical and Translational Science Institute (Winston-Salem, North Carolina) for their help extracting EHR data.

Dermatologic conditions affect approximately one-third of individuals in the United States.1,2 Nearly 1 in 4 physician office visits in the United States are for skin conditions, and less than one-third of these visits are with dermatologists. Although many of these patients may prefer to see a dermatologist for their concerns, they may not be able to access specialist care.3 The limited supply and urban-focused distribution of dermatologists along with reduced acceptance of state-funded insurance plans and long appointment wait times all pose considerable challenges to individuals seeking dermatologic care.2 Electronic consultations (e-consults) have emerged as a promising solution to overcoming these barriers while providing high-quality dermatologic care to a large diverse patient population.2,4 Although e-consults can be of service to all dermatology patients, this modality may be especially beneficial to underserved populations, such as the uninsured and Medicaid patients—groups that historically have experienced limited access to dermatology care due to the low reimbursement rates and high administrative burdens accompanying care delivery.4 This limited access leads to inequity in care, as timely access to dermatology is associated with improved diagnostic accuracy and disease outcomes.3 E-consult implementation can facilitate timely access for these underserved populations and bypass additional barriers to care such as lack of transportation or time off work. Prior e-consult studies have demonstrated relatively high numbers of Medicaid patients utilizing e-consult services.3,5

Although in-person visits remain the gold standard for diagnosis and treatment of dermatologic conditions, e-consults placed by primary care providers (PCPs) can improve access and help triage patients who require in-person dermatology visits.6 In this study, we conducted a retrospective chart review to characterize the e-consults requested of the dermatology department at a large tertiary care medical center in Winston-Salem, North Carolina.

Methods

The electronic health record (EHR) of Atrium Health Wake Forest Baptist (Winston-Salem, North Carolina) was screened for eligible patients from January 1, 2020, to May 31, 2021. Patients—both adult (aged ≥18 years) and pediatric (aged <18 years)—were included if they underwent a dermatology e-consult within this time frame. Provider notes in the medical records were reviewed to determine the nature of the lesion, how long the dermatologist took to complete the e-consult, whether an in-person appointment was recommended, and whether the patient was seen by dermatology within 90 days of the e-consult. Institutional review board approval was obtained.

For each e-consult, the PCP obtained clinical photographs of the lesion in question either through the EHR mobile application or by having patients upload their own photographs directly to their medical records. The referring PCP then completed a brief template regarding the patient’s clinical question and medical history and then sent the completed information to the consulting dermatologist’s EHR inbox. From there, the dermatologist could view the clinical question, documented photographs, and patient medical record to create a brief consult note with recommendations. The note was then sent back via EHR to the PCP to follow up with the patient. Patients were not charged for the e-consult.

Characteristics of Adult and Pediatric E-consult Patients

Results

Two hundred fifty-four dermatology e-consults were requested by providers at the study center (eTable), which included 252 unique patients (2 patients had 2 separate e-consults regarding different clinical questions). The median time for completion of the e-consult—from submission of the PCP’s e-consult request to dermatologist completion—was 0.37 days. Fifty-six patients (22.0%) were recommended for an in-person appointment (Figure), 33 (58.9%) of whom ultimately scheduled the in-person appointment, and the median length of time between the completion of the e-consult and the in-person appointment was 16.5 days. The remaining 198 patients (78.0%) were not triaged to receive an in-person appointment following the e-consult,but 2 patients (8.7%) were ultimately seen in-person anyway via other referral pathways, with a median length of 33 days between e-consult completion and the in-person appointment. One hundred seventy-six patients (69.8%) avoided an in-person dermatology visit, although 38 (21.6%) of those patients were fewer than 90 days out from their e-consults at the time of data collection. The 254 e-consults included patients from 50 different zip codes, 49 (98.0%) of which were in North Carolina.

Adult and pediatric electronic consultations (e-consults) resulted in reduced frequencies of in-person dermatology appointments.
Adult and pediatric electronic consultations (e-consults) resulted in reduced frequencies of in-person dermatology appointments.a2 patients had 2 separate e-consults regarding different clinical questions.

Comment

An e-consult is an asynchronous telehealth modality through which PCPs can request specialty evaluation to provide diagnostic and therapeutic guidance, facilitate PCP-specialist coordination of care, and increase access to specialty care with reduced wait times.7,8 Increased care access is especially important, as specialty referral can decrease overall health care expenditure; however, the demand for specialists often exceeds the availability.8 Our e-consult program drastically reduced the time from patients’ initial presentation at their PCP’s office to dermatologist recommendations for treatment or need for in-person dermatology follow-up.

In our analysis, patients were of different racial, ethnic, and socioeconomic backgrounds and lived across a variety of zip codes, predominantly in central and western North Carolina. Almost three-quarters of the patients resided in zip codes where the average income was less than the North Carolina median household income ($66,196).9 Additionally, 82 patients (32.3%) were uninsured or on Medicaid (eTable). These economically disadvantaged patient populations historically have had limited access to dermatologic care.4 One study showed that privately insured individuals were accepted as new patients by dermatologists 91% of the time compared to a 29.8% acceptance rate for publicly insured individuals.10 Uninsured and Medicaid patients also have to wait 34% longer for an appointment compared to individuals with Medicare or private insurance.2 Considering these patients may already be at an economic disadvantage when it comes to seeing and paying for dermatologic services, e-consults may reduce patient travel and appointment expenses while increasing access to specialty care. Based on a 2020 study, each e-consult generates an estimated savings of $80 out-of-pocket per patient per avoided in-person visit.11

 

 

In our study, the most common condition for an e-consult in both adult and pediatric patients was rash, which is consistent with prior e-consult studies.5,11 We found that most e-consult patients were not recommended for an in-person dermatology visit, and for those who were recommended to have an in-person visit, the wait time was reduced (Figure). These results corroborate that e-consults may be used as an important triage tool for determining whether a specialist appointment is indicated as well as a public health tool, as timely evaluation is associated with better dermatologic health care outcomes.3 However, the number of patients who did not present for an in-person appointment in our study may be overestimated, as 38 patients’ (21.6%) e-consults were conducted fewer than 90 days before our data collection. Although none of these patients had been seen in person, it is possible they requested an in-person visit after their medical records were reviewed for this study. Additionally, it is possible patients sought care from outside providers not documented in the EHR.

With regard to the payment model for the e-consult program, Atrium Health Wake Forest Baptist initially piloted the e-consult system through a partnership with the American Academy of Medical Colleges’ Project CORE: Coordinating Optimal Referral Experiences (https://www.aamc.org/what-we-do/mission-areas/health-care/project-core). Grant funding through Project CORE allowed both the referring PCP and the specialist completing the e-consult to each receive approximately 0.5 relative value units in payment for each consult completed. Based on early adoption successes, the institution has created additional internal funding to support the continued expansion of the e-consult system and is incentivized to continue funding, as proper utilization of e-consults improves patient access to timely specialist care, avoids no-shows or last-minute cancellations for specialist appointments, and decreases back-door access to specialist care through the emergency department and urgent care facilities.5 Although 0.5 relative value units is not equivalent compensation to an in-person office visit, our study showed that e-consults can be completed much more quickly and efficiently and do not utilize nursing staff or other office resources.

Conclusion

E-consults are an effective telehealth modality that can increase patients’ access to dermatologic specialty care. Patients who typically are underrepresented in dermatology practices especially may benefit from increased accessibility, and all patients requiring in-person visits may benefit from reduced appointment wait times. The savings generated by in-person appointment avoidance reduce overall health care expenditure as well as the burden of individual expenses. The short turnaround time for e-consults also allows PCPs to better manage dermatologic issues in a timely manner. Integrating and expanding e-consult programs into everyday practice would extend specialty care to broader populations and help reduce barriers to access to dermatologic care.

Acknowledgments—The authors thank the Wake Forest University School of Medicine Department of Medical Education and Department of Dermatology (Winston-Salem, North Carolina) for their contributions to this research study as well as the Wake Forest Clinical and Translational Science Institute (Winston-Salem, North Carolina) for their help extracting EHR data.

References
  1. Hay RJ, Johns NE, Williams HC, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol. 2014;134:1527-1534.
  2. Naka F, Lu J, Porto A, et al. Impact of dermatology econsults on access to care and skin cancer screening in underserved populations: a model for teledermatology services in community health centers. J Am Acad Dermatol. 2018;78:293-302.
  3. Mulcahy A, Mehrotra A, Edison K, et al. Variation in dermatologist visits by sociodemographic characteristics. J Am Acad Dermatol. 2017;76:918-924.
  4. Yang X, Barbieri JS, Kovarik CL. Cost analysis of a store-and-forward teledermatology consult system in Philadelphia. J Am Acad Dermatol. 2019;81:758-764.
  5. Wang RF, Trinidad J, Lawrence J, et al. Improved patient access and outcomes with the integration of an econsult program (teledermatology) within a large academic medical center. J Am Acad Dermatol. 2020;83:1633-1638.
  6. Lee KJ, Finnane A, Soyer HP. Recent trends in teledermatology and teledermoscopy. Dermatol Pract Concept. 2018;8:214-223.
  7. Parikh PJ, Mowrey C, Gallimore J, et al. Evaluating e-consultation implementations based on use and time-line across various specialties. Int J Med Inform. 2017;108:42-48.
  8. Wasfy JH, Rao SK, Kalwani N, et al. Longer-term impact of cardiology e-consults. Am Heart J. 2016;173:86-93.
  9. United States Census Bureau. QuickFacts: North Carolina; United States. Accessed February 26, 2024. https://www.census.gov/quickfacts/fact/table/NC,US/PST045222
  10. Alghothani L, Jacks SK, Vander Horst A, et al. Disparities in access to dermatologic care according to insurance type. Arch Dermatol. 2012;148:956-957.
  11. Seiger K, Hawryluk EB, Kroshinsky D, et al. Pediatric dermatology econsults: reduced wait times and dermatology office visits. Pediatr Dermatol. 2020;37:804-810.
References
  1. Hay RJ, Johns NE, Williams HC, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol. 2014;134:1527-1534.
  2. Naka F, Lu J, Porto A, et al. Impact of dermatology econsults on access to care and skin cancer screening in underserved populations: a model for teledermatology services in community health centers. J Am Acad Dermatol. 2018;78:293-302.
  3. Mulcahy A, Mehrotra A, Edison K, et al. Variation in dermatologist visits by sociodemographic characteristics. J Am Acad Dermatol. 2017;76:918-924.
  4. Yang X, Barbieri JS, Kovarik CL. Cost analysis of a store-and-forward teledermatology consult system in Philadelphia. J Am Acad Dermatol. 2019;81:758-764.
  5. Wang RF, Trinidad J, Lawrence J, et al. Improved patient access and outcomes with the integration of an econsult program (teledermatology) within a large academic medical center. J Am Acad Dermatol. 2020;83:1633-1638.
  6. Lee KJ, Finnane A, Soyer HP. Recent trends in teledermatology and teledermoscopy. Dermatol Pract Concept. 2018;8:214-223.
  7. Parikh PJ, Mowrey C, Gallimore J, et al. Evaluating e-consultation implementations based on use and time-line across various specialties. Int J Med Inform. 2017;108:42-48.
  8. Wasfy JH, Rao SK, Kalwani N, et al. Longer-term impact of cardiology e-consults. Am Heart J. 2016;173:86-93.
  9. United States Census Bureau. QuickFacts: North Carolina; United States. Accessed February 26, 2024. https://www.census.gov/quickfacts/fact/table/NC,US/PST045222
  10. Alghothani L, Jacks SK, Vander Horst A, et al. Disparities in access to dermatologic care according to insurance type. Arch Dermatol. 2012;148:956-957.
  11. Seiger K, Hawryluk EB, Kroshinsky D, et al. Pediatric dermatology econsults: reduced wait times and dermatology office visits. Pediatr Dermatol. 2020;37:804-810.
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  • Most electronic consult patients may be able to avoid in-person dermatology appointments.
  • E-consults can increase patient access to dermatologic specialty care.
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Palliative Care: Utilization Patterns in Inpatient Dermatology

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Palliative Care: Utilization Patterns in Inpatient Dermatology
IN PARTNERSHIP WITH THE SOCIETY OF DERMATOLOGY HOSPITALISTS

Palliative care (PC) is a field of medicine that focuses on improving quality of life by managing physical symptoms as well as mental and spiritual well-being in patients with severe illnesses.1,2 Despite cases of severe dermatologic disease, the use of PC in the field of dermatology is limited, often leaving patients with a range of unmet needs.2,3 In one study that explored PC in patients with melanoma, only one-third of patients with advanced melanoma had a PC consultation.4 Reasons behind the lack of utilization of PC in dermatology include time constraints and limited training in addressing the complex psychosocial needs of patients with severe dermatologic illnesses.1 We conducted a retrospective, cross-sectional, single-institution study of specific inpatient dermatology consultations over a 5-year period to describe PC utilization among patients who were hospitalized with select severe dermatologic diseases.

Methods

A retrospective, cross-sectional study of inpatient dermatology consultations over a 5-year period (October 2016 to October 2021) was performed at Atrium Health Wake Forest Baptist Medical Center (Winston-Salem, North Carolina). Patients’ medical records were reviewed if they had one of the following diseases: bullous pemphigoid, calciphylaxis, cutaneous T-cell lymphoma (CTCL), drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, erythrodermic psoriasis, graft-vs-host disease, pemphigus vulgaris (PV), purpura fulminans, pyoderma gangrenosum, and Stevens-Johnson syndrome/toxic epidermal necrolysis. These diseases were selected for inclusion because they have been associated with a documented increase in inpatient mortality and have been described in the published literature on PC in dermatology.2 This study was reviewed and approved by the Wake Forest University institutional review board.

Use of PC consultative services along with other associated consultative care (ie, recreation therapy [RT], acute pain management, pastoral care) was assessed for each patient. Recreation therapy included specific interventions such as music therapy, arts/craft therapy, pet therapy, and other services with the goal of improving patient cognitive, emotional, and social function. For patients with a completed PC consultation, goals for PC intervention were recorded.

Results

The total study sample included 193 inpatient dermatology consultations. The mean age of the patients was 58.9 years (range, 2–100 years); 66.8% (129/193) were White and 28.5% (55/193) were Black (Table). Palliative care was consulted in 5.7% of cases, with consultations being requested by the primary care team. Reasons for PC consultation included assessment of the patient’s goals of care (4.1% [8/193]), pain management (3.6% [7/193]), non–pain symptom management (2.6% [5/193]), psychosocial support (1.6% [3/193]), and transitions of care (1.0% [2/193]). The average length of patients’ hospital stay prior to PC consultation was 11.5 days(range, 1–32 days). Acute pain management was the reason for consultation in 15.0% of cases (29/193), RT in 21.8% (42/193), and pastoral care in 13.5% (26/193) of cases. Patients with calciphylaxis received the most PC and pain consultations, but fewer than half received these services. Patients with calciphylaxis, PV, purpura fulminans, and CTCL received a higher percentage of PC consultations than the overall cohort, while patients with calciphylaxis, DRESS syndrome, PV, and pyoderma gangrenosum received relatively more pain consultations than the overall cohort (Figure).

Patient Demographics and Dermatologic Diagnosis

Comment

Clinical practice guidelines for quality PC stress the importance of specialists being familiar with these services and the ability to involve PC as part of the treatment plan to achieve better care for patients with serious illnesses.5 Our results demonstrated low rates of PC consultation services for dermatology patients, which supports the existing literature and suggests that PC may be highly underutilized in inpatient settings for patients with serious skin diseases. Use of PC was infrequent and was initiated relatively late in the course of hospital admission, which can negatively impact a patient’s well-being and care experience and can increase the care burden on their caregivers and families.2

Percentage of patients within each disease entity who received palliative care (PC), acute pain management, recreation therapy (RT), or pastoral care consultations during hospitalization.
Percentage of patients within each disease entity who received palliative care (PC), acute pain management, recreation therapy (RT), or pastoral care consultations during hospitalization. BP indicates bullous pemphigoid; CTCL, cutaneous T-cell lymphoma; DRESS, drug reaction with eosinophilia and systemic symptoms; GVHD, graft-vs-host disease; PG, pyoderma gangrenosum; PV, pemphigus vulgaris; SJS/TEN, StevensJohnson syndrome/toxic epidermal necrolysis.

Our results suggest a discrepancy in the frequency of formal PC and other palliative consultative services used for dermatologic diseases, with non-PC services including RT, acute pain management, and pastoral care more likely to be utilized. Impacting this finding may be that RT, pastoral care, and acute pain management are provided by nonphysician providers at our institution, not attending faculty staffing PC services. Patients with calciphylaxis were more likely to have PC consultations, potentially due to medicine providers’ familiarity with its morbidity and mortality, as it is commonly associated with end-stage renal disease. Similarly, internal medicine providers may be more familiar with pain classically associated with PG and PV and may be more likely to engage pain experts. Some diseases with notable morbidity and potential mortality were underrepresented including SJS/TEN, erythrodermic psoriasis, CTCL, and GVHD.

Limitations of our study included examination of data from a single institution, as well as the small sample sizes in specific subgroups, which prevented us from making comparisons between diseases. The cross-sectional design also limited our ability to control for confounding variables.

Conclusion

We urge dermatology consultation services to advocate for patients with serious skin diseases andinclude PC consultation as part of their recommendations to primary care teams. Further research should characterize the specific needs of patients that may be addressed by PC services and explore ways dermatologists and others can identify and provide specialty care to hospitalized patients.

References
  1. Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med. 2015;373:747-755.
  2. Thompson LL, Chen ST, Lawton A, et al. Palliative care in dermatology: a clinical primer, review of the literature, and needs assessment. J Am Acad Dermatol. 2021;85:708-717. doi:10.1016/j.jaad.2020.08.029
  3. Yang CS, Quan VL, Charrow A. The power of a palliative perspective in dermatology. JAMA Dermatol. 2022;158:609-610. doi:10.1001/jamadermatol.2022.1298
  4. Osagiede O, Colibaseanu DT, Spaulding AC, et al. Palliative care use among patients with solid cancer tumors. J Palliat Care. 2018;33:149-158.
  5. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. National Coalition for Hospice and Palliative Care; 2018. Accessed June 21, 2023. https://www.nationalcoalitionhpc.org/wp-content/uploads/2018/10/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf
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From the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

The authors no conflict of interest.

Correspondence: Lindsay C. Strowd, MD, Wake Forest University School of Medicine, Department of Dermatology, Medical Center Blvd, Winston-Salem, NC 27157 (lchaney@wakehealth.edu).

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From the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

The authors no conflict of interest.

Correspondence: Lindsay C. Strowd, MD, Wake Forest University School of Medicine, Department of Dermatology, Medical Center Blvd, Winston-Salem, NC 27157 (lchaney@wakehealth.edu).

Author and Disclosure Information

From the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

The authors no conflict of interest.

Correspondence: Lindsay C. Strowd, MD, Wake Forest University School of Medicine, Department of Dermatology, Medical Center Blvd, Winston-Salem, NC 27157 (lchaney@wakehealth.edu).

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IN PARTNERSHIP WITH THE SOCIETY OF DERMATOLOGY HOSPITALISTS
IN PARTNERSHIP WITH THE SOCIETY OF DERMATOLOGY HOSPITALISTS

Palliative care (PC) is a field of medicine that focuses on improving quality of life by managing physical symptoms as well as mental and spiritual well-being in patients with severe illnesses.1,2 Despite cases of severe dermatologic disease, the use of PC in the field of dermatology is limited, often leaving patients with a range of unmet needs.2,3 In one study that explored PC in patients with melanoma, only one-third of patients with advanced melanoma had a PC consultation.4 Reasons behind the lack of utilization of PC in dermatology include time constraints and limited training in addressing the complex psychosocial needs of patients with severe dermatologic illnesses.1 We conducted a retrospective, cross-sectional, single-institution study of specific inpatient dermatology consultations over a 5-year period to describe PC utilization among patients who were hospitalized with select severe dermatologic diseases.

Methods

A retrospective, cross-sectional study of inpatient dermatology consultations over a 5-year period (October 2016 to October 2021) was performed at Atrium Health Wake Forest Baptist Medical Center (Winston-Salem, North Carolina). Patients’ medical records were reviewed if they had one of the following diseases: bullous pemphigoid, calciphylaxis, cutaneous T-cell lymphoma (CTCL), drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, erythrodermic psoriasis, graft-vs-host disease, pemphigus vulgaris (PV), purpura fulminans, pyoderma gangrenosum, and Stevens-Johnson syndrome/toxic epidermal necrolysis. These diseases were selected for inclusion because they have been associated with a documented increase in inpatient mortality and have been described in the published literature on PC in dermatology.2 This study was reviewed and approved by the Wake Forest University institutional review board.

Use of PC consultative services along with other associated consultative care (ie, recreation therapy [RT], acute pain management, pastoral care) was assessed for each patient. Recreation therapy included specific interventions such as music therapy, arts/craft therapy, pet therapy, and other services with the goal of improving patient cognitive, emotional, and social function. For patients with a completed PC consultation, goals for PC intervention were recorded.

Results

The total study sample included 193 inpatient dermatology consultations. The mean age of the patients was 58.9 years (range, 2–100 years); 66.8% (129/193) were White and 28.5% (55/193) were Black (Table). Palliative care was consulted in 5.7% of cases, with consultations being requested by the primary care team. Reasons for PC consultation included assessment of the patient’s goals of care (4.1% [8/193]), pain management (3.6% [7/193]), non–pain symptom management (2.6% [5/193]), psychosocial support (1.6% [3/193]), and transitions of care (1.0% [2/193]). The average length of patients’ hospital stay prior to PC consultation was 11.5 days(range, 1–32 days). Acute pain management was the reason for consultation in 15.0% of cases (29/193), RT in 21.8% (42/193), and pastoral care in 13.5% (26/193) of cases. Patients with calciphylaxis received the most PC and pain consultations, but fewer than half received these services. Patients with calciphylaxis, PV, purpura fulminans, and CTCL received a higher percentage of PC consultations than the overall cohort, while patients with calciphylaxis, DRESS syndrome, PV, and pyoderma gangrenosum received relatively more pain consultations than the overall cohort (Figure).

Patient Demographics and Dermatologic Diagnosis

Comment

Clinical practice guidelines for quality PC stress the importance of specialists being familiar with these services and the ability to involve PC as part of the treatment plan to achieve better care for patients with serious illnesses.5 Our results demonstrated low rates of PC consultation services for dermatology patients, which supports the existing literature and suggests that PC may be highly underutilized in inpatient settings for patients with serious skin diseases. Use of PC was infrequent and was initiated relatively late in the course of hospital admission, which can negatively impact a patient’s well-being and care experience and can increase the care burden on their caregivers and families.2

Percentage of patients within each disease entity who received palliative care (PC), acute pain management, recreation therapy (RT), or pastoral care consultations during hospitalization.
Percentage of patients within each disease entity who received palliative care (PC), acute pain management, recreation therapy (RT), or pastoral care consultations during hospitalization. BP indicates bullous pemphigoid; CTCL, cutaneous T-cell lymphoma; DRESS, drug reaction with eosinophilia and systemic symptoms; GVHD, graft-vs-host disease; PG, pyoderma gangrenosum; PV, pemphigus vulgaris; SJS/TEN, StevensJohnson syndrome/toxic epidermal necrolysis.

Our results suggest a discrepancy in the frequency of formal PC and other palliative consultative services used for dermatologic diseases, with non-PC services including RT, acute pain management, and pastoral care more likely to be utilized. Impacting this finding may be that RT, pastoral care, and acute pain management are provided by nonphysician providers at our institution, not attending faculty staffing PC services. Patients with calciphylaxis were more likely to have PC consultations, potentially due to medicine providers’ familiarity with its morbidity and mortality, as it is commonly associated with end-stage renal disease. Similarly, internal medicine providers may be more familiar with pain classically associated with PG and PV and may be more likely to engage pain experts. Some diseases with notable morbidity and potential mortality were underrepresented including SJS/TEN, erythrodermic psoriasis, CTCL, and GVHD.

Limitations of our study included examination of data from a single institution, as well as the small sample sizes in specific subgroups, which prevented us from making comparisons between diseases. The cross-sectional design also limited our ability to control for confounding variables.

Conclusion

We urge dermatology consultation services to advocate for patients with serious skin diseases andinclude PC consultation as part of their recommendations to primary care teams. Further research should characterize the specific needs of patients that may be addressed by PC services and explore ways dermatologists and others can identify and provide specialty care to hospitalized patients.

Palliative care (PC) is a field of medicine that focuses on improving quality of life by managing physical symptoms as well as mental and spiritual well-being in patients with severe illnesses.1,2 Despite cases of severe dermatologic disease, the use of PC in the field of dermatology is limited, often leaving patients with a range of unmet needs.2,3 In one study that explored PC in patients with melanoma, only one-third of patients with advanced melanoma had a PC consultation.4 Reasons behind the lack of utilization of PC in dermatology include time constraints and limited training in addressing the complex psychosocial needs of patients with severe dermatologic illnesses.1 We conducted a retrospective, cross-sectional, single-institution study of specific inpatient dermatology consultations over a 5-year period to describe PC utilization among patients who were hospitalized with select severe dermatologic diseases.

Methods

A retrospective, cross-sectional study of inpatient dermatology consultations over a 5-year period (October 2016 to October 2021) was performed at Atrium Health Wake Forest Baptist Medical Center (Winston-Salem, North Carolina). Patients’ medical records were reviewed if they had one of the following diseases: bullous pemphigoid, calciphylaxis, cutaneous T-cell lymphoma (CTCL), drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, erythrodermic psoriasis, graft-vs-host disease, pemphigus vulgaris (PV), purpura fulminans, pyoderma gangrenosum, and Stevens-Johnson syndrome/toxic epidermal necrolysis. These diseases were selected for inclusion because they have been associated with a documented increase in inpatient mortality and have been described in the published literature on PC in dermatology.2 This study was reviewed and approved by the Wake Forest University institutional review board.

Use of PC consultative services along with other associated consultative care (ie, recreation therapy [RT], acute pain management, pastoral care) was assessed for each patient. Recreation therapy included specific interventions such as music therapy, arts/craft therapy, pet therapy, and other services with the goal of improving patient cognitive, emotional, and social function. For patients with a completed PC consultation, goals for PC intervention were recorded.

Results

The total study sample included 193 inpatient dermatology consultations. The mean age of the patients was 58.9 years (range, 2–100 years); 66.8% (129/193) were White and 28.5% (55/193) were Black (Table). Palliative care was consulted in 5.7% of cases, with consultations being requested by the primary care team. Reasons for PC consultation included assessment of the patient’s goals of care (4.1% [8/193]), pain management (3.6% [7/193]), non–pain symptom management (2.6% [5/193]), psychosocial support (1.6% [3/193]), and transitions of care (1.0% [2/193]). The average length of patients’ hospital stay prior to PC consultation was 11.5 days(range, 1–32 days). Acute pain management was the reason for consultation in 15.0% of cases (29/193), RT in 21.8% (42/193), and pastoral care in 13.5% (26/193) of cases. Patients with calciphylaxis received the most PC and pain consultations, but fewer than half received these services. Patients with calciphylaxis, PV, purpura fulminans, and CTCL received a higher percentage of PC consultations than the overall cohort, while patients with calciphylaxis, DRESS syndrome, PV, and pyoderma gangrenosum received relatively more pain consultations than the overall cohort (Figure).

Patient Demographics and Dermatologic Diagnosis

Comment

Clinical practice guidelines for quality PC stress the importance of specialists being familiar with these services and the ability to involve PC as part of the treatment plan to achieve better care for patients with serious illnesses.5 Our results demonstrated low rates of PC consultation services for dermatology patients, which supports the existing literature and suggests that PC may be highly underutilized in inpatient settings for patients with serious skin diseases. Use of PC was infrequent and was initiated relatively late in the course of hospital admission, which can negatively impact a patient’s well-being and care experience and can increase the care burden on their caregivers and families.2

Percentage of patients within each disease entity who received palliative care (PC), acute pain management, recreation therapy (RT), or pastoral care consultations during hospitalization.
Percentage of patients within each disease entity who received palliative care (PC), acute pain management, recreation therapy (RT), or pastoral care consultations during hospitalization. BP indicates bullous pemphigoid; CTCL, cutaneous T-cell lymphoma; DRESS, drug reaction with eosinophilia and systemic symptoms; GVHD, graft-vs-host disease; PG, pyoderma gangrenosum; PV, pemphigus vulgaris; SJS/TEN, StevensJohnson syndrome/toxic epidermal necrolysis.

Our results suggest a discrepancy in the frequency of formal PC and other palliative consultative services used for dermatologic diseases, with non-PC services including RT, acute pain management, and pastoral care more likely to be utilized. Impacting this finding may be that RT, pastoral care, and acute pain management are provided by nonphysician providers at our institution, not attending faculty staffing PC services. Patients with calciphylaxis were more likely to have PC consultations, potentially due to medicine providers’ familiarity with its morbidity and mortality, as it is commonly associated with end-stage renal disease. Similarly, internal medicine providers may be more familiar with pain classically associated with PG and PV and may be more likely to engage pain experts. Some diseases with notable morbidity and potential mortality were underrepresented including SJS/TEN, erythrodermic psoriasis, CTCL, and GVHD.

Limitations of our study included examination of data from a single institution, as well as the small sample sizes in specific subgroups, which prevented us from making comparisons between diseases. The cross-sectional design also limited our ability to control for confounding variables.

Conclusion

We urge dermatology consultation services to advocate for patients with serious skin diseases andinclude PC consultation as part of their recommendations to primary care teams. Further research should characterize the specific needs of patients that may be addressed by PC services and explore ways dermatologists and others can identify and provide specialty care to hospitalized patients.

References
  1. Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med. 2015;373:747-755.
  2. Thompson LL, Chen ST, Lawton A, et al. Palliative care in dermatology: a clinical primer, review of the literature, and needs assessment. J Am Acad Dermatol. 2021;85:708-717. doi:10.1016/j.jaad.2020.08.029
  3. Yang CS, Quan VL, Charrow A. The power of a palliative perspective in dermatology. JAMA Dermatol. 2022;158:609-610. doi:10.1001/jamadermatol.2022.1298
  4. Osagiede O, Colibaseanu DT, Spaulding AC, et al. Palliative care use among patients with solid cancer tumors. J Palliat Care. 2018;33:149-158.
  5. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. National Coalition for Hospice and Palliative Care; 2018. Accessed June 21, 2023. https://www.nationalcoalitionhpc.org/wp-content/uploads/2018/10/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf
References
  1. Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med. 2015;373:747-755.
  2. Thompson LL, Chen ST, Lawton A, et al. Palliative care in dermatology: a clinical primer, review of the literature, and needs assessment. J Am Acad Dermatol. 2021;85:708-717. doi:10.1016/j.jaad.2020.08.029
  3. Yang CS, Quan VL, Charrow A. The power of a palliative perspective in dermatology. JAMA Dermatol. 2022;158:609-610. doi:10.1001/jamadermatol.2022.1298
  4. Osagiede O, Colibaseanu DT, Spaulding AC, et al. Palliative care use among patients with solid cancer tumors. J Palliat Care. 2018;33:149-158.
  5. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. National Coalition for Hospice and Palliative Care; 2018. Accessed June 21, 2023. https://www.nationalcoalitionhpc.org/wp-content/uploads/2018/10/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf
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Practice Points

  • Although severe dermatologic disease negatively impacts patients’ quality of life, palliative care may be underutilized in this population.
  • Palliative care should be an integral part of caring for patients who are admitted to the hospital with serious dermatologic illnesses.
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Interstitial Granulomatous Dermatitis as an Adverse Reaction to Vedolizumab

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Mon, 03/07/2022 - 16:24
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Interstitial Granulomatous Dermatitis as an Adverse Reaction to Vedolizumab

The number of monoclonal antibodies developed for therapeutic use has rapidly expanded over the last decade due to their generally favorable adverse effect (AE) profiles and efficacy.1 Tumor necrosis factor α inhibitors and general integrin antagonists are well-known examples of such monoclonal antibodies. Common conditions utilizing immunotherapy include inflammatory bowel diseases (IBDs), such as Crohn disease and ulcerative colitis (UC).2

The monoclonal antibody vedolizumab, approved in 2014 for moderate to severe UC and Crohn disease, selectively antagonizes α4β7 integrin to target a specific population of gastrointestinal T lymphocytes, preventing their mobilization to areas of inflammation.3 Adverse effects in patients treated with vedolizumab occur at a rate comparable to placebo and largely are considered nonserious4,5; the most commonly reported AE is disease exacerbation (13%–17% of patients).5,6 Published reports of cutaneous AEs at administration of vedolizumab include urticaria during infusion, appearance of cutaneous manifestations characteristic of IBD, psoriasis, Henoch-Schönlein purpura, and Sweet syndrome.7-10

We present the case of a 61-year-old woman with UC who developed reactive granulomatous dermatitis (RGD), interstitial granulomatous dermatitis (IGD) type secondary to vedolizumab. This adverse reaction has not, to our knowledge, been previously reported.

Case Report

A 61-year-old woman with a medical history of UC treated with vedolizumab and myelodysplastic syndrome treated with intravenous immunoglobulin (due to hypogammaglobulinemia following allogeneic stem cell transplantation 14 months prior) presented with a concern of a rash. The patient had been in a baseline state of health until 1 week after receiving her second dose of vedolizumab, at which time she developed a mildly pruritic maculopapular rash on the back and chest. Triamcinolone ointment and hydroxyzine were recommended during an initial telehealth consultation with an oncologist with minimal improvement. The rash continued to spread distally with worsening pruritus.

The patient returned to her oncologist for a routine follow-up appointment 5 days after initial teleconsultation. She reported poor oral intake due to oropharyngeal pain and a worsening rash; her husband added a report of recent onset of somnolence. She was admitted to the hospital, and intravenous fluids were administered.

At admission, the patient was hypotensive; vital signs were otherwise normal. Physical examination revealed the oropharynx was erythematous. Pink lichenoid papules coalescing into plaques were present diffusely across the trunk, arms, and legs; the hands, feet, and face were spared (Figure 1).

Photograph courtesy of William Beuerlein, DO (Jacksonville, Florida).
FIGURE 1. Well-defined papules coalescing into plaques on the anterior aspects of the thighs.

A complete blood cell count and comprehensive metabolic panel were unremarkable. A lumbar puncture, chest radiograph, blood cultures, urinalysis, and urine cultures did not identify a clear infectious cause for the rash, though the workup for infection did raise concern about active cytomegalovirus (CMV) infection with colitis and pneumonitis. Computed tomography of the head showed no acute hemorrhage.

 

 

Dermatology was consulted and determined that the appearance of the rash was most consistent with a lichenoid drug eruption, likely secondary to vedolizumab that was administered 1 week before the rash onset. Analysis of a skin biopsy revealed a dense dermal histiocytic and lymphocytic infiltrate in close approximation to blood vessels, confirmed by immunohistochemical staining for CD45, CD43, CD68, CD34, c-KIT, and myeloperoxidase (Figures 2A and 2B). Colloidal iron staining of the specimen revealed no mucin (Figure 2C).

Photographs courtesy of William Beuerlein, DO (Jacksonville, Florida) and Angela Niehaus, MD (WinstonSalem, North Carolina).
FIGURE 2. A, Histopathology of a punch biopsy revealed a dense dermal infiltrate of mostly chronic inflammatory cells (H&E, original magnification ×400). B, Histiocytes cuffed blood vessels on immunohistochemistry (CD68, original magnification ×400). C, There was an absence of mucin with colloidal iron stain (original magnification ×4).

Taken together, the clinical presentation and histopathologic findings were determined to be most consistent with RGD, IGD type, with secondary vasculitis due to vedolizumab. The patient was treated with triamcinolone ointment and low-dose prednisone. Vedolizumab was discontinued. The rash resolved several weeks after cessation of vedolizumab.

Comment

This case describes the development of RGD, IGD type, as an AE of vedolizumab for the treatment of IBD. Reactive granulomatous dermatitis encompasses a spectrum of cutaneous reactions that includes the diagnosis formerly distinctly identified as IGD.11 This variety of RGD is characterized by histologic findings of heavy histiocytic inflammation in the reticular layer of the dermis with interstitial and perivascular neutrophils, lymphocytes, and histiocytes, as well as the absence of mucin. Interstitial granulomatous dermatitis–type reactions commonly are associated with autoimmune conditions and medications, with accumulating examples occurring in the setting of other biologic therapies, including the IL-6 receptor inhibitor tocilizumab; the programmed death receptor-1 inhibitor nivolumab; and the tumor necrosis factor α inhibitors infliximab, etanercept, and adalimumab.12-15

Although our patient represents CMV infection while being treated with vedolizumab, the relationship between the two is unclear. Development of CMV infection while receiving vedolizumab has been reported in the literature in a patient who was concurrently immunosuppressed with azathioprine.16 In contrast, vedolizumab administration has been utilized as a treatment of CMV infection in IBD patients, either alone or in combination with antiviral agents, with successful resolution of infection.17,18 Additional observations of the interaction between CMV infection and vedolizumab would be required to determine if the onset of CMV infection in this patient represents an additional risk of the medication.

Identifying a relationship between a monoclonal antibody therapy, such as vedolizumab, and RGD, IGD type, might be difficult in clinical practice, particularly if this type of reaction has not been previously associated with the culprit medication. In our patient, onset of cutaneous findings in relation to dosing of vedolizumab and exclusion of other possible causes of the rash supported the decision to stop vedolizumab. However, this decision often is challenging in patients with multiple concurrent medical conditions and those whose therapeutic options are limited.

Conclusion

Ulcerative colitis is not an uncommon condition; utilization of targeted monoclonal antibodies as a treatment strategy is expanding.2,19 As implementation of vedolizumab as a targeted biologic therapy for this disease increases, additional cases of IGD might emerge with greater frequency. Because IBD and autoimmune conditions have a tendency to coincide, awareness of the reaction presented here might be particularly important for dermatologists managing cutaneous manifestations of autoimmune conditions, as patients might present with a clinical picture complicated by preexisting skin findings.20 Furthermore, as reports of RGD, IGD type, in response to several monoclonal antibodies accumulate, it is prudent for all physicians to be aware of this potential complication of this class of medication so that they can make educated decisions about continuing monoclonal antibody therapy.

References
  1. Grilo AL, Mantalaris A. The increasingly human and profitable monoclonal antibody market. Trends Biotechnol. 2019;37:9-16. doi:10.1016/j.tibtech.2018.05.014
  2. Yu H, MacIsaac D, Wong JJ, et al. Market share and costs of biologic therapies for inflammatory bowel disease in the USA. Aliment Pharmacol Ther. 2018;47:364-370. doi:10.1111/apt.14430
  3. Wyant T, Fedyk E, Abhyankar B. An overview of the mechanism of action of the monoclonal antibody vedolizumab. J Crohns Colitis. 2016;10:1437-1444. doi:10.1093/ecco-jcc/jjw092
  4. Mosli MH, MacDonald JK, Bickston SJ, et al. Vedolizumab for induction and maintenance of remission in ulcerative colitis: a Cochrane systematic review and meta-analysis. Inflamm Bowel Dis. 2015;21:1151-1159. doi:10.1097/MIB.0000000000000396
  5. Cohen RD, Bhayat F, Blake A, et al. The safety profile of vedolizumab in ulcerative colitis and Crohn’s disease: 4 years of global post-marketing data. J Crohns Colitis. 2020;14:192-204. doi:10.1093/ecco-jcc/jjz137
  6. Sands BE, Feagan BG, Rutgeerts P, et al. Effects of vedolizumab induction therapy for patients with Crohn’s disease in whom tumor necrosis factor antagonist treatment failed. Gastroenterology. 2014;147:618-627.e3. doi:10.1053/j.gastro.2014.05.008
  7. Tadbiri S, Peyrin-Biroulet L, Serrero M, et al; GETAID OBSERV-IBD Study Group. Impact of vedolizumab therapy on extra-intestinal manifestations in patients with inflammatory bowel disease: a multicentre cohort study nested in the OBSERV-IBD cohort. Aliment Pharmacol Ther. 2018;47:485-493. doi:10.1111/apt.14419
  8. Pereira Guedes T, Pedroto I, Lago P. Vedolizumab-associated psoriasis: until where does gut selectivity go? Rev Esp Enferm Dig. 2020;112:580-581. doi:10.17235/reed.2020.6817/2019
  9. Gold SL, Magro C, Scherl E. A unique infusion reaction to vedolizumab in a patient with Crohn’s disease. Gastroenterology. 2018;155:981-982. doi:10.1053/j.gastro.2018.03.048
  10. Martínez Andrés B, Sastre Lozano V, Sánchez Melgarejo JF. Sweet syndrome after treatment with vedolizumab in a patient with Crohn’s disease. Rev Esp Enferm Dig. 2018;110:530. doi:10.17235/reed.2018.5603/2018
  11. Rosenbach M, English JC 3rd. Reactive granulomatous dermatitis: a review of palisaded neutrophilic and granulomatous dermatitis, interstitial granulomatous dermatitis, interstitial granulomatous drug reaction, and a proposed reclassification. Dermatol Clin. 2015;33:373-387. doi:10.1016/j.det.2015.03.005
  12. Crowson AN, Magro C. Interstitial granulomatous dermatitis with arthritis. Hum Pathol. 2004;35:779-780. doi:10.1016/j.humpath.2004.05.001
  13. Altemir A, Iglesias-Sancho M, Sola-Casas MdeLA, et al. Interstitial granulomatous dermatitis following tocilizumab, a paradoxical reaction? Dermatol Ther. 2020;33:e14207. doi:10.1111/dth.14207
  14. Singh P, Wolfe SP, Alloo A, et al. Interstitial granulomatous dermatitis and granulomatous arteritis in the setting of PD-1 inhibitor therapy for metastatic melanoma. J Cutan Pathol. 2020;47:65-69. doi:10.1111/cup.13562
  15. Deng A, Harvey V, Sina B, et al. Interstitial granulomatous dermatitis associated with the use of tumor necrosis factor alpha inhibitors. Arch Dermatol. 2006;142:198-202. doi:10.1001/archderm.142.2.198
  16. Bonfanti E, Bracco C, Biancheri P, et al. Fever during anti-integrin therapy: new immunodeficiency. Eur J Case Rep Intern Med. 2020;7:001288. doi:10.12890/2020_001288
  17. Rawa-Gołe˛biewska A, Lenarcik M, Zagórowicz E. Resolution of CMV infection in the bowel on vedolizumab therapy. J Crohns Colitis. 2019;13:1234-1235. doi:10.1093/ecco-jcc/jjz033
  18. Hommel C, Pillet S, Rahier J-F. Comment on: ‘Resolution of CMV infection in the bowel on vedolizumab therapy’. J Crohns Colitis. 2020;14:148-149. doi:10.1093/ecco-jcc/jjz108
  19. Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2017;390:2769-2778. doi:10.1016/S0140-6736(17)32448-0
  20. Halling ML, Kjeldsen J, Knudsen T, et al. Patients with inflammatory bowel disease have increased risk of autoimmune and inflammatory diseases. World J Gastroenterol. 2017;23:6137-6146. doi:10.3748/wjg.v23.i33.6137
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Ms. Beuerlein is from the Wake Forest School of Medicine, Winston-Salem, North Carolina. Drs. Martin and Strowd are from the Department of Dermatology, Wake Forest Baptist Health, Winston-Salem.

Ms. Beuerlein and Dr. Martin report no conflict of interest. Dr. Strowd has received grants or funding, or both, from Eli Lilly and Company, Galderma, Janssen Pharmaceuticals, Pfizer, and Sanofi Regeneron.

Correspondence: Katherine G. Beuerlein, BS, Wake Forest School of Medicine, 475 Vine St, Winston-Salem, NC 27101 (katebeuer@yahoo.com).

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Ms. Beuerlein is from the Wake Forest School of Medicine, Winston-Salem, North Carolina. Drs. Martin and Strowd are from the Department of Dermatology, Wake Forest Baptist Health, Winston-Salem.

Ms. Beuerlein and Dr. Martin report no conflict of interest. Dr. Strowd has received grants or funding, or both, from Eli Lilly and Company, Galderma, Janssen Pharmaceuticals, Pfizer, and Sanofi Regeneron.

Correspondence: Katherine G. Beuerlein, BS, Wake Forest School of Medicine, 475 Vine St, Winston-Salem, NC 27101 (katebeuer@yahoo.com).

Author and Disclosure Information

Ms. Beuerlein is from the Wake Forest School of Medicine, Winston-Salem, North Carolina. Drs. Martin and Strowd are from the Department of Dermatology, Wake Forest Baptist Health, Winston-Salem.

Ms. Beuerlein and Dr. Martin report no conflict of interest. Dr. Strowd has received grants or funding, or both, from Eli Lilly and Company, Galderma, Janssen Pharmaceuticals, Pfizer, and Sanofi Regeneron.

Correspondence: Katherine G. Beuerlein, BS, Wake Forest School of Medicine, 475 Vine St, Winston-Salem, NC 27101 (katebeuer@yahoo.com).

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The number of monoclonal antibodies developed for therapeutic use has rapidly expanded over the last decade due to their generally favorable adverse effect (AE) profiles and efficacy.1 Tumor necrosis factor α inhibitors and general integrin antagonists are well-known examples of such monoclonal antibodies. Common conditions utilizing immunotherapy include inflammatory bowel diseases (IBDs), such as Crohn disease and ulcerative colitis (UC).2

The monoclonal antibody vedolizumab, approved in 2014 for moderate to severe UC and Crohn disease, selectively antagonizes α4β7 integrin to target a specific population of gastrointestinal T lymphocytes, preventing their mobilization to areas of inflammation.3 Adverse effects in patients treated with vedolizumab occur at a rate comparable to placebo and largely are considered nonserious4,5; the most commonly reported AE is disease exacerbation (13%–17% of patients).5,6 Published reports of cutaneous AEs at administration of vedolizumab include urticaria during infusion, appearance of cutaneous manifestations characteristic of IBD, psoriasis, Henoch-Schönlein purpura, and Sweet syndrome.7-10

We present the case of a 61-year-old woman with UC who developed reactive granulomatous dermatitis (RGD), interstitial granulomatous dermatitis (IGD) type secondary to vedolizumab. This adverse reaction has not, to our knowledge, been previously reported.

Case Report

A 61-year-old woman with a medical history of UC treated with vedolizumab and myelodysplastic syndrome treated with intravenous immunoglobulin (due to hypogammaglobulinemia following allogeneic stem cell transplantation 14 months prior) presented with a concern of a rash. The patient had been in a baseline state of health until 1 week after receiving her second dose of vedolizumab, at which time she developed a mildly pruritic maculopapular rash on the back and chest. Triamcinolone ointment and hydroxyzine were recommended during an initial telehealth consultation with an oncologist with minimal improvement. The rash continued to spread distally with worsening pruritus.

The patient returned to her oncologist for a routine follow-up appointment 5 days after initial teleconsultation. She reported poor oral intake due to oropharyngeal pain and a worsening rash; her husband added a report of recent onset of somnolence. She was admitted to the hospital, and intravenous fluids were administered.

At admission, the patient was hypotensive; vital signs were otherwise normal. Physical examination revealed the oropharynx was erythematous. Pink lichenoid papules coalescing into plaques were present diffusely across the trunk, arms, and legs; the hands, feet, and face were spared (Figure 1).

Photograph courtesy of William Beuerlein, DO (Jacksonville, Florida).
FIGURE 1. Well-defined papules coalescing into plaques on the anterior aspects of the thighs.

A complete blood cell count and comprehensive metabolic panel were unremarkable. A lumbar puncture, chest radiograph, blood cultures, urinalysis, and urine cultures did not identify a clear infectious cause for the rash, though the workup for infection did raise concern about active cytomegalovirus (CMV) infection with colitis and pneumonitis. Computed tomography of the head showed no acute hemorrhage.

 

 

Dermatology was consulted and determined that the appearance of the rash was most consistent with a lichenoid drug eruption, likely secondary to vedolizumab that was administered 1 week before the rash onset. Analysis of a skin biopsy revealed a dense dermal histiocytic and lymphocytic infiltrate in close approximation to blood vessels, confirmed by immunohistochemical staining for CD45, CD43, CD68, CD34, c-KIT, and myeloperoxidase (Figures 2A and 2B). Colloidal iron staining of the specimen revealed no mucin (Figure 2C).

Photographs courtesy of William Beuerlein, DO (Jacksonville, Florida) and Angela Niehaus, MD (WinstonSalem, North Carolina).
FIGURE 2. A, Histopathology of a punch biopsy revealed a dense dermal infiltrate of mostly chronic inflammatory cells (H&E, original magnification ×400). B, Histiocytes cuffed blood vessels on immunohistochemistry (CD68, original magnification ×400). C, There was an absence of mucin with colloidal iron stain (original magnification ×4).

Taken together, the clinical presentation and histopathologic findings were determined to be most consistent with RGD, IGD type, with secondary vasculitis due to vedolizumab. The patient was treated with triamcinolone ointment and low-dose prednisone. Vedolizumab was discontinued. The rash resolved several weeks after cessation of vedolizumab.

Comment

This case describes the development of RGD, IGD type, as an AE of vedolizumab for the treatment of IBD. Reactive granulomatous dermatitis encompasses a spectrum of cutaneous reactions that includes the diagnosis formerly distinctly identified as IGD.11 This variety of RGD is characterized by histologic findings of heavy histiocytic inflammation in the reticular layer of the dermis with interstitial and perivascular neutrophils, lymphocytes, and histiocytes, as well as the absence of mucin. Interstitial granulomatous dermatitis–type reactions commonly are associated with autoimmune conditions and medications, with accumulating examples occurring in the setting of other biologic therapies, including the IL-6 receptor inhibitor tocilizumab; the programmed death receptor-1 inhibitor nivolumab; and the tumor necrosis factor α inhibitors infliximab, etanercept, and adalimumab.12-15

Although our patient represents CMV infection while being treated with vedolizumab, the relationship between the two is unclear. Development of CMV infection while receiving vedolizumab has been reported in the literature in a patient who was concurrently immunosuppressed with azathioprine.16 In contrast, vedolizumab administration has been utilized as a treatment of CMV infection in IBD patients, either alone or in combination with antiviral agents, with successful resolution of infection.17,18 Additional observations of the interaction between CMV infection and vedolizumab would be required to determine if the onset of CMV infection in this patient represents an additional risk of the medication.

Identifying a relationship between a monoclonal antibody therapy, such as vedolizumab, and RGD, IGD type, might be difficult in clinical practice, particularly if this type of reaction has not been previously associated with the culprit medication. In our patient, onset of cutaneous findings in relation to dosing of vedolizumab and exclusion of other possible causes of the rash supported the decision to stop vedolizumab. However, this decision often is challenging in patients with multiple concurrent medical conditions and those whose therapeutic options are limited.

Conclusion

Ulcerative colitis is not an uncommon condition; utilization of targeted monoclonal antibodies as a treatment strategy is expanding.2,19 As implementation of vedolizumab as a targeted biologic therapy for this disease increases, additional cases of IGD might emerge with greater frequency. Because IBD and autoimmune conditions have a tendency to coincide, awareness of the reaction presented here might be particularly important for dermatologists managing cutaneous manifestations of autoimmune conditions, as patients might present with a clinical picture complicated by preexisting skin findings.20 Furthermore, as reports of RGD, IGD type, in response to several monoclonal antibodies accumulate, it is prudent for all physicians to be aware of this potential complication of this class of medication so that they can make educated decisions about continuing monoclonal antibody therapy.

The number of monoclonal antibodies developed for therapeutic use has rapidly expanded over the last decade due to their generally favorable adverse effect (AE) profiles and efficacy.1 Tumor necrosis factor α inhibitors and general integrin antagonists are well-known examples of such monoclonal antibodies. Common conditions utilizing immunotherapy include inflammatory bowel diseases (IBDs), such as Crohn disease and ulcerative colitis (UC).2

The monoclonal antibody vedolizumab, approved in 2014 for moderate to severe UC and Crohn disease, selectively antagonizes α4β7 integrin to target a specific population of gastrointestinal T lymphocytes, preventing their mobilization to areas of inflammation.3 Adverse effects in patients treated with vedolizumab occur at a rate comparable to placebo and largely are considered nonserious4,5; the most commonly reported AE is disease exacerbation (13%–17% of patients).5,6 Published reports of cutaneous AEs at administration of vedolizumab include urticaria during infusion, appearance of cutaneous manifestations characteristic of IBD, psoriasis, Henoch-Schönlein purpura, and Sweet syndrome.7-10

We present the case of a 61-year-old woman with UC who developed reactive granulomatous dermatitis (RGD), interstitial granulomatous dermatitis (IGD) type secondary to vedolizumab. This adverse reaction has not, to our knowledge, been previously reported.

Case Report

A 61-year-old woman with a medical history of UC treated with vedolizumab and myelodysplastic syndrome treated with intravenous immunoglobulin (due to hypogammaglobulinemia following allogeneic stem cell transplantation 14 months prior) presented with a concern of a rash. The patient had been in a baseline state of health until 1 week after receiving her second dose of vedolizumab, at which time she developed a mildly pruritic maculopapular rash on the back and chest. Triamcinolone ointment and hydroxyzine were recommended during an initial telehealth consultation with an oncologist with minimal improvement. The rash continued to spread distally with worsening pruritus.

The patient returned to her oncologist for a routine follow-up appointment 5 days after initial teleconsultation. She reported poor oral intake due to oropharyngeal pain and a worsening rash; her husband added a report of recent onset of somnolence. She was admitted to the hospital, and intravenous fluids were administered.

At admission, the patient was hypotensive; vital signs were otherwise normal. Physical examination revealed the oropharynx was erythematous. Pink lichenoid papules coalescing into plaques were present diffusely across the trunk, arms, and legs; the hands, feet, and face were spared (Figure 1).

Photograph courtesy of William Beuerlein, DO (Jacksonville, Florida).
FIGURE 1. Well-defined papules coalescing into plaques on the anterior aspects of the thighs.

A complete blood cell count and comprehensive metabolic panel were unremarkable. A lumbar puncture, chest radiograph, blood cultures, urinalysis, and urine cultures did not identify a clear infectious cause for the rash, though the workup for infection did raise concern about active cytomegalovirus (CMV) infection with colitis and pneumonitis. Computed tomography of the head showed no acute hemorrhage.

 

 

Dermatology was consulted and determined that the appearance of the rash was most consistent with a lichenoid drug eruption, likely secondary to vedolizumab that was administered 1 week before the rash onset. Analysis of a skin biopsy revealed a dense dermal histiocytic and lymphocytic infiltrate in close approximation to blood vessels, confirmed by immunohistochemical staining for CD45, CD43, CD68, CD34, c-KIT, and myeloperoxidase (Figures 2A and 2B). Colloidal iron staining of the specimen revealed no mucin (Figure 2C).

Photographs courtesy of William Beuerlein, DO (Jacksonville, Florida) and Angela Niehaus, MD (WinstonSalem, North Carolina).
FIGURE 2. A, Histopathology of a punch biopsy revealed a dense dermal infiltrate of mostly chronic inflammatory cells (H&E, original magnification ×400). B, Histiocytes cuffed blood vessels on immunohistochemistry (CD68, original magnification ×400). C, There was an absence of mucin with colloidal iron stain (original magnification ×4).

Taken together, the clinical presentation and histopathologic findings were determined to be most consistent with RGD, IGD type, with secondary vasculitis due to vedolizumab. The patient was treated with triamcinolone ointment and low-dose prednisone. Vedolizumab was discontinued. The rash resolved several weeks after cessation of vedolizumab.

Comment

This case describes the development of RGD, IGD type, as an AE of vedolizumab for the treatment of IBD. Reactive granulomatous dermatitis encompasses a spectrum of cutaneous reactions that includes the diagnosis formerly distinctly identified as IGD.11 This variety of RGD is characterized by histologic findings of heavy histiocytic inflammation in the reticular layer of the dermis with interstitial and perivascular neutrophils, lymphocytes, and histiocytes, as well as the absence of mucin. Interstitial granulomatous dermatitis–type reactions commonly are associated with autoimmune conditions and medications, with accumulating examples occurring in the setting of other biologic therapies, including the IL-6 receptor inhibitor tocilizumab; the programmed death receptor-1 inhibitor nivolumab; and the tumor necrosis factor α inhibitors infliximab, etanercept, and adalimumab.12-15

Although our patient represents CMV infection while being treated with vedolizumab, the relationship between the two is unclear. Development of CMV infection while receiving vedolizumab has been reported in the literature in a patient who was concurrently immunosuppressed with azathioprine.16 In contrast, vedolizumab administration has been utilized as a treatment of CMV infection in IBD patients, either alone or in combination with antiviral agents, with successful resolution of infection.17,18 Additional observations of the interaction between CMV infection and vedolizumab would be required to determine if the onset of CMV infection in this patient represents an additional risk of the medication.

Identifying a relationship between a monoclonal antibody therapy, such as vedolizumab, and RGD, IGD type, might be difficult in clinical practice, particularly if this type of reaction has not been previously associated with the culprit medication. In our patient, onset of cutaneous findings in relation to dosing of vedolizumab and exclusion of other possible causes of the rash supported the decision to stop vedolizumab. However, this decision often is challenging in patients with multiple concurrent medical conditions and those whose therapeutic options are limited.

Conclusion

Ulcerative colitis is not an uncommon condition; utilization of targeted monoclonal antibodies as a treatment strategy is expanding.2,19 As implementation of vedolizumab as a targeted biologic therapy for this disease increases, additional cases of IGD might emerge with greater frequency. Because IBD and autoimmune conditions have a tendency to coincide, awareness of the reaction presented here might be particularly important for dermatologists managing cutaneous manifestations of autoimmune conditions, as patients might present with a clinical picture complicated by preexisting skin findings.20 Furthermore, as reports of RGD, IGD type, in response to several monoclonal antibodies accumulate, it is prudent for all physicians to be aware of this potential complication of this class of medication so that they can make educated decisions about continuing monoclonal antibody therapy.

References
  1. Grilo AL, Mantalaris A. The increasingly human and profitable monoclonal antibody market. Trends Biotechnol. 2019;37:9-16. doi:10.1016/j.tibtech.2018.05.014
  2. Yu H, MacIsaac D, Wong JJ, et al. Market share and costs of biologic therapies for inflammatory bowel disease in the USA. Aliment Pharmacol Ther. 2018;47:364-370. doi:10.1111/apt.14430
  3. Wyant T, Fedyk E, Abhyankar B. An overview of the mechanism of action of the monoclonal antibody vedolizumab. J Crohns Colitis. 2016;10:1437-1444. doi:10.1093/ecco-jcc/jjw092
  4. Mosli MH, MacDonald JK, Bickston SJ, et al. Vedolizumab for induction and maintenance of remission in ulcerative colitis: a Cochrane systematic review and meta-analysis. Inflamm Bowel Dis. 2015;21:1151-1159. doi:10.1097/MIB.0000000000000396
  5. Cohen RD, Bhayat F, Blake A, et al. The safety profile of vedolizumab in ulcerative colitis and Crohn’s disease: 4 years of global post-marketing data. J Crohns Colitis. 2020;14:192-204. doi:10.1093/ecco-jcc/jjz137
  6. Sands BE, Feagan BG, Rutgeerts P, et al. Effects of vedolizumab induction therapy for patients with Crohn’s disease in whom tumor necrosis factor antagonist treatment failed. Gastroenterology. 2014;147:618-627.e3. doi:10.1053/j.gastro.2014.05.008
  7. Tadbiri S, Peyrin-Biroulet L, Serrero M, et al; GETAID OBSERV-IBD Study Group. Impact of vedolizumab therapy on extra-intestinal manifestations in patients with inflammatory bowel disease: a multicentre cohort study nested in the OBSERV-IBD cohort. Aliment Pharmacol Ther. 2018;47:485-493. doi:10.1111/apt.14419
  8. Pereira Guedes T, Pedroto I, Lago P. Vedolizumab-associated psoriasis: until where does gut selectivity go? Rev Esp Enferm Dig. 2020;112:580-581. doi:10.17235/reed.2020.6817/2019
  9. Gold SL, Magro C, Scherl E. A unique infusion reaction to vedolizumab in a patient with Crohn’s disease. Gastroenterology. 2018;155:981-982. doi:10.1053/j.gastro.2018.03.048
  10. Martínez Andrés B, Sastre Lozano V, Sánchez Melgarejo JF. Sweet syndrome after treatment with vedolizumab in a patient with Crohn’s disease. Rev Esp Enferm Dig. 2018;110:530. doi:10.17235/reed.2018.5603/2018
  11. Rosenbach M, English JC 3rd. Reactive granulomatous dermatitis: a review of palisaded neutrophilic and granulomatous dermatitis, interstitial granulomatous dermatitis, interstitial granulomatous drug reaction, and a proposed reclassification. Dermatol Clin. 2015;33:373-387. doi:10.1016/j.det.2015.03.005
  12. Crowson AN, Magro C. Interstitial granulomatous dermatitis with arthritis. Hum Pathol. 2004;35:779-780. doi:10.1016/j.humpath.2004.05.001
  13. Altemir A, Iglesias-Sancho M, Sola-Casas MdeLA, et al. Interstitial granulomatous dermatitis following tocilizumab, a paradoxical reaction? Dermatol Ther. 2020;33:e14207. doi:10.1111/dth.14207
  14. Singh P, Wolfe SP, Alloo A, et al. Interstitial granulomatous dermatitis and granulomatous arteritis in the setting of PD-1 inhibitor therapy for metastatic melanoma. J Cutan Pathol. 2020;47:65-69. doi:10.1111/cup.13562
  15. Deng A, Harvey V, Sina B, et al. Interstitial granulomatous dermatitis associated with the use of tumor necrosis factor alpha inhibitors. Arch Dermatol. 2006;142:198-202. doi:10.1001/archderm.142.2.198
  16. Bonfanti E, Bracco C, Biancheri P, et al. Fever during anti-integrin therapy: new immunodeficiency. Eur J Case Rep Intern Med. 2020;7:001288. doi:10.12890/2020_001288
  17. Rawa-Gołe˛biewska A, Lenarcik M, Zagórowicz E. Resolution of CMV infection in the bowel on vedolizumab therapy. J Crohns Colitis. 2019;13:1234-1235. doi:10.1093/ecco-jcc/jjz033
  18. Hommel C, Pillet S, Rahier J-F. Comment on: ‘Resolution of CMV infection in the bowel on vedolizumab therapy’. J Crohns Colitis. 2020;14:148-149. doi:10.1093/ecco-jcc/jjz108
  19. Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2017;390:2769-2778. doi:10.1016/S0140-6736(17)32448-0
  20. Halling ML, Kjeldsen J, Knudsen T, et al. Patients with inflammatory bowel disease have increased risk of autoimmune and inflammatory diseases. World J Gastroenterol. 2017;23:6137-6146. doi:10.3748/wjg.v23.i33.6137
References
  1. Grilo AL, Mantalaris A. The increasingly human and profitable monoclonal antibody market. Trends Biotechnol. 2019;37:9-16. doi:10.1016/j.tibtech.2018.05.014
  2. Yu H, MacIsaac D, Wong JJ, et al. Market share and costs of biologic therapies for inflammatory bowel disease in the USA. Aliment Pharmacol Ther. 2018;47:364-370. doi:10.1111/apt.14430
  3. Wyant T, Fedyk E, Abhyankar B. An overview of the mechanism of action of the monoclonal antibody vedolizumab. J Crohns Colitis. 2016;10:1437-1444. doi:10.1093/ecco-jcc/jjw092
  4. Mosli MH, MacDonald JK, Bickston SJ, et al. Vedolizumab for induction and maintenance of remission in ulcerative colitis: a Cochrane systematic review and meta-analysis. Inflamm Bowel Dis. 2015;21:1151-1159. doi:10.1097/MIB.0000000000000396
  5. Cohen RD, Bhayat F, Blake A, et al. The safety profile of vedolizumab in ulcerative colitis and Crohn’s disease: 4 years of global post-marketing data. J Crohns Colitis. 2020;14:192-204. doi:10.1093/ecco-jcc/jjz137
  6. Sands BE, Feagan BG, Rutgeerts P, et al. Effects of vedolizumab induction therapy for patients with Crohn’s disease in whom tumor necrosis factor antagonist treatment failed. Gastroenterology. 2014;147:618-627.e3. doi:10.1053/j.gastro.2014.05.008
  7. Tadbiri S, Peyrin-Biroulet L, Serrero M, et al; GETAID OBSERV-IBD Study Group. Impact of vedolizumab therapy on extra-intestinal manifestations in patients with inflammatory bowel disease: a multicentre cohort study nested in the OBSERV-IBD cohort. Aliment Pharmacol Ther. 2018;47:485-493. doi:10.1111/apt.14419
  8. Pereira Guedes T, Pedroto I, Lago P. Vedolizumab-associated psoriasis: until where does gut selectivity go? Rev Esp Enferm Dig. 2020;112:580-581. doi:10.17235/reed.2020.6817/2019
  9. Gold SL, Magro C, Scherl E. A unique infusion reaction to vedolizumab in a patient with Crohn’s disease. Gastroenterology. 2018;155:981-982. doi:10.1053/j.gastro.2018.03.048
  10. Martínez Andrés B, Sastre Lozano V, Sánchez Melgarejo JF. Sweet syndrome after treatment with vedolizumab in a patient with Crohn’s disease. Rev Esp Enferm Dig. 2018;110:530. doi:10.17235/reed.2018.5603/2018
  11. Rosenbach M, English JC 3rd. Reactive granulomatous dermatitis: a review of palisaded neutrophilic and granulomatous dermatitis, interstitial granulomatous dermatitis, interstitial granulomatous drug reaction, and a proposed reclassification. Dermatol Clin. 2015;33:373-387. doi:10.1016/j.det.2015.03.005
  12. Crowson AN, Magro C. Interstitial granulomatous dermatitis with arthritis. Hum Pathol. 2004;35:779-780. doi:10.1016/j.humpath.2004.05.001
  13. Altemir A, Iglesias-Sancho M, Sola-Casas MdeLA, et al. Interstitial granulomatous dermatitis following tocilizumab, a paradoxical reaction? Dermatol Ther. 2020;33:e14207. doi:10.1111/dth.14207
  14. Singh P, Wolfe SP, Alloo A, et al. Interstitial granulomatous dermatitis and granulomatous arteritis in the setting of PD-1 inhibitor therapy for metastatic melanoma. J Cutan Pathol. 2020;47:65-69. doi:10.1111/cup.13562
  15. Deng A, Harvey V, Sina B, et al. Interstitial granulomatous dermatitis associated with the use of tumor necrosis factor alpha inhibitors. Arch Dermatol. 2006;142:198-202. doi:10.1001/archderm.142.2.198
  16. Bonfanti E, Bracco C, Biancheri P, et al. Fever during anti-integrin therapy: new immunodeficiency. Eur J Case Rep Intern Med. 2020;7:001288. doi:10.12890/2020_001288
  17. Rawa-Gołe˛biewska A, Lenarcik M, Zagórowicz E. Resolution of CMV infection in the bowel on vedolizumab therapy. J Crohns Colitis. 2019;13:1234-1235. doi:10.1093/ecco-jcc/jjz033
  18. Hommel C, Pillet S, Rahier J-F. Comment on: ‘Resolution of CMV infection in the bowel on vedolizumab therapy’. J Crohns Colitis. 2020;14:148-149. doi:10.1093/ecco-jcc/jjz108
  19. Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2017;390:2769-2778. doi:10.1016/S0140-6736(17)32448-0
  20. Halling ML, Kjeldsen J, Knudsen T, et al. Patients with inflammatory bowel disease have increased risk of autoimmune and inflammatory diseases. World J Gastroenterol. 2017;23:6137-6146. doi:10.3748/wjg.v23.i33.6137
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  • Reactive granulomatous dermatitis, interstitial granulomatous dermatitis (IGD) type, can occur as an adverse reaction to vedolizumab despite the minimal adverse effect profile of the medication.
  • Evidence of IGD type reactions to monoclonal antibodies is accumulating; this disorder can be considered in the differential diagnosis for patients who develop a new rash when treated with an agent of this therapeutic class.
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Concurrent Atopic Dermatitis and Psoriasis Vulgaris: Implications for Targeted Biologic Therapy

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Concurrent Atopic Dermatitis and Psoriasis Vulgaris: Implications for Targeted Biologic Therapy

Psoriasis vulgaris is a chronic inflammatory skin condition associated with notable elevation in helper T cell (TH) production of TH1/TH17-mediated inflammatory cytokines, including IL-17A.1 Upon binding of IL-17A to IL-17 receptors in the skin, an inflammatory cascade is triggered, resulting in the classic clinical appearance of psoriasis. Moderate to severe psoriasis often is managed by suppressing TH1/TH17-mediated inflammation using targeted immune therapy such as secukinumab, an IL-17A inhibitor.2 Atopic dermatitis (AD), another chronic inflammatory dermatosis, is associated with substantial elevation in TH2-mediated inflammatory cytokines, such as IL-4.3 Dupilumab, which interacts with IL-4R, disrupts the IL-4 and IL-13 signaling pathways and demonstrates considerable efficacy in the treatment of moderate to severe AD.4

A case series has shown that suppression of the TH1/TH17-mediated inflammation of psoriasis may paradoxically result in the development of TH2-mediated AD.5 Similarly, a recent case report described a patient who developed psoriasis following treatment of AD with dupilumab.6 Herein, we describe a patient with a history of psoriasis that was well controlled with secukinumab who developed severe refractory erythrodermic AD that resolved with dupilumab treatment. Following clearance of AD with dupilumab, he exhibited psoriasis recurrence.

Case Report

A 39-year-old man with a lifelong history of psoriasis was admitted to the hospital for management of severe erythroderma. Four years prior, secukinumab was initiated for treatment of psoriasis, resulting in excellent clinical response. He discontinued secukinumab after 2 years of treatment because of insurance coverage issues and managed his condition with only topical corticosteroids. He restarted secukinumab 10 months before admission because of a psoriasis flare. Shortly after resuming secukinumab, he developed a severe exfoliative erythroderma that was not responsive to corticosteroids, etanercept, methotrexate, or ustekinumab.

A psoriasis patient who was treated with secukinumab later developed atopic dermatitis.
FIGURE 1. A psoriasis patient who was treated with secukinumab later developed atopic dermatitis. A, Diffuse erythema and edema of the lower extremities. B, Diffuse erythema and scaling of the back.

On initial presentation, physical examination revealed diffuse erythema and scaling with associated edema of the face, trunk, and extremities (Figure 1). A biopsy from the patient’s right arm demonstrated a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis (Figure 2). Cyclosporine 225 mg twice daily and topical corticosteroids were started.

Histopathology of an erythroderma biopsy revealed a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis.
FIGURE 2. Histopathology of an erythroderma biopsy revealed a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis (H&E, original magnification ×40).

Over the next several months, the patient had several admissions secondary to recurrent skin abscesses in the setting of refractory erythroderma. He underwent trials of infliximab, corticosteroids, intravenous immunoglobulin, guselkumab, and acitretin with minimal improvement. He underwent an extensive laboratory and radiologic workup, which was notable for cyclical peripheral eosinophilia and elevated IgE levels correlating with the erythroderma flares. A second biopsy was obtained and continued to demonstrate changes consistent with AD.

Scattered erythematous plaques with overlying silvery scale were seen on the abdomen.
FIGURE 3. Following treatment of atopic dermatitis with dupilumab, psoriatic lesions recurred. Scattered erythematous plaques with overlying silvery scale were seen on the abdomen.

Four months after the initial hospitalization, all psoriasis medications were stopped, and the patient was started on dupilumab 300 mg/2 mL every 2 weeks and an 8-week oral prednisone taper. This combination led to notable clinical improvement and resolution of peripheral eosinophilia. Several months after disease remission, he began to develop worsening erythema and pruritus on the trunk and extremities, followed by the development of new psoriatic lesions (Figure 3) with a biopsy consistent with psoriasis (Figure 4). The patient was continued on dupilumab, but cyclosporine was added. The patient self-discontinued dupilumab owing to injection-site discomfort and has been slowly weaning off oral cyclosporine with 1 to 2 remaining eczematous plaques and 1 to 2 psoriatic plaques managed by topical corticosteroids.

Histopathology revealed new psoriatic lesions following treatment of atopic dermatitis with dupilumab.
FIGURE 4. Histopathology revealed new psoriatic lesions following treatment of atopic dermatitis with dupilumab (H&E, original magnification ×20).

Comment

We present a patient with psoriasis that was well controlled on secukinumab who developed severe AD following treatment with secukinumab. The AD resolved following treatment with dupilumab and a tapering dose of prednisone. However, after several months of treatment with dupilumab alone, he began to develop psoriatic lesions again. This case supports findings in a case series describing the development of AD in patients with psoriasis treated with IL-17 inhibitors5 and a recent case report describing a patient with AD who developed psoriasis following treatment with an IL-4/IL-13 inhibitor.6

 

 

Recognized adverse effects demonstrate biologic medications’ contributions to both normal as well as aberrant immunologic responses. For example, IL-17 plays an essential role in innate and adaptive immune responses against infections at mucosal and cutaneous interfaces, as demonstrated by chronic mucocutaneous candidiasis in patients with genetic defects in IL-17–related pathways.7 Similarly, in patients taking IL-17 antagonists, an increase in the incidence of Candida infections has been observed.8 In patients with concurrent psoriasis and inflammatory bowel disease (IBD), treatment with IL-17 inhibitors is contraindicated due to the risk of exacerbating the IBD. This observation is somewhat paradoxical, as increased IL-17 release by TH17 cells is implicated in the pathogenesis of IBD.9 Interestingly, it is now thought that IL-17 may play a protective role in T-cell–driven intestinal inflammation through induction of protective intestinal epithelial gene expression and increased mucosal defense against gut microbes, explaining the worsening of IBD in patients on IL-17 inhibitors.10 These adverse effects illustrate the complicated and varied roles biologic medications play in immunologic response.

Given that TH1 and TH2 exert opposing immune mechanisms, it is uncommon for psoriasis and AD to coexist in a single patient. However, patients who exhibit concurrent findings may represent a unique population in which psoriasis and AD coexist, perhaps because of an underlying genetic predisposition. Moreover, targeted treatment of pathways unique to these disease processes may result in paradoxical flaring of the nontargeted pathway. It also is possible that inhibition of a specific T-cell pathway in a subset of patients will result in an immunologic imbalance, favoring increased activity of the opposing pathway in the absence of coexisting disease. In the case presented here, the findings may be explained by secukinumab’s inhibition of TH1/TH17-mediated inflammation, which resulted in a shift to a TH2-mediated inflammatory response manifesting as AD, as well as dupilumab’s inhibition of TH2-mediated inflammation, which caused a shift back to TH1-mediated inflammatory pathways. Additionally, for patients with changing morphologies exacerbated by biologic medications, alternative diagnoses, such as cutaneous T-cell lymphoma, may be considered.

Conclusion

We report an unusual case of secukinumab-induced AD in a patient with psoriasis that resolved following several months of treatment with dupilumab and a tapering dose of prednisone. Subsequently, this same patient developed re-emergence of psoriatic lesions with continued use of dupilumab, which was eventually discontinued by the patient despite appropriate disease control. In addition to illustrating the underlying pathophysiologic mechanisms of 2 common inflammatory dermatologic conditions, this case highlights how pharmacologic interventions targeted at specific immunologic pathways may have unintended consequences. Further investigation into the effects of targeted biologics on the TH1/TH2 immune axis is warranted to better understand the mechanism and possible implications of the phenotypic switching presented in this case.

References
  1. Diani M, Altomare G, Reali E. T helper cell subsets in clinical manifestations of psoriasis. J Immunol Res. 2016;2016:7692024.
  2. Langley RG, Elewski BE, Lebwohl M, et al. Secukinumab in plaque psoriasis—results of two phase 3 trials. N Engl J Med. 2014;371:326-338.
  3. van der Heijden FL, Wierenga EA, Bos JD, et al. High frequency of IL-4-producing CD4+ allergen-specific T lymphocytes in atopic dermatitis lesional skin. J Invest Dermatol. 1991;97:389-394.
  4. Beck LA, Thaçi D, Hamilton JD, et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. N Engl J Med. 2014;371:130-139.
  5. Lai FYX, Higgins E, Smith CH, et al. Morphologic switch from psoriasiform to eczematous dermatitis after anti-IL-17 therapy: a case series. JAMA Dermatol. 2019;155:1082-1084.
  6. Varma A, Levitt J. Dupilumab-induced phenotype switching from atopic dermatitis to psoriasis. JAAD Case Rep. 2020;6:217-218.
  7. Ling Y, Puel A. IL-17 and infections. Actas Dermosifiliogr. 2014;105(suppl 1):34-40.
  8. Saunte DM, Mrowietz U, Puig L, et al. Candida infections in patients with psoriasis and psoriatic arthritis treated with interleukin-17 inhibitors and their practical management. Br J Dermatol. 2017;177:47-62.
  9. Hölttä V, Klemetti P, Sipponen T, et al. IL-23/IL-17 immunity as a hallmark of Crohn’s disease. Inflamm Bowel Dis. 2008;14:1175-1184.
  10. Smith MK, Pai J, Panaccione R, et al. Crohn’s-like disease in a patient exposed to anti-interleukin-17 blockade (ixekizumab) for the treatment of chronic plaque psoriasis: a case report. BMC Gastroenterol. 2019;19:162.
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The authors report no conflict of interest.

Correspondence: Matthew C. Johnson, MD, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (mattcjohnson.md@gmail.com).

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Psoriasis vulgaris is a chronic inflammatory skin condition associated with notable elevation in helper T cell (TH) production of TH1/TH17-mediated inflammatory cytokines, including IL-17A.1 Upon binding of IL-17A to IL-17 receptors in the skin, an inflammatory cascade is triggered, resulting in the classic clinical appearance of psoriasis. Moderate to severe psoriasis often is managed by suppressing TH1/TH17-mediated inflammation using targeted immune therapy such as secukinumab, an IL-17A inhibitor.2 Atopic dermatitis (AD), another chronic inflammatory dermatosis, is associated with substantial elevation in TH2-mediated inflammatory cytokines, such as IL-4.3 Dupilumab, which interacts with IL-4R, disrupts the IL-4 and IL-13 signaling pathways and demonstrates considerable efficacy in the treatment of moderate to severe AD.4

A case series has shown that suppression of the TH1/TH17-mediated inflammation of psoriasis may paradoxically result in the development of TH2-mediated AD.5 Similarly, a recent case report described a patient who developed psoriasis following treatment of AD with dupilumab.6 Herein, we describe a patient with a history of psoriasis that was well controlled with secukinumab who developed severe refractory erythrodermic AD that resolved with dupilumab treatment. Following clearance of AD with dupilumab, he exhibited psoriasis recurrence.

Case Report

A 39-year-old man with a lifelong history of psoriasis was admitted to the hospital for management of severe erythroderma. Four years prior, secukinumab was initiated for treatment of psoriasis, resulting in excellent clinical response. He discontinued secukinumab after 2 years of treatment because of insurance coverage issues and managed his condition with only topical corticosteroids. He restarted secukinumab 10 months before admission because of a psoriasis flare. Shortly after resuming secukinumab, he developed a severe exfoliative erythroderma that was not responsive to corticosteroids, etanercept, methotrexate, or ustekinumab.

A psoriasis patient who was treated with secukinumab later developed atopic dermatitis.
FIGURE 1. A psoriasis patient who was treated with secukinumab later developed atopic dermatitis. A, Diffuse erythema and edema of the lower extremities. B, Diffuse erythema and scaling of the back.

On initial presentation, physical examination revealed diffuse erythema and scaling with associated edema of the face, trunk, and extremities (Figure 1). A biopsy from the patient’s right arm demonstrated a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis (Figure 2). Cyclosporine 225 mg twice daily and topical corticosteroids were started.

Histopathology of an erythroderma biopsy revealed a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis.
FIGURE 2. Histopathology of an erythroderma biopsy revealed a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis (H&E, original magnification ×40).

Over the next several months, the patient had several admissions secondary to recurrent skin abscesses in the setting of refractory erythroderma. He underwent trials of infliximab, corticosteroids, intravenous immunoglobulin, guselkumab, and acitretin with minimal improvement. He underwent an extensive laboratory and radiologic workup, which was notable for cyclical peripheral eosinophilia and elevated IgE levels correlating with the erythroderma flares. A second biopsy was obtained and continued to demonstrate changes consistent with AD.

Scattered erythematous plaques with overlying silvery scale were seen on the abdomen.
FIGURE 3. Following treatment of atopic dermatitis with dupilumab, psoriatic lesions recurred. Scattered erythematous plaques with overlying silvery scale were seen on the abdomen.

Four months after the initial hospitalization, all psoriasis medications were stopped, and the patient was started on dupilumab 300 mg/2 mL every 2 weeks and an 8-week oral prednisone taper. This combination led to notable clinical improvement and resolution of peripheral eosinophilia. Several months after disease remission, he began to develop worsening erythema and pruritus on the trunk and extremities, followed by the development of new psoriatic lesions (Figure 3) with a biopsy consistent with psoriasis (Figure 4). The patient was continued on dupilumab, but cyclosporine was added. The patient self-discontinued dupilumab owing to injection-site discomfort and has been slowly weaning off oral cyclosporine with 1 to 2 remaining eczematous plaques and 1 to 2 psoriatic plaques managed by topical corticosteroids.

Histopathology revealed new psoriatic lesions following treatment of atopic dermatitis with dupilumab.
FIGURE 4. Histopathology revealed new psoriatic lesions following treatment of atopic dermatitis with dupilumab (H&E, original magnification ×20).

Comment

We present a patient with psoriasis that was well controlled on secukinumab who developed severe AD following treatment with secukinumab. The AD resolved following treatment with dupilumab and a tapering dose of prednisone. However, after several months of treatment with dupilumab alone, he began to develop psoriatic lesions again. This case supports findings in a case series describing the development of AD in patients with psoriasis treated with IL-17 inhibitors5 and a recent case report describing a patient with AD who developed psoriasis following treatment with an IL-4/IL-13 inhibitor.6

 

 

Recognized adverse effects demonstrate biologic medications’ contributions to both normal as well as aberrant immunologic responses. For example, IL-17 plays an essential role in innate and adaptive immune responses against infections at mucosal and cutaneous interfaces, as demonstrated by chronic mucocutaneous candidiasis in patients with genetic defects in IL-17–related pathways.7 Similarly, in patients taking IL-17 antagonists, an increase in the incidence of Candida infections has been observed.8 In patients with concurrent psoriasis and inflammatory bowel disease (IBD), treatment with IL-17 inhibitors is contraindicated due to the risk of exacerbating the IBD. This observation is somewhat paradoxical, as increased IL-17 release by TH17 cells is implicated in the pathogenesis of IBD.9 Interestingly, it is now thought that IL-17 may play a protective role in T-cell–driven intestinal inflammation through induction of protective intestinal epithelial gene expression and increased mucosal defense against gut microbes, explaining the worsening of IBD in patients on IL-17 inhibitors.10 These adverse effects illustrate the complicated and varied roles biologic medications play in immunologic response.

Given that TH1 and TH2 exert opposing immune mechanisms, it is uncommon for psoriasis and AD to coexist in a single patient. However, patients who exhibit concurrent findings may represent a unique population in which psoriasis and AD coexist, perhaps because of an underlying genetic predisposition. Moreover, targeted treatment of pathways unique to these disease processes may result in paradoxical flaring of the nontargeted pathway. It also is possible that inhibition of a specific T-cell pathway in a subset of patients will result in an immunologic imbalance, favoring increased activity of the opposing pathway in the absence of coexisting disease. In the case presented here, the findings may be explained by secukinumab’s inhibition of TH1/TH17-mediated inflammation, which resulted in a shift to a TH2-mediated inflammatory response manifesting as AD, as well as dupilumab’s inhibition of TH2-mediated inflammation, which caused a shift back to TH1-mediated inflammatory pathways. Additionally, for patients with changing morphologies exacerbated by biologic medications, alternative diagnoses, such as cutaneous T-cell lymphoma, may be considered.

Conclusion

We report an unusual case of secukinumab-induced AD in a patient with psoriasis that resolved following several months of treatment with dupilumab and a tapering dose of prednisone. Subsequently, this same patient developed re-emergence of psoriatic lesions with continued use of dupilumab, which was eventually discontinued by the patient despite appropriate disease control. In addition to illustrating the underlying pathophysiologic mechanisms of 2 common inflammatory dermatologic conditions, this case highlights how pharmacologic interventions targeted at specific immunologic pathways may have unintended consequences. Further investigation into the effects of targeted biologics on the TH1/TH2 immune axis is warranted to better understand the mechanism and possible implications of the phenotypic switching presented in this case.

Psoriasis vulgaris is a chronic inflammatory skin condition associated with notable elevation in helper T cell (TH) production of TH1/TH17-mediated inflammatory cytokines, including IL-17A.1 Upon binding of IL-17A to IL-17 receptors in the skin, an inflammatory cascade is triggered, resulting in the classic clinical appearance of psoriasis. Moderate to severe psoriasis often is managed by suppressing TH1/TH17-mediated inflammation using targeted immune therapy such as secukinumab, an IL-17A inhibitor.2 Atopic dermatitis (AD), another chronic inflammatory dermatosis, is associated with substantial elevation in TH2-mediated inflammatory cytokines, such as IL-4.3 Dupilumab, which interacts with IL-4R, disrupts the IL-4 and IL-13 signaling pathways and demonstrates considerable efficacy in the treatment of moderate to severe AD.4

A case series has shown that suppression of the TH1/TH17-mediated inflammation of psoriasis may paradoxically result in the development of TH2-mediated AD.5 Similarly, a recent case report described a patient who developed psoriasis following treatment of AD with dupilumab.6 Herein, we describe a patient with a history of psoriasis that was well controlled with secukinumab who developed severe refractory erythrodermic AD that resolved with dupilumab treatment. Following clearance of AD with dupilumab, he exhibited psoriasis recurrence.

Case Report

A 39-year-old man with a lifelong history of psoriasis was admitted to the hospital for management of severe erythroderma. Four years prior, secukinumab was initiated for treatment of psoriasis, resulting in excellent clinical response. He discontinued secukinumab after 2 years of treatment because of insurance coverage issues and managed his condition with only topical corticosteroids. He restarted secukinumab 10 months before admission because of a psoriasis flare. Shortly after resuming secukinumab, he developed a severe exfoliative erythroderma that was not responsive to corticosteroids, etanercept, methotrexate, or ustekinumab.

A psoriasis patient who was treated with secukinumab later developed atopic dermatitis.
FIGURE 1. A psoriasis patient who was treated with secukinumab later developed atopic dermatitis. A, Diffuse erythema and edema of the lower extremities. B, Diffuse erythema and scaling of the back.

On initial presentation, physical examination revealed diffuse erythema and scaling with associated edema of the face, trunk, and extremities (Figure 1). A biopsy from the patient’s right arm demonstrated a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis (Figure 2). Cyclosporine 225 mg twice daily and topical corticosteroids were started.

Histopathology of an erythroderma biopsy revealed a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis.
FIGURE 2. Histopathology of an erythroderma biopsy revealed a superficial perivascular inflammatory infiltrate composed of lymphocytes, histiocytes, and scattered eosinophils consistent with spongiotic dermatitis (H&E, original magnification ×40).

Over the next several months, the patient had several admissions secondary to recurrent skin abscesses in the setting of refractory erythroderma. He underwent trials of infliximab, corticosteroids, intravenous immunoglobulin, guselkumab, and acitretin with minimal improvement. He underwent an extensive laboratory and radiologic workup, which was notable for cyclical peripheral eosinophilia and elevated IgE levels correlating with the erythroderma flares. A second biopsy was obtained and continued to demonstrate changes consistent with AD.

Scattered erythematous plaques with overlying silvery scale were seen on the abdomen.
FIGURE 3. Following treatment of atopic dermatitis with dupilumab, psoriatic lesions recurred. Scattered erythematous plaques with overlying silvery scale were seen on the abdomen.

Four months after the initial hospitalization, all psoriasis medications were stopped, and the patient was started on dupilumab 300 mg/2 mL every 2 weeks and an 8-week oral prednisone taper. This combination led to notable clinical improvement and resolution of peripheral eosinophilia. Several months after disease remission, he began to develop worsening erythema and pruritus on the trunk and extremities, followed by the development of new psoriatic lesions (Figure 3) with a biopsy consistent with psoriasis (Figure 4). The patient was continued on dupilumab, but cyclosporine was added. The patient self-discontinued dupilumab owing to injection-site discomfort and has been slowly weaning off oral cyclosporine with 1 to 2 remaining eczematous plaques and 1 to 2 psoriatic plaques managed by topical corticosteroids.

Histopathology revealed new psoriatic lesions following treatment of atopic dermatitis with dupilumab.
FIGURE 4. Histopathology revealed new psoriatic lesions following treatment of atopic dermatitis with dupilumab (H&E, original magnification ×20).

Comment

We present a patient with psoriasis that was well controlled on secukinumab who developed severe AD following treatment with secukinumab. The AD resolved following treatment with dupilumab and a tapering dose of prednisone. However, after several months of treatment with dupilumab alone, he began to develop psoriatic lesions again. This case supports findings in a case series describing the development of AD in patients with psoriasis treated with IL-17 inhibitors5 and a recent case report describing a patient with AD who developed psoriasis following treatment with an IL-4/IL-13 inhibitor.6

 

 

Recognized adverse effects demonstrate biologic medications’ contributions to both normal as well as aberrant immunologic responses. For example, IL-17 plays an essential role in innate and adaptive immune responses against infections at mucosal and cutaneous interfaces, as demonstrated by chronic mucocutaneous candidiasis in patients with genetic defects in IL-17–related pathways.7 Similarly, in patients taking IL-17 antagonists, an increase in the incidence of Candida infections has been observed.8 In patients with concurrent psoriasis and inflammatory bowel disease (IBD), treatment with IL-17 inhibitors is contraindicated due to the risk of exacerbating the IBD. This observation is somewhat paradoxical, as increased IL-17 release by TH17 cells is implicated in the pathogenesis of IBD.9 Interestingly, it is now thought that IL-17 may play a protective role in T-cell–driven intestinal inflammation through induction of protective intestinal epithelial gene expression and increased mucosal defense against gut microbes, explaining the worsening of IBD in patients on IL-17 inhibitors.10 These adverse effects illustrate the complicated and varied roles biologic medications play in immunologic response.

Given that TH1 and TH2 exert opposing immune mechanisms, it is uncommon for psoriasis and AD to coexist in a single patient. However, patients who exhibit concurrent findings may represent a unique population in which psoriasis and AD coexist, perhaps because of an underlying genetic predisposition. Moreover, targeted treatment of pathways unique to these disease processes may result in paradoxical flaring of the nontargeted pathway. It also is possible that inhibition of a specific T-cell pathway in a subset of patients will result in an immunologic imbalance, favoring increased activity of the opposing pathway in the absence of coexisting disease. In the case presented here, the findings may be explained by secukinumab’s inhibition of TH1/TH17-mediated inflammation, which resulted in a shift to a TH2-mediated inflammatory response manifesting as AD, as well as dupilumab’s inhibition of TH2-mediated inflammation, which caused a shift back to TH1-mediated inflammatory pathways. Additionally, for patients with changing morphologies exacerbated by biologic medications, alternative diagnoses, such as cutaneous T-cell lymphoma, may be considered.

Conclusion

We report an unusual case of secukinumab-induced AD in a patient with psoriasis that resolved following several months of treatment with dupilumab and a tapering dose of prednisone. Subsequently, this same patient developed re-emergence of psoriatic lesions with continued use of dupilumab, which was eventually discontinued by the patient despite appropriate disease control. In addition to illustrating the underlying pathophysiologic mechanisms of 2 common inflammatory dermatologic conditions, this case highlights how pharmacologic interventions targeted at specific immunologic pathways may have unintended consequences. Further investigation into the effects of targeted biologics on the TH1/TH2 immune axis is warranted to better understand the mechanism and possible implications of the phenotypic switching presented in this case.

References
  1. Diani M, Altomare G, Reali E. T helper cell subsets in clinical manifestations of psoriasis. J Immunol Res. 2016;2016:7692024.
  2. Langley RG, Elewski BE, Lebwohl M, et al. Secukinumab in plaque psoriasis—results of two phase 3 trials. N Engl J Med. 2014;371:326-338.
  3. van der Heijden FL, Wierenga EA, Bos JD, et al. High frequency of IL-4-producing CD4+ allergen-specific T lymphocytes in atopic dermatitis lesional skin. J Invest Dermatol. 1991;97:389-394.
  4. Beck LA, Thaçi D, Hamilton JD, et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. N Engl J Med. 2014;371:130-139.
  5. Lai FYX, Higgins E, Smith CH, et al. Morphologic switch from psoriasiform to eczematous dermatitis after anti-IL-17 therapy: a case series. JAMA Dermatol. 2019;155:1082-1084.
  6. Varma A, Levitt J. Dupilumab-induced phenotype switching from atopic dermatitis to psoriasis. JAAD Case Rep. 2020;6:217-218.
  7. Ling Y, Puel A. IL-17 and infections. Actas Dermosifiliogr. 2014;105(suppl 1):34-40.
  8. Saunte DM, Mrowietz U, Puig L, et al. Candida infections in patients with psoriasis and psoriatic arthritis treated with interleukin-17 inhibitors and their practical management. Br J Dermatol. 2017;177:47-62.
  9. Hölttä V, Klemetti P, Sipponen T, et al. IL-23/IL-17 immunity as a hallmark of Crohn’s disease. Inflamm Bowel Dis. 2008;14:1175-1184.
  10. Smith MK, Pai J, Panaccione R, et al. Crohn’s-like disease in a patient exposed to anti-interleukin-17 blockade (ixekizumab) for the treatment of chronic plaque psoriasis: a case report. BMC Gastroenterol. 2019;19:162.
References
  1. Diani M, Altomare G, Reali E. T helper cell subsets in clinical manifestations of psoriasis. J Immunol Res. 2016;2016:7692024.
  2. Langley RG, Elewski BE, Lebwohl M, et al. Secukinumab in plaque psoriasis—results of two phase 3 trials. N Engl J Med. 2014;371:326-338.
  3. van der Heijden FL, Wierenga EA, Bos JD, et al. High frequency of IL-4-producing CD4+ allergen-specific T lymphocytes in atopic dermatitis lesional skin. J Invest Dermatol. 1991;97:389-394.
  4. Beck LA, Thaçi D, Hamilton JD, et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. N Engl J Med. 2014;371:130-139.
  5. Lai FYX, Higgins E, Smith CH, et al. Morphologic switch from psoriasiform to eczematous dermatitis after anti-IL-17 therapy: a case series. JAMA Dermatol. 2019;155:1082-1084.
  6. Varma A, Levitt J. Dupilumab-induced phenotype switching from atopic dermatitis to psoriasis. JAAD Case Rep. 2020;6:217-218.
  7. Ling Y, Puel A. IL-17 and infections. Actas Dermosifiliogr. 2014;105(suppl 1):34-40.
  8. Saunte DM, Mrowietz U, Puig L, et al. Candida infections in patients with psoriasis and psoriatic arthritis treated with interleukin-17 inhibitors and their practical management. Br J Dermatol. 2017;177:47-62.
  9. Hölttä V, Klemetti P, Sipponen T, et al. IL-23/IL-17 immunity as a hallmark of Crohn’s disease. Inflamm Bowel Dis. 2008;14:1175-1184.
  10. Smith MK, Pai J, Panaccione R, et al. Crohn’s-like disease in a patient exposed to anti-interleukin-17 blockade (ixekizumab) for the treatment of chronic plaque psoriasis: a case report. BMC Gastroenterol. 2019;19:162.
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  • Treatment of psoriasis vulgaris, a helper T cell TH1/TH17-mediated skin condition, with secukinumab may result in phenotypic switching to TH2-mediated atopic dermatitis.
  • Atopic dermatitis responds well to dupilumab but may result in phenotypic switching to psoriasis.
  • Biologic therapies targeted at specific immunologic pathways may have unintended consequences on the TH1/TH2 immune axis.
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Gaps in Treatment Guidelines for Atopic Dermatitis

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Gaps in Treatment Guidelines for Atopic Dermatitis

Treatment options for atopic dermatitis have evolved significantly in the past several years, but the current guidelines have yet to catch up.

Drs Steven Feldman and Lindsay Strowd, from Wake Forest School of Medicine, discuss gaps in the American Academy of Dermatology treatment guidelines for atopic dermatitis.

The current guidelines have not been updated to include medications approved for atopic dermatitis, including crisaborole, a steroid-sparing ointment used to treat mild to moderate disease in patients 3 months of age and older.

Another drug that has been approved since the 2014 guidelines is the biologic dupilumab, which is a monoclonal antibody that acts on the IL-4 receptor. The agent inhibits the binding of IL-4 receptors to the principal cytokines responsible for mediating the disease. Dupilumab is administered by injection and is approved for patients 6 years and older with moderate to severe disease.

The doctors also discuss therapies for atopic dermatitis currently in development, including topical and oral JAK inhibitors. They agree that the long-term benefit of topical JAK inhibitors may be limited, but that oral JAK inhibitors have the potential to be more effective than dupilumab and more acceptable to patients who do not like injections.

--

Steven R. Feldman, MD, PhD, Professor, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina

 

Steven R. Feldman, MD, PhD, has disclosed the following relevant financial relationships:
Serve(d) as a consultant for: AbbVie; Alvotech; Advance Medical; Almirall; Arena; Bristol-Myers Squibb; Caremark; Amgen; Celgene; Galderma Laboratories; Gerson Lehrman Group; Guidepoint Global; Helsinn; Janssen; Kikaku; Leo Pharma; Eli Lilly and Company; Merck; Mylan; Novartis; Ortho Dermatology; Pfizer; Regeneron; Sanofi; Sienna; Sun Pharma; Suncare Research; Xenoport
Serve(d) as a speaker for: AbbVie; Amgen; Celgene; Janssen; Leo Pharma; Eli Lilly and Company; Novartis; Ortho Dermatology; Pfizer; Regeneron; Sanofi; Sun Pharma
Receive(d) grant support from: AbbVie; Amgen; Celgene; Galderma Laboratories; Janssen; Eli Lilly and Company; Novartis; Pfizer; Regeneron; Sanofi
Receive(d) royalties from: Informa; UpToDate; Xlibris
Holds stock in: Causa Technologies; Medical Quality Enhancement Corporation
Serves as founder and chief technology officer for: Causa Technologies

 

Lindsay C. Strowd, MD, Associate Professor, Vice Chair, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina

Lindsay C. Strowd, MD, has disclosed no relevant financial relationships.

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Treatment options for atopic dermatitis have evolved significantly in the past several years, but the current guidelines have yet to catch up.

Drs Steven Feldman and Lindsay Strowd, from Wake Forest School of Medicine, discuss gaps in the American Academy of Dermatology treatment guidelines for atopic dermatitis.

The current guidelines have not been updated to include medications approved for atopic dermatitis, including crisaborole, a steroid-sparing ointment used to treat mild to moderate disease in patients 3 months of age and older.

Another drug that has been approved since the 2014 guidelines is the biologic dupilumab, which is a monoclonal antibody that acts on the IL-4 receptor. The agent inhibits the binding of IL-4 receptors to the principal cytokines responsible for mediating the disease. Dupilumab is administered by injection and is approved for patients 6 years and older with moderate to severe disease.

The doctors also discuss therapies for atopic dermatitis currently in development, including topical and oral JAK inhibitors. They agree that the long-term benefit of topical JAK inhibitors may be limited, but that oral JAK inhibitors have the potential to be more effective than dupilumab and more acceptable to patients who do not like injections.

--

Steven R. Feldman, MD, PhD, Professor, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina

 

Steven R. Feldman, MD, PhD, has disclosed the following relevant financial relationships:
Serve(d) as a consultant for: AbbVie; Alvotech; Advance Medical; Almirall; Arena; Bristol-Myers Squibb; Caremark; Amgen; Celgene; Galderma Laboratories; Gerson Lehrman Group; Guidepoint Global; Helsinn; Janssen; Kikaku; Leo Pharma; Eli Lilly and Company; Merck; Mylan; Novartis; Ortho Dermatology; Pfizer; Regeneron; Sanofi; Sienna; Sun Pharma; Suncare Research; Xenoport
Serve(d) as a speaker for: AbbVie; Amgen; Celgene; Janssen; Leo Pharma; Eli Lilly and Company; Novartis; Ortho Dermatology; Pfizer; Regeneron; Sanofi; Sun Pharma
Receive(d) grant support from: AbbVie; Amgen; Celgene; Galderma Laboratories; Janssen; Eli Lilly and Company; Novartis; Pfizer; Regeneron; Sanofi
Receive(d) royalties from: Informa; UpToDate; Xlibris
Holds stock in: Causa Technologies; Medical Quality Enhancement Corporation
Serves as founder and chief technology officer for: Causa Technologies

 

Lindsay C. Strowd, MD, Associate Professor, Vice Chair, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina

Lindsay C. Strowd, MD, has disclosed no relevant financial relationships.

Treatment options for atopic dermatitis have evolved significantly in the past several years, but the current guidelines have yet to catch up.

Drs Steven Feldman and Lindsay Strowd, from Wake Forest School of Medicine, discuss gaps in the American Academy of Dermatology treatment guidelines for atopic dermatitis.

The current guidelines have not been updated to include medications approved for atopic dermatitis, including crisaborole, a steroid-sparing ointment used to treat mild to moderate disease in patients 3 months of age and older.

Another drug that has been approved since the 2014 guidelines is the biologic dupilumab, which is a monoclonal antibody that acts on the IL-4 receptor. The agent inhibits the binding of IL-4 receptors to the principal cytokines responsible for mediating the disease. Dupilumab is administered by injection and is approved for patients 6 years and older with moderate to severe disease.

The doctors also discuss therapies for atopic dermatitis currently in development, including topical and oral JAK inhibitors. They agree that the long-term benefit of topical JAK inhibitors may be limited, but that oral JAK inhibitors have the potential to be more effective than dupilumab and more acceptable to patients who do not like injections.

--

Steven R. Feldman, MD, PhD, Professor, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina

 

Steven R. Feldman, MD, PhD, has disclosed the following relevant financial relationships:
Serve(d) as a consultant for: AbbVie; Alvotech; Advance Medical; Almirall; Arena; Bristol-Myers Squibb; Caremark; Amgen; Celgene; Galderma Laboratories; Gerson Lehrman Group; Guidepoint Global; Helsinn; Janssen; Kikaku; Leo Pharma; Eli Lilly and Company; Merck; Mylan; Novartis; Ortho Dermatology; Pfizer; Regeneron; Sanofi; Sienna; Sun Pharma; Suncare Research; Xenoport
Serve(d) as a speaker for: AbbVie; Amgen; Celgene; Janssen; Leo Pharma; Eli Lilly and Company; Novartis; Ortho Dermatology; Pfizer; Regeneron; Sanofi; Sun Pharma
Receive(d) grant support from: AbbVie; Amgen; Celgene; Galderma Laboratories; Janssen; Eli Lilly and Company; Novartis; Pfizer; Regeneron; Sanofi
Receive(d) royalties from: Informa; UpToDate; Xlibris
Holds stock in: Causa Technologies; Medical Quality Enhancement Corporation
Serves as founder and chief technology officer for: Causa Technologies

 

Lindsay C. Strowd, MD, Associate Professor, Vice Chair, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina

Lindsay C. Strowd, MD, has disclosed no relevant financial relationships.

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Clinical Characterization of Leukemia Cutis Presentation

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IN PARTNERSHIP WITH THE SOCIETY FOR DERMATOLOGY HOSPITALISTS

Leukemia is a malignant, life-threatening neoplasm affecting the hematopoietic system. Extramedullary manifestations can occur in various organs, including skin.1 Skin findings in leukemia patients are common and varied, including pallor secondary to anemia, petechiae or ecchymoses due to thrombocytopenia, and skin manifestations of neutropenia and chemotherapy.2 When patients with leukemia develop skin lesions without leukemic infiltration, the resulting nonspecific cutaneous manifestations are known as leukemids.3 Specific cutaneous manifestations of leukemia resulting from direct invasion of leukemic cells into the epidermis, dermis, or subcutis are referred to as leukemia cutis (LC).2,3

Acute myeloid leukemia (AML) is the most common type of leukemia associated with LC, but LC also is seen in other leukemias with various frequencies.1 The lesions of LC can present anywhere on skin, though it has been reported that LC has a tendency to occur at sites of prior ongoing inflammation,2,4 most commonly the extremities, trunk, and face.2,5,6 LC lesions have a range of morphological findings and most commonly present as nodules, papules, and plaques.1,7

Most reports of LC in the literature are case reports or case series with small numbers of subjects.3,6,8 A study of LC patients (N=75) in Korea by Kang et al7 has been the only one to analyze clinical characteristics of LC since 2000.



The aim of this study was to further contribute to the knowledge of clinical characteristics of LC. Clinical patterns of 46 patients were analyzed to further characterize the presentation of LC and to compare our results with those in the literature.

Methods

We conducted a single-institution retrospective review of medical records of patients with LC diagnosed in the Department of Dermatology at Wake Forest School of Medicine (Winston-Salem, North Carolina) over a 17-year period (2001-2017). The study protocol was approved by the institutional review board of Wake Forest University School of Medicine (IRB No. 00054474). Patients had a leukemia diagnosis established by bone marrow biopsy. Patients were included in this analysis if they had ongoing active leukemia and a skin biopsy consistent with LC. Patients of all sexes and ages were included in the cohort. Patients were excluded if they presented only with nonspecific cutaneous lesions associated with leukemia (leukemids). After removing duplicate records from a total of 60 patients initially identified, 46 unique patients were included in this study.

 

 

Results

Demographics
Fifty-six percent (26/46) of patients were male. The average age at diagnosis of leukemia was 58 years (range, 8.5 months–84 years). Eighty-five percent of patients were white (39/46), 11% were black (5/46), 2% were Hispanic (1/46), and 2% were of unknown ethnicity (1/46).

Eighty percent (37/46) of patients with LC had AML; 3 of these patients had a prior diagnosis of chronic myeloid leukemia (CML) and 2 had myelodysplastic syndrome (MDS) that did not develop LC until after they had transitioned to AML. Other subtypes of leukemia in this patient population included acute lymphoblastic leukemia (ALL)(n=2), plasma cell leukemia (PCL)(n=2), undifferentiated leukemia (n=2), chronic lymphocytic leukemia (CLL)(n=1), myelodysplastic syndrome (n=1), and Burkitt-type leukemia (n=1).

Distribution and Morphology of LC Lesions
The clinical appearance of LC was widely variable in morphology and anatomic location (Table 1 and Figure). Eighty-four percent of LC occurrences involved more than one lesion (n=32); 14% were a solitary lesion (n=6). For the 2 patients who had 2 separate episodes of LC, the initial presentation of LC was multiple lesions; recurrent LC at relapse presented as a solitary lesion in both cases. Most LC lesions (77% [67/87]) occurred on the trunk or extremities; 23% (20/87) of LC lesions occurred on less common sites, such as the groin, face, hands, feet, and mucosa. Papules (38% [22/58]) and nodules (31% [18/58]) were the most common morphology; macules, plaques, and ulcers were observed less frequently. Clinical descriptions of LC lesions varied widely, with the most common descriptive characteristics being erythematous (57% [20/35]), violaceous (31% [11/35]), and asymptomatic (84% [32/38]). Rare descriptors included flesh colored, hyperpigmented, tender, pruritic, edema, crusting, and confluent erythematous.

Clinical presentation of leukemia cutis. A, Erythematous papules on the trunk. B, Violaceous infiltrative plaques on the chest. C, Violaceous firm nodule on the oral mucosa. D, Violaceous infiltrative plaques on the breast. E, Erythematous firm nodules on the occipital scalp.


Interval Between Leukemia Diagnosis and LC Diagnosis
Approximately 59% (n=27) of patients had LC as a presenting finding of their leukemia (Table 2). Twenty-two percent (n=10) developed LC at the time of leukemia relapse; 20% (n=9) developed LC during consolidation or salvage chemotherapy. Two AML patients had recurrent episodes of LC both at initial presentation of leukemia and when AML relapsed. Two other AML patients received a diagnosis of LC at the same time as a negative concurrent bone marrow biopsy (ie, aleukemic LC). Mean duration between diagnosis of leukemia and diagnosis of LC was 0.4 months (CLL), 1.0 month (ALL), 4.7 months (AML), and 7.15 months (PCL). In cases of MDS and CML transformation to AML, the interval was 6.5 and 4.9 months, respectively.



Interval Between LC Diagnosis and Death
As a whole, 17% (n=8) of patients were living at the time this article was written (eTable). Of patients who are still living, 10.9% (n=5) have AML. Looking at the cohort of patients with AML and LC, average age at AML diagnosis was 59.8 years. Average time from diagnosis of leukemia to death was 17.3 months (range, 0.6–49.6 months) for AML; 17.0 months (range, 10.0–24.0 months) for CML transformation to AML; 15.0 months (range, 12.0–18.0 months) for PCL; 14.75 months (range, 11.0–18.5 months) for undifferentiated leukemia; and 8.95 months (range, 4.2–13.7 months) for MDS transformation to AML. The interval between leukemia diagnosis and death was notably shorter for the CLL patient (4.0 months) and the deceased ALL patient (2.4 months). Mean duration between LC diagnosis and death was 11.7 months (AML), 11.2 months (undifferentiated leukemia), 9.9 months (CML transformation to AML), 2.75 months (PCL), and 2.4 months (MDS transformation to AML). The shortest intervals between LC diagnosis and death were seen in CLL (0.5 months) and ALL (0.4 months).

 

 

Discussion

Cutaneous manifestations are not uncommon in leukemia patients and can have a number of causes, including paraneoplastic cutaneous manifestations, such as pyoderma gangrenosum and Sweet syndrome; infection; cutaneous toxicities from antineoplastic agents; and LC.2 Leukemia cutis can be confused with other skin lesions in leukemia patients; diagnosis requires biopsy.2,9

We analyzed clinical characteristics and prognosis of 46 patients with LC over a 17-year period. To the best of our knowledge, this is the largest study of LC patients published in the United States. A similar study by Kang et al7 analyzed 75 patients in Korea; however, the incidence of LC among different types of leukemia in the Korean population cannot be applied to Western countries. We did compare the clinical characteristics of our cohort of patients to those reported by Kang et al7 and other studies including a smaller number of patients.

In this study, the male to female ratio was 1.3 to 1 compared to the 2:1 ratio reported by Kang et al.7 The mean age of leukemia diagnosis among our patients was 58 years, which is notably older than the mean age previously reported.7 In this cohort, 4 patients (8.7%) were 34 years or younger, including 1 infant aged 8.5 months; 24 (52.2%) were aged 35 to 64 years; and 18 (39.1%) were 65 years and older.

Consistent with other studies,2,5,7 the most common type of leukemia in patients who developed LC was AML (80%). Among AML patients, the mean age at AML diagnosis (59.8 years) was notably younger than the reported US average age of patients who had a diagnosis of AML (68 years).10 Gender breakdown was slightly different than US statistics: 63% of AML patients in our group were male, whereas AML is only slightly more common among men in the United States.10

Clinically, skin lesions observed most commonly were (in decreasing order) papules, nodules, macules, plaques, and ulcers. Papules (38%) were the most common lesion overall in our study, which differed from the Kang et al7 report in which nodules were the most common. Nodules (31%) were the second most common LC morphology among our patients. Among AML patients, papules were seen in 56% of patients (18/32); nodules were seen in 44% (14/32). The extremities (when combined together) were the most common location of LC lesions (46% [arms, 24%; legs, 22%]); the trunk was the second most common body region (31%). Our study did not find a difference among most common LC anatomic sites compared to other studies.5,7 Less common sites in our cohort included the head, scalp/ears, neck, hands, mucosa, and feet. All body sites were represented, including ocular and oral mucosa and groin, a finding that underscores the importance of complete and comprehensive skin examinations in this patient population. The terms erythematous and violaceous were used to describe the color of most lesions (88%), which commonly presented as multiple lesions (84%) and often were asymptomatic (84%).

It has been reported that, first, in most cases of LC, the condition develops in patients who have already been given a diagnosis of leukemia and, second, simultaneous manifestation of systemic leukemia and LC is less common.11,12 Leukemia cutis also can precede peripheral or bone marrow leukemia (known as aleukemic LC).1,13 Two AML patients (4.3% [2/46]) in this study met criteria for aleukemic LC because they had LC at the same time as negative bone marrow biopsy, which is consistent with a prior report that aleukemic LC can affect as many as 7% of patients.1 Our results differed slightly from prior studies in that most of our patients had LC as one of the presenting manifestations of their leukemia.3,7

Regardless of leukemia type, patients were likely to die within 1 year of LC diagnosis, on average, which is consistent with prior reports.7,11,12 However, the time between diagnosis of LC and death varied greatly among our patients (range, 12 days to 4.1 years). From 2007 to 2013, the 5-year relative survival rate overall for leukemia patients in the US population (by type) was 86.2% (CLL), 71.0% (ALL), 68.0% (CML), and 27.4% (AML).14 Compared to these national statistics, the relative survival rate in LC is poor, with patients who have AML surviving, on average, less than 8 months from time of leukemia diagnosis, whereas ALL and CLL patients survive less than 6 months.



When LC is a late presentation of B-cell CLL or when it presents as myeloid leukemia, blastic transformation (Richter syndrome), or T-cell CLL, it is occasionally associated with poor prognosis, though LC does not affect survival.15-17 In a study of the association of LC with survival in AML, 5-year survival among 62 AML patients with LC was 8.6%, shorter than 28.3% among the 186 matched patients with AML without LC.18 Similarly, the estimated 5-year survival for all patients with AML, according to Surveillance, Epidemiology, and End Results Program data (2007-2013), was 27.4%.14 Based on those results, LC might be a good prognostic indicator in patients with AML.

Conclusion

This study characterized the clinical presentation of LC, which is highly variable in appearance, symptoms, distribution, and stage of leukemia at presentation. In our study cohort, LC most commonly presented as asymptomatic erythematous or violaceous papules or nodules in older male AML patients at leukemia diagnosis. Given such wide variability, dermatologists and oncologists need to keep LC in the differential diagnosis for any new skin lesion and to have a low threshold for performing skin biopsy. Complete and thorough skin examinations should be performed on leukemia patients throughout the course of their disease to identify LC early so that treatment can be implemented in a timely fashion at initial diagnosis, first sign of relapse, or change in disease state.

References
  1. Wagner G, Fenchel K, Back W, et al. Leukemia cutis—epidemiology, clinical presentation, and differential diagnoses. J Dtsch Dermatol Ges. 2012;10:27-36.
  2. Grunwald MR, McDonnell MH, Induru R, et al. Cutaneous manifestations in leukemia patients. Semin Oncol. 2016;43:359-365.
  3. Martínez-Leboráns L, Victoria-Martínez A, Torregrosa-Calatayu JL, et al. Leukemia cutis: a report of 17 cases and a review of literature. Actas Dermosifiliogr. 2016;107:e65-e69.
  4. Li L, Wang Y, Lian CG, et al. Clinical and pathological features of myeloid leukemia cutis. An Bras Dermatol. 2018;93:216-221.
  5. Paydas¸ S, Zorludemir S. Leukaemia cutis and leukaemic vasculitis. Br J Dermatol. 2000;143:773-779.
  6. Lee JI, Park HJ, Oh ST, et al. A case of leukemia cutis at the site of a prior catheter insertion. Ann Dermatol. 2009;21:193-196.
  7. Kang YS, Kim HS, Park HJ, et al. Clinical characteristics of 75 patients with leukemia cutis. J Korean Med Sci. 2013;28:614-619.
  8. Stern M, Halter J, Buser A, et al. Leukemia cutis preceding systemic relapse of acute myeloid leukemia. Int J Hematol. 2008;87:108-109.
  9. Patel LM, Maghari A, Schwartz RA, et al. Myeloid leukemia cutis in the setting of myelodysplastic syndrome: a crucial dermatological diagnosis. Int J Dermatol. 2012;51:383-388.
  10. American Cancer Society. Cancer Facts & Figures 2019. Atlanta, GA: American Cancer Society; 2019. http://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf. Accessed November 21, 2019.
  11. Cho-Vega JH, Medeiros LJ, Prieto VG, et al. Leukemia cutis. Am J Clin Pathol. 2008;129:130-142.
  12. Su WP. Clinical, histopathologic, and immunohistochemical correlations in leukemia cutis. Semin Dermatol. 1994;13:223-230.
  13. Barzilai A, Lyakhovitsky A, Goldberg I, et al. Aleukemic monocytic leukemia cutis. Cutis. 2002;69:301-­304
  14. Howlader N, Noone AM, Krapcho M, et al, eds. SEER cancer statistics review (CSR) 1975-2014. Bethesda, MD: National Cancer Institute; April 2017. https://seer.cancer.gov/archive/csr/1975_2014/. Accessed November 21, 2019.
  15. Cerroni L, Zenahlik P, Höfler G, et al. Specific cutaneous infiltrates of B-cell chronic lymphocytic leukemia: a clinicopathologic and prognostic study of 42 patients. Am J Surg Pathol. 1996;20:1000-1010.
  16. Colburn DE, Welch MA, Giles FJ. Skin infiltration with chronic lymphocytic leukemia is consistent with a good prognosis. Hematology. 2002;7:187-188.
  17. Ratnam KV, Khor CJ, Su WP. Leukemia cutis. Dermatol Clin. 1994;12:419-431. 
  18. Wang CX, Pusic I, Anadkat MJ. Association of leukemia cutis with survival in acute myeloid leukemia. JAMA Dermatol. 2019;155:826-832.
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From the Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The authors report no conflict of interest.

The eTable is available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Wasim Haidari, BS, BA, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (wh374@georgetown.edu).

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From the Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The authors report no conflict of interest.

The eTable is available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Wasim Haidari, BS, BA, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (wh374@georgetown.edu).

Author and Disclosure Information

From the Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The authors report no conflict of interest.

The eTable is available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Wasim Haidari, BS, BA, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (wh374@georgetown.edu).

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IN PARTNERSHIP WITH THE SOCIETY FOR DERMATOLOGY HOSPITALISTS
IN PARTNERSHIP WITH THE SOCIETY FOR DERMATOLOGY HOSPITALISTS

Leukemia is a malignant, life-threatening neoplasm affecting the hematopoietic system. Extramedullary manifestations can occur in various organs, including skin.1 Skin findings in leukemia patients are common and varied, including pallor secondary to anemia, petechiae or ecchymoses due to thrombocytopenia, and skin manifestations of neutropenia and chemotherapy.2 When patients with leukemia develop skin lesions without leukemic infiltration, the resulting nonspecific cutaneous manifestations are known as leukemids.3 Specific cutaneous manifestations of leukemia resulting from direct invasion of leukemic cells into the epidermis, dermis, or subcutis are referred to as leukemia cutis (LC).2,3

Acute myeloid leukemia (AML) is the most common type of leukemia associated with LC, but LC also is seen in other leukemias with various frequencies.1 The lesions of LC can present anywhere on skin, though it has been reported that LC has a tendency to occur at sites of prior ongoing inflammation,2,4 most commonly the extremities, trunk, and face.2,5,6 LC lesions have a range of morphological findings and most commonly present as nodules, papules, and plaques.1,7

Most reports of LC in the literature are case reports or case series with small numbers of subjects.3,6,8 A study of LC patients (N=75) in Korea by Kang et al7 has been the only one to analyze clinical characteristics of LC since 2000.



The aim of this study was to further contribute to the knowledge of clinical characteristics of LC. Clinical patterns of 46 patients were analyzed to further characterize the presentation of LC and to compare our results with those in the literature.

Methods

We conducted a single-institution retrospective review of medical records of patients with LC diagnosed in the Department of Dermatology at Wake Forest School of Medicine (Winston-Salem, North Carolina) over a 17-year period (2001-2017). The study protocol was approved by the institutional review board of Wake Forest University School of Medicine (IRB No. 00054474). Patients had a leukemia diagnosis established by bone marrow biopsy. Patients were included in this analysis if they had ongoing active leukemia and a skin biopsy consistent with LC. Patients of all sexes and ages were included in the cohort. Patients were excluded if they presented only with nonspecific cutaneous lesions associated with leukemia (leukemids). After removing duplicate records from a total of 60 patients initially identified, 46 unique patients were included in this study.

 

 

Results

Demographics
Fifty-six percent (26/46) of patients were male. The average age at diagnosis of leukemia was 58 years (range, 8.5 months–84 years). Eighty-five percent of patients were white (39/46), 11% were black (5/46), 2% were Hispanic (1/46), and 2% were of unknown ethnicity (1/46).

Eighty percent (37/46) of patients with LC had AML; 3 of these patients had a prior diagnosis of chronic myeloid leukemia (CML) and 2 had myelodysplastic syndrome (MDS) that did not develop LC until after they had transitioned to AML. Other subtypes of leukemia in this patient population included acute lymphoblastic leukemia (ALL)(n=2), plasma cell leukemia (PCL)(n=2), undifferentiated leukemia (n=2), chronic lymphocytic leukemia (CLL)(n=1), myelodysplastic syndrome (n=1), and Burkitt-type leukemia (n=1).

Distribution and Morphology of LC Lesions
The clinical appearance of LC was widely variable in morphology and anatomic location (Table 1 and Figure). Eighty-four percent of LC occurrences involved more than one lesion (n=32); 14% were a solitary lesion (n=6). For the 2 patients who had 2 separate episodes of LC, the initial presentation of LC was multiple lesions; recurrent LC at relapse presented as a solitary lesion in both cases. Most LC lesions (77% [67/87]) occurred on the trunk or extremities; 23% (20/87) of LC lesions occurred on less common sites, such as the groin, face, hands, feet, and mucosa. Papules (38% [22/58]) and nodules (31% [18/58]) were the most common morphology; macules, plaques, and ulcers were observed less frequently. Clinical descriptions of LC lesions varied widely, with the most common descriptive characteristics being erythematous (57% [20/35]), violaceous (31% [11/35]), and asymptomatic (84% [32/38]). Rare descriptors included flesh colored, hyperpigmented, tender, pruritic, edema, crusting, and confluent erythematous.

Clinical presentation of leukemia cutis. A, Erythematous papules on the trunk. B, Violaceous infiltrative plaques on the chest. C, Violaceous firm nodule on the oral mucosa. D, Violaceous infiltrative plaques on the breast. E, Erythematous firm nodules on the occipital scalp.


Interval Between Leukemia Diagnosis and LC Diagnosis
Approximately 59% (n=27) of patients had LC as a presenting finding of their leukemia (Table 2). Twenty-two percent (n=10) developed LC at the time of leukemia relapse; 20% (n=9) developed LC during consolidation or salvage chemotherapy. Two AML patients had recurrent episodes of LC both at initial presentation of leukemia and when AML relapsed. Two other AML patients received a diagnosis of LC at the same time as a negative concurrent bone marrow biopsy (ie, aleukemic LC). Mean duration between diagnosis of leukemia and diagnosis of LC was 0.4 months (CLL), 1.0 month (ALL), 4.7 months (AML), and 7.15 months (PCL). In cases of MDS and CML transformation to AML, the interval was 6.5 and 4.9 months, respectively.



Interval Between LC Diagnosis and Death
As a whole, 17% (n=8) of patients were living at the time this article was written (eTable). Of patients who are still living, 10.9% (n=5) have AML. Looking at the cohort of patients with AML and LC, average age at AML diagnosis was 59.8 years. Average time from diagnosis of leukemia to death was 17.3 months (range, 0.6–49.6 months) for AML; 17.0 months (range, 10.0–24.0 months) for CML transformation to AML; 15.0 months (range, 12.0–18.0 months) for PCL; 14.75 months (range, 11.0–18.5 months) for undifferentiated leukemia; and 8.95 months (range, 4.2–13.7 months) for MDS transformation to AML. The interval between leukemia diagnosis and death was notably shorter for the CLL patient (4.0 months) and the deceased ALL patient (2.4 months). Mean duration between LC diagnosis and death was 11.7 months (AML), 11.2 months (undifferentiated leukemia), 9.9 months (CML transformation to AML), 2.75 months (PCL), and 2.4 months (MDS transformation to AML). The shortest intervals between LC diagnosis and death were seen in CLL (0.5 months) and ALL (0.4 months).

 

 

Discussion

Cutaneous manifestations are not uncommon in leukemia patients and can have a number of causes, including paraneoplastic cutaneous manifestations, such as pyoderma gangrenosum and Sweet syndrome; infection; cutaneous toxicities from antineoplastic agents; and LC.2 Leukemia cutis can be confused with other skin lesions in leukemia patients; diagnosis requires biopsy.2,9

We analyzed clinical characteristics and prognosis of 46 patients with LC over a 17-year period. To the best of our knowledge, this is the largest study of LC patients published in the United States. A similar study by Kang et al7 analyzed 75 patients in Korea; however, the incidence of LC among different types of leukemia in the Korean population cannot be applied to Western countries. We did compare the clinical characteristics of our cohort of patients to those reported by Kang et al7 and other studies including a smaller number of patients.

In this study, the male to female ratio was 1.3 to 1 compared to the 2:1 ratio reported by Kang et al.7 The mean age of leukemia diagnosis among our patients was 58 years, which is notably older than the mean age previously reported.7 In this cohort, 4 patients (8.7%) were 34 years or younger, including 1 infant aged 8.5 months; 24 (52.2%) were aged 35 to 64 years; and 18 (39.1%) were 65 years and older.

Consistent with other studies,2,5,7 the most common type of leukemia in patients who developed LC was AML (80%). Among AML patients, the mean age at AML diagnosis (59.8 years) was notably younger than the reported US average age of patients who had a diagnosis of AML (68 years).10 Gender breakdown was slightly different than US statistics: 63% of AML patients in our group were male, whereas AML is only slightly more common among men in the United States.10

Clinically, skin lesions observed most commonly were (in decreasing order) papules, nodules, macules, plaques, and ulcers. Papules (38%) were the most common lesion overall in our study, which differed from the Kang et al7 report in which nodules were the most common. Nodules (31%) were the second most common LC morphology among our patients. Among AML patients, papules were seen in 56% of patients (18/32); nodules were seen in 44% (14/32). The extremities (when combined together) were the most common location of LC lesions (46% [arms, 24%; legs, 22%]); the trunk was the second most common body region (31%). Our study did not find a difference among most common LC anatomic sites compared to other studies.5,7 Less common sites in our cohort included the head, scalp/ears, neck, hands, mucosa, and feet. All body sites were represented, including ocular and oral mucosa and groin, a finding that underscores the importance of complete and comprehensive skin examinations in this patient population. The terms erythematous and violaceous were used to describe the color of most lesions (88%), which commonly presented as multiple lesions (84%) and often were asymptomatic (84%).

It has been reported that, first, in most cases of LC, the condition develops in patients who have already been given a diagnosis of leukemia and, second, simultaneous manifestation of systemic leukemia and LC is less common.11,12 Leukemia cutis also can precede peripheral or bone marrow leukemia (known as aleukemic LC).1,13 Two AML patients (4.3% [2/46]) in this study met criteria for aleukemic LC because they had LC at the same time as negative bone marrow biopsy, which is consistent with a prior report that aleukemic LC can affect as many as 7% of patients.1 Our results differed slightly from prior studies in that most of our patients had LC as one of the presenting manifestations of their leukemia.3,7

Regardless of leukemia type, patients were likely to die within 1 year of LC diagnosis, on average, which is consistent with prior reports.7,11,12 However, the time between diagnosis of LC and death varied greatly among our patients (range, 12 days to 4.1 years). From 2007 to 2013, the 5-year relative survival rate overall for leukemia patients in the US population (by type) was 86.2% (CLL), 71.0% (ALL), 68.0% (CML), and 27.4% (AML).14 Compared to these national statistics, the relative survival rate in LC is poor, with patients who have AML surviving, on average, less than 8 months from time of leukemia diagnosis, whereas ALL and CLL patients survive less than 6 months.



When LC is a late presentation of B-cell CLL or when it presents as myeloid leukemia, blastic transformation (Richter syndrome), or T-cell CLL, it is occasionally associated with poor prognosis, though LC does not affect survival.15-17 In a study of the association of LC with survival in AML, 5-year survival among 62 AML patients with LC was 8.6%, shorter than 28.3% among the 186 matched patients with AML without LC.18 Similarly, the estimated 5-year survival for all patients with AML, according to Surveillance, Epidemiology, and End Results Program data (2007-2013), was 27.4%.14 Based on those results, LC might be a good prognostic indicator in patients with AML.

Conclusion

This study characterized the clinical presentation of LC, which is highly variable in appearance, symptoms, distribution, and stage of leukemia at presentation. In our study cohort, LC most commonly presented as asymptomatic erythematous or violaceous papules or nodules in older male AML patients at leukemia diagnosis. Given such wide variability, dermatologists and oncologists need to keep LC in the differential diagnosis for any new skin lesion and to have a low threshold for performing skin biopsy. Complete and thorough skin examinations should be performed on leukemia patients throughout the course of their disease to identify LC early so that treatment can be implemented in a timely fashion at initial diagnosis, first sign of relapse, or change in disease state.

Leukemia is a malignant, life-threatening neoplasm affecting the hematopoietic system. Extramedullary manifestations can occur in various organs, including skin.1 Skin findings in leukemia patients are common and varied, including pallor secondary to anemia, petechiae or ecchymoses due to thrombocytopenia, and skin manifestations of neutropenia and chemotherapy.2 When patients with leukemia develop skin lesions without leukemic infiltration, the resulting nonspecific cutaneous manifestations are known as leukemids.3 Specific cutaneous manifestations of leukemia resulting from direct invasion of leukemic cells into the epidermis, dermis, or subcutis are referred to as leukemia cutis (LC).2,3

Acute myeloid leukemia (AML) is the most common type of leukemia associated with LC, but LC also is seen in other leukemias with various frequencies.1 The lesions of LC can present anywhere on skin, though it has been reported that LC has a tendency to occur at sites of prior ongoing inflammation,2,4 most commonly the extremities, trunk, and face.2,5,6 LC lesions have a range of morphological findings and most commonly present as nodules, papules, and plaques.1,7

Most reports of LC in the literature are case reports or case series with small numbers of subjects.3,6,8 A study of LC patients (N=75) in Korea by Kang et al7 has been the only one to analyze clinical characteristics of LC since 2000.



The aim of this study was to further contribute to the knowledge of clinical characteristics of LC. Clinical patterns of 46 patients were analyzed to further characterize the presentation of LC and to compare our results with those in the literature.

Methods

We conducted a single-institution retrospective review of medical records of patients with LC diagnosed in the Department of Dermatology at Wake Forest School of Medicine (Winston-Salem, North Carolina) over a 17-year period (2001-2017). The study protocol was approved by the institutional review board of Wake Forest University School of Medicine (IRB No. 00054474). Patients had a leukemia diagnosis established by bone marrow biopsy. Patients were included in this analysis if they had ongoing active leukemia and a skin biopsy consistent with LC. Patients of all sexes and ages were included in the cohort. Patients were excluded if they presented only with nonspecific cutaneous lesions associated with leukemia (leukemids). After removing duplicate records from a total of 60 patients initially identified, 46 unique patients were included in this study.

 

 

Results

Demographics
Fifty-six percent (26/46) of patients were male. The average age at diagnosis of leukemia was 58 years (range, 8.5 months–84 years). Eighty-five percent of patients were white (39/46), 11% were black (5/46), 2% were Hispanic (1/46), and 2% were of unknown ethnicity (1/46).

Eighty percent (37/46) of patients with LC had AML; 3 of these patients had a prior diagnosis of chronic myeloid leukemia (CML) and 2 had myelodysplastic syndrome (MDS) that did not develop LC until after they had transitioned to AML. Other subtypes of leukemia in this patient population included acute lymphoblastic leukemia (ALL)(n=2), plasma cell leukemia (PCL)(n=2), undifferentiated leukemia (n=2), chronic lymphocytic leukemia (CLL)(n=1), myelodysplastic syndrome (n=1), and Burkitt-type leukemia (n=1).

Distribution and Morphology of LC Lesions
The clinical appearance of LC was widely variable in morphology and anatomic location (Table 1 and Figure). Eighty-four percent of LC occurrences involved more than one lesion (n=32); 14% were a solitary lesion (n=6). For the 2 patients who had 2 separate episodes of LC, the initial presentation of LC was multiple lesions; recurrent LC at relapse presented as a solitary lesion in both cases. Most LC lesions (77% [67/87]) occurred on the trunk or extremities; 23% (20/87) of LC lesions occurred on less common sites, such as the groin, face, hands, feet, and mucosa. Papules (38% [22/58]) and nodules (31% [18/58]) were the most common morphology; macules, plaques, and ulcers were observed less frequently. Clinical descriptions of LC lesions varied widely, with the most common descriptive characteristics being erythematous (57% [20/35]), violaceous (31% [11/35]), and asymptomatic (84% [32/38]). Rare descriptors included flesh colored, hyperpigmented, tender, pruritic, edema, crusting, and confluent erythematous.

Clinical presentation of leukemia cutis. A, Erythematous papules on the trunk. B, Violaceous infiltrative plaques on the chest. C, Violaceous firm nodule on the oral mucosa. D, Violaceous infiltrative plaques on the breast. E, Erythematous firm nodules on the occipital scalp.


Interval Between Leukemia Diagnosis and LC Diagnosis
Approximately 59% (n=27) of patients had LC as a presenting finding of their leukemia (Table 2). Twenty-two percent (n=10) developed LC at the time of leukemia relapse; 20% (n=9) developed LC during consolidation or salvage chemotherapy. Two AML patients had recurrent episodes of LC both at initial presentation of leukemia and when AML relapsed. Two other AML patients received a diagnosis of LC at the same time as a negative concurrent bone marrow biopsy (ie, aleukemic LC). Mean duration between diagnosis of leukemia and diagnosis of LC was 0.4 months (CLL), 1.0 month (ALL), 4.7 months (AML), and 7.15 months (PCL). In cases of MDS and CML transformation to AML, the interval was 6.5 and 4.9 months, respectively.



Interval Between LC Diagnosis and Death
As a whole, 17% (n=8) of patients were living at the time this article was written (eTable). Of patients who are still living, 10.9% (n=5) have AML. Looking at the cohort of patients with AML and LC, average age at AML diagnosis was 59.8 years. Average time from diagnosis of leukemia to death was 17.3 months (range, 0.6–49.6 months) for AML; 17.0 months (range, 10.0–24.0 months) for CML transformation to AML; 15.0 months (range, 12.0–18.0 months) for PCL; 14.75 months (range, 11.0–18.5 months) for undifferentiated leukemia; and 8.95 months (range, 4.2–13.7 months) for MDS transformation to AML. The interval between leukemia diagnosis and death was notably shorter for the CLL patient (4.0 months) and the deceased ALL patient (2.4 months). Mean duration between LC diagnosis and death was 11.7 months (AML), 11.2 months (undifferentiated leukemia), 9.9 months (CML transformation to AML), 2.75 months (PCL), and 2.4 months (MDS transformation to AML). The shortest intervals between LC diagnosis and death were seen in CLL (0.5 months) and ALL (0.4 months).

 

 

Discussion

Cutaneous manifestations are not uncommon in leukemia patients and can have a number of causes, including paraneoplastic cutaneous manifestations, such as pyoderma gangrenosum and Sweet syndrome; infection; cutaneous toxicities from antineoplastic agents; and LC.2 Leukemia cutis can be confused with other skin lesions in leukemia patients; diagnosis requires biopsy.2,9

We analyzed clinical characteristics and prognosis of 46 patients with LC over a 17-year period. To the best of our knowledge, this is the largest study of LC patients published in the United States. A similar study by Kang et al7 analyzed 75 patients in Korea; however, the incidence of LC among different types of leukemia in the Korean population cannot be applied to Western countries. We did compare the clinical characteristics of our cohort of patients to those reported by Kang et al7 and other studies including a smaller number of patients.

In this study, the male to female ratio was 1.3 to 1 compared to the 2:1 ratio reported by Kang et al.7 The mean age of leukemia diagnosis among our patients was 58 years, which is notably older than the mean age previously reported.7 In this cohort, 4 patients (8.7%) were 34 years or younger, including 1 infant aged 8.5 months; 24 (52.2%) were aged 35 to 64 years; and 18 (39.1%) were 65 years and older.

Consistent with other studies,2,5,7 the most common type of leukemia in patients who developed LC was AML (80%). Among AML patients, the mean age at AML diagnosis (59.8 years) was notably younger than the reported US average age of patients who had a diagnosis of AML (68 years).10 Gender breakdown was slightly different than US statistics: 63% of AML patients in our group were male, whereas AML is only slightly more common among men in the United States.10

Clinically, skin lesions observed most commonly were (in decreasing order) papules, nodules, macules, plaques, and ulcers. Papules (38%) were the most common lesion overall in our study, which differed from the Kang et al7 report in which nodules were the most common. Nodules (31%) were the second most common LC morphology among our patients. Among AML patients, papules were seen in 56% of patients (18/32); nodules were seen in 44% (14/32). The extremities (when combined together) were the most common location of LC lesions (46% [arms, 24%; legs, 22%]); the trunk was the second most common body region (31%). Our study did not find a difference among most common LC anatomic sites compared to other studies.5,7 Less common sites in our cohort included the head, scalp/ears, neck, hands, mucosa, and feet. All body sites were represented, including ocular and oral mucosa and groin, a finding that underscores the importance of complete and comprehensive skin examinations in this patient population. The terms erythematous and violaceous were used to describe the color of most lesions (88%), which commonly presented as multiple lesions (84%) and often were asymptomatic (84%).

It has been reported that, first, in most cases of LC, the condition develops in patients who have already been given a diagnosis of leukemia and, second, simultaneous manifestation of systemic leukemia and LC is less common.11,12 Leukemia cutis also can precede peripheral or bone marrow leukemia (known as aleukemic LC).1,13 Two AML patients (4.3% [2/46]) in this study met criteria for aleukemic LC because they had LC at the same time as negative bone marrow biopsy, which is consistent with a prior report that aleukemic LC can affect as many as 7% of patients.1 Our results differed slightly from prior studies in that most of our patients had LC as one of the presenting manifestations of their leukemia.3,7

Regardless of leukemia type, patients were likely to die within 1 year of LC diagnosis, on average, which is consistent with prior reports.7,11,12 However, the time between diagnosis of LC and death varied greatly among our patients (range, 12 days to 4.1 years). From 2007 to 2013, the 5-year relative survival rate overall for leukemia patients in the US population (by type) was 86.2% (CLL), 71.0% (ALL), 68.0% (CML), and 27.4% (AML).14 Compared to these national statistics, the relative survival rate in LC is poor, with patients who have AML surviving, on average, less than 8 months from time of leukemia diagnosis, whereas ALL and CLL patients survive less than 6 months.



When LC is a late presentation of B-cell CLL or when it presents as myeloid leukemia, blastic transformation (Richter syndrome), or T-cell CLL, it is occasionally associated with poor prognosis, though LC does not affect survival.15-17 In a study of the association of LC with survival in AML, 5-year survival among 62 AML patients with LC was 8.6%, shorter than 28.3% among the 186 matched patients with AML without LC.18 Similarly, the estimated 5-year survival for all patients with AML, according to Surveillance, Epidemiology, and End Results Program data (2007-2013), was 27.4%.14 Based on those results, LC might be a good prognostic indicator in patients with AML.

Conclusion

This study characterized the clinical presentation of LC, which is highly variable in appearance, symptoms, distribution, and stage of leukemia at presentation. In our study cohort, LC most commonly presented as asymptomatic erythematous or violaceous papules or nodules in older male AML patients at leukemia diagnosis. Given such wide variability, dermatologists and oncologists need to keep LC in the differential diagnosis for any new skin lesion and to have a low threshold for performing skin biopsy. Complete and thorough skin examinations should be performed on leukemia patients throughout the course of their disease to identify LC early so that treatment can be implemented in a timely fashion at initial diagnosis, first sign of relapse, or change in disease state.

References
  1. Wagner G, Fenchel K, Back W, et al. Leukemia cutis—epidemiology, clinical presentation, and differential diagnoses. J Dtsch Dermatol Ges. 2012;10:27-36.
  2. Grunwald MR, McDonnell MH, Induru R, et al. Cutaneous manifestations in leukemia patients. Semin Oncol. 2016;43:359-365.
  3. Martínez-Leboráns L, Victoria-Martínez A, Torregrosa-Calatayu JL, et al. Leukemia cutis: a report of 17 cases and a review of literature. Actas Dermosifiliogr. 2016;107:e65-e69.
  4. Li L, Wang Y, Lian CG, et al. Clinical and pathological features of myeloid leukemia cutis. An Bras Dermatol. 2018;93:216-221.
  5. Paydas¸ S, Zorludemir S. Leukaemia cutis and leukaemic vasculitis. Br J Dermatol. 2000;143:773-779.
  6. Lee JI, Park HJ, Oh ST, et al. A case of leukemia cutis at the site of a prior catheter insertion. Ann Dermatol. 2009;21:193-196.
  7. Kang YS, Kim HS, Park HJ, et al. Clinical characteristics of 75 patients with leukemia cutis. J Korean Med Sci. 2013;28:614-619.
  8. Stern M, Halter J, Buser A, et al. Leukemia cutis preceding systemic relapse of acute myeloid leukemia. Int J Hematol. 2008;87:108-109.
  9. Patel LM, Maghari A, Schwartz RA, et al. Myeloid leukemia cutis in the setting of myelodysplastic syndrome: a crucial dermatological diagnosis. Int J Dermatol. 2012;51:383-388.
  10. American Cancer Society. Cancer Facts & Figures 2019. Atlanta, GA: American Cancer Society; 2019. http://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf. Accessed November 21, 2019.
  11. Cho-Vega JH, Medeiros LJ, Prieto VG, et al. Leukemia cutis. Am J Clin Pathol. 2008;129:130-142.
  12. Su WP. Clinical, histopathologic, and immunohistochemical correlations in leukemia cutis. Semin Dermatol. 1994;13:223-230.
  13. Barzilai A, Lyakhovitsky A, Goldberg I, et al. Aleukemic monocytic leukemia cutis. Cutis. 2002;69:301-­304
  14. Howlader N, Noone AM, Krapcho M, et al, eds. SEER cancer statistics review (CSR) 1975-2014. Bethesda, MD: National Cancer Institute; April 2017. https://seer.cancer.gov/archive/csr/1975_2014/. Accessed November 21, 2019.
  15. Cerroni L, Zenahlik P, Höfler G, et al. Specific cutaneous infiltrates of B-cell chronic lymphocytic leukemia: a clinicopathologic and prognostic study of 42 patients. Am J Surg Pathol. 1996;20:1000-1010.
  16. Colburn DE, Welch MA, Giles FJ. Skin infiltration with chronic lymphocytic leukemia is consistent with a good prognosis. Hematology. 2002;7:187-188.
  17. Ratnam KV, Khor CJ, Su WP. Leukemia cutis. Dermatol Clin. 1994;12:419-431. 
  18. Wang CX, Pusic I, Anadkat MJ. Association of leukemia cutis with survival in acute myeloid leukemia. JAMA Dermatol. 2019;155:826-832.
References
  1. Wagner G, Fenchel K, Back W, et al. Leukemia cutis—epidemiology, clinical presentation, and differential diagnoses. J Dtsch Dermatol Ges. 2012;10:27-36.
  2. Grunwald MR, McDonnell MH, Induru R, et al. Cutaneous manifestations in leukemia patients. Semin Oncol. 2016;43:359-365.
  3. Martínez-Leboráns L, Victoria-Martínez A, Torregrosa-Calatayu JL, et al. Leukemia cutis: a report of 17 cases and a review of literature. Actas Dermosifiliogr. 2016;107:e65-e69.
  4. Li L, Wang Y, Lian CG, et al. Clinical and pathological features of myeloid leukemia cutis. An Bras Dermatol. 2018;93:216-221.
  5. Paydas¸ S, Zorludemir S. Leukaemia cutis and leukaemic vasculitis. Br J Dermatol. 2000;143:773-779.
  6. Lee JI, Park HJ, Oh ST, et al. A case of leukemia cutis at the site of a prior catheter insertion. Ann Dermatol. 2009;21:193-196.
  7. Kang YS, Kim HS, Park HJ, et al. Clinical characteristics of 75 patients with leukemia cutis. J Korean Med Sci. 2013;28:614-619.
  8. Stern M, Halter J, Buser A, et al. Leukemia cutis preceding systemic relapse of acute myeloid leukemia. Int J Hematol. 2008;87:108-109.
  9. Patel LM, Maghari A, Schwartz RA, et al. Myeloid leukemia cutis in the setting of myelodysplastic syndrome: a crucial dermatological diagnosis. Int J Dermatol. 2012;51:383-388.
  10. American Cancer Society. Cancer Facts & Figures 2019. Atlanta, GA: American Cancer Society; 2019. http://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf. Accessed November 21, 2019.
  11. Cho-Vega JH, Medeiros LJ, Prieto VG, et al. Leukemia cutis. Am J Clin Pathol. 2008;129:130-142.
  12. Su WP. Clinical, histopathologic, and immunohistochemical correlations in leukemia cutis. Semin Dermatol. 1994;13:223-230.
  13. Barzilai A, Lyakhovitsky A, Goldberg I, et al. Aleukemic monocytic leukemia cutis. Cutis. 2002;69:301-­304
  14. Howlader N, Noone AM, Krapcho M, et al, eds. SEER cancer statistics review (CSR) 1975-2014. Bethesda, MD: National Cancer Institute; April 2017. https://seer.cancer.gov/archive/csr/1975_2014/. Accessed November 21, 2019.
  15. Cerroni L, Zenahlik P, Höfler G, et al. Specific cutaneous infiltrates of B-cell chronic lymphocytic leukemia: a clinicopathologic and prognostic study of 42 patients. Am J Surg Pathol. 1996;20:1000-1010.
  16. Colburn DE, Welch MA, Giles FJ. Skin infiltration with chronic lymphocytic leukemia is consistent with a good prognosis. Hematology. 2002;7:187-188.
  17. Ratnam KV, Khor CJ, Su WP. Leukemia cutis. Dermatol Clin. 1994;12:419-431. 
  18. Wang CX, Pusic I, Anadkat MJ. Association of leukemia cutis with survival in acute myeloid leukemia. JAMA Dermatol. 2019;155:826-832.
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Practice Points

  • Complete and comprehensive skin examination is important in leukemia patients, as leukemia cutis (LC) lesions can present in all body sites including ocular and oral mucosa as well as the groin.
  • Given the wide variability in appearance, symptoms, distribution, and stage of leukemia at presentation, dermatologists and oncologists need to keep LC in the differential diagnosis for any new skin lesion and to have a low threshold for performing skin biopsy.
  • Performing thorough skin examination on leukemia patients throughout the course of their disease may help identify LC early so that treatment can be implemented in a timely fashion at initial diagnosis, first sign of relapse, or change in disease state.
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Direct Immunofluorescence Staining Patterns in Blistering Disorders

Review the PDF of the fact sheet on Direct Immunofluorescence Staining Patterns in Blistering Disorders with board-relevant, easy-to-review material. This fact sheet reviews the dermatologic conditions that typically have positive immunofluorescence staining patterns.

Practice Questions

1. Which autoimmune blistering disease shows deposition of immunoglobulin on the floor of salt-split skin?

a. BP
b. dermatitis herpetiformis
c. epidermolysis bullosa acquisita
d. paraneoplastic pemphigus
e. PV

 

 

2. What medicine is commonly implicated in drug-induced pemphigus?

a. acetaminophen
b. amoxicillin
c. naproxen
d. penicillamine
e. penicillin

 

 

3. Which autoimmune blistering disease predominantly shows deposition of IgG on DIF?

a. dermatitis herpetiformis
b. IgA pemphigus
c. linear IgA bullous dermatosis
d. paraneoplastic pemphigus
e. porphyria cutanea tarda

 

 

4. Which of the following diseases has a negative direct immunofluorescence?

a. dermatitis herpetiformis
b. herpes gestationis
c. pemphigus vulgaris
d. porphyria cutanea tarda
e. transient acantholytic dermatosis

 

 

5. Which of the following diseases shows a linear deposition of IgG and C3 along the dermoepidermal junction?

a. CP
b. IgA pemphigus
c. PF
d. porphyria cutanea tarda
e. PV

Answers to practice questions provided on next page

 

 

Practice Question Answers

1. Which autoimmune blistering disease shows deposition of immunoglobulin on the floor of salt-split skin?
a. BP
b. dermatitis herpetiformis
c. epidermolysis bullosa acquisita
d. paraneoplastic pemphigus
e. PV

 

2. What medicine is commonly implicated in drug-induced pemphigus?
a. acetaminophen
b. amoxicillin
c. naproxen
d. penicillamine
e. penicillin

 

3. Which autoimmune blistering disease predominantly shows deposition of IgG on DIF?
a. dermatitis herpetiformis
b. IgA pemphigus
c. linear IgA bullous dermatosis
d. paraneoplastic pemphigus
e. porphyria cutanea tarda

 

4. Which of the following diseases has a negative direct immunofluorescence?
a. dermatitis herpetiformis
b. herpes gestationis
c. pemphigus vulgaris
d. porphyria cutanea tarda
e. transient acantholytic dermatosis

 

5. Which of the following diseases shows a linear deposition of IgG and C3 along the dermoepidermal junction?
a. CP
b. IgA pemphigus
c. PF
d. porphyria cutanea tarda
e. PV

Article PDF
Author and Disclosure Information

Dr. Strowd is Assistant Professor of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The author reports no conflict of interest.

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Dr. Strowd is Assistant Professor of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The author reports no conflict of interest.

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Dr. Strowd is Assistant Professor of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The author reports no conflict of interest.

Article PDF
Article PDF

Review the PDF of the fact sheet on Direct Immunofluorescence Staining Patterns in Blistering Disorders with board-relevant, easy-to-review material. This fact sheet reviews the dermatologic conditions that typically have positive immunofluorescence staining patterns.

Practice Questions

1. Which autoimmune blistering disease shows deposition of immunoglobulin on the floor of salt-split skin?

a. BP
b. dermatitis herpetiformis
c. epidermolysis bullosa acquisita
d. paraneoplastic pemphigus
e. PV

 

 

2. What medicine is commonly implicated in drug-induced pemphigus?

a. acetaminophen
b. amoxicillin
c. naproxen
d. penicillamine
e. penicillin

 

 

3. Which autoimmune blistering disease predominantly shows deposition of IgG on DIF?

a. dermatitis herpetiformis
b. IgA pemphigus
c. linear IgA bullous dermatosis
d. paraneoplastic pemphigus
e. porphyria cutanea tarda

 

 

4. Which of the following diseases has a negative direct immunofluorescence?

a. dermatitis herpetiformis
b. herpes gestationis
c. pemphigus vulgaris
d. porphyria cutanea tarda
e. transient acantholytic dermatosis

 

 

5. Which of the following diseases shows a linear deposition of IgG and C3 along the dermoepidermal junction?

a. CP
b. IgA pemphigus
c. PF
d. porphyria cutanea tarda
e. PV

Answers to practice questions provided on next page

 

 

Practice Question Answers

1. Which autoimmune blistering disease shows deposition of immunoglobulin on the floor of salt-split skin?
a. BP
b. dermatitis herpetiformis
c. epidermolysis bullosa acquisita
d. paraneoplastic pemphigus
e. PV

 

2. What medicine is commonly implicated in drug-induced pemphigus?
a. acetaminophen
b. amoxicillin
c. naproxen
d. penicillamine
e. penicillin

 

3. Which autoimmune blistering disease predominantly shows deposition of IgG on DIF?
a. dermatitis herpetiformis
b. IgA pemphigus
c. linear IgA bullous dermatosis
d. paraneoplastic pemphigus
e. porphyria cutanea tarda

 

4. Which of the following diseases has a negative direct immunofluorescence?
a. dermatitis herpetiformis
b. herpes gestationis
c. pemphigus vulgaris
d. porphyria cutanea tarda
e. transient acantholytic dermatosis

 

5. Which of the following diseases shows a linear deposition of IgG and C3 along the dermoepidermal junction?
a. CP
b. IgA pemphigus
c. PF
d. porphyria cutanea tarda
e. PV

Review the PDF of the fact sheet on Direct Immunofluorescence Staining Patterns in Blistering Disorders with board-relevant, easy-to-review material. This fact sheet reviews the dermatologic conditions that typically have positive immunofluorescence staining patterns.

Practice Questions

1. Which autoimmune blistering disease shows deposition of immunoglobulin on the floor of salt-split skin?

a. BP
b. dermatitis herpetiformis
c. epidermolysis bullosa acquisita
d. paraneoplastic pemphigus
e. PV

 

 

2. What medicine is commonly implicated in drug-induced pemphigus?

a. acetaminophen
b. amoxicillin
c. naproxen
d. penicillamine
e. penicillin

 

 

3. Which autoimmune blistering disease predominantly shows deposition of IgG on DIF?

a. dermatitis herpetiformis
b. IgA pemphigus
c. linear IgA bullous dermatosis
d. paraneoplastic pemphigus
e. porphyria cutanea tarda

 

 

4. Which of the following diseases has a negative direct immunofluorescence?

a. dermatitis herpetiformis
b. herpes gestationis
c. pemphigus vulgaris
d. porphyria cutanea tarda
e. transient acantholytic dermatosis

 

 

5. Which of the following diseases shows a linear deposition of IgG and C3 along the dermoepidermal junction?

a. CP
b. IgA pemphigus
c. PF
d. porphyria cutanea tarda
e. PV

Answers to practice questions provided on next page

 

 

Practice Question Answers

1. Which autoimmune blistering disease shows deposition of immunoglobulin on the floor of salt-split skin?
a. BP
b. dermatitis herpetiformis
c. epidermolysis bullosa acquisita
d. paraneoplastic pemphigus
e. PV

 

2. What medicine is commonly implicated in drug-induced pemphigus?
a. acetaminophen
b. amoxicillin
c. naproxen
d. penicillamine
e. penicillin

 

3. Which autoimmune blistering disease predominantly shows deposition of IgG on DIF?
a. dermatitis herpetiformis
b. IgA pemphigus
c. linear IgA bullous dermatosis
d. paraneoplastic pemphigus
e. porphyria cutanea tarda

 

4. Which of the following diseases has a negative direct immunofluorescence?
a. dermatitis herpetiformis
b. herpes gestationis
c. pemphigus vulgaris
d. porphyria cutanea tarda
e. transient acantholytic dermatosis

 

5. Which of the following diseases shows a linear deposition of IgG and C3 along the dermoepidermal junction?
a. CP
b. IgA pemphigus
c. PF
d. porphyria cutanea tarda
e. PV

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Biologics for Psoriasis

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Biologics for Psoriasis

Review the PDF of the fact sheet on biologics for psoriasis with board-relevant, easy-to-review material. This month's fact sheet discusses the current US Food and Drug Administration–approved biologic medications for psoriasis and psoriatic arthritis, including the mechanism of action, dosing, and side effects.

Practice Questions

1. Which biologic is administered as an intravenous infusion?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

2. Which biologic is dosed based on body weight?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

3. Which biologic has been shown to worsen existing Crohn disease?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

4. Which biologic is a fusion protein?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

5. Which biologic has been shown to cause reversible posterior leukoencephalopathy syndrome?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

Answers to practice questions provided on next page

 

 

Practice Question Answers

1. Which biologic is administered as an intravenous infusion?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

2. Which biologic is dosed based on body weight?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

3. Which biologic has been shown to worsen existing Crohn disease?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

4. Which biologic is a fusion protein?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

5. Which biologic has been shown to cause reversible posterior leukoencephalopathy syndrome?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

Article PDF
Author and Disclosure Information

Dr. Strowd is from Clinical Associates at Reisterstown, Maryland.

The author reports no conflict of interest.

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Dr. Strowd is from Clinical Associates at Reisterstown, Maryland.

The author reports no conflict of interest.

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Review the PDF of the fact sheet on biologics for psoriasis with board-relevant, easy-to-review material. This month's fact sheet discusses the current US Food and Drug Administration–approved biologic medications for psoriasis and psoriatic arthritis, including the mechanism of action, dosing, and side effects.

Practice Questions

1. Which biologic is administered as an intravenous infusion?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

2. Which biologic is dosed based on body weight?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

3. Which biologic has been shown to worsen existing Crohn disease?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

4. Which biologic is a fusion protein?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

5. Which biologic has been shown to cause reversible posterior leukoencephalopathy syndrome?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

Answers to practice questions provided on next page

 

 

Practice Question Answers

1. Which biologic is administered as an intravenous infusion?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

2. Which biologic is dosed based on body weight?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

3. Which biologic has been shown to worsen existing Crohn disease?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

4. Which biologic is a fusion protein?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

5. Which biologic has been shown to cause reversible posterior leukoencephalopathy syndrome?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

Review the PDF of the fact sheet on biologics for psoriasis with board-relevant, easy-to-review material. This month's fact sheet discusses the current US Food and Drug Administration–approved biologic medications for psoriasis and psoriatic arthritis, including the mechanism of action, dosing, and side effects.

Practice Questions

1. Which biologic is administered as an intravenous infusion?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

2. Which biologic is dosed based on body weight?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

3. Which biologic has been shown to worsen existing Crohn disease?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

4. Which biologic is a fusion protein?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

 

5. Which biologic has been shown to cause reversible posterior leukoencephalopathy syndrome?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

Answers to practice questions provided on next page

 

 

Practice Question Answers

1. Which biologic is administered as an intravenous infusion?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

2. Which biologic is dosed based on body weight?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

3. Which biologic has been shown to worsen existing Crohn disease?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

4. Which biologic is a fusion protein?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

 

5. Which biologic has been shown to cause reversible posterior leukoencephalopathy syndrome?

a. adalimumab

b. etanercept

c. infliximab

d. secukinumab

e. ustekinumab

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Blistering Diseases in Newborns

Article Type
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Thu, 01/10/2019 - 13:27
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Blistering Diseases in Newborns

Review the PDF of the fact sheet on blistering diseases in newborns
with board-relevant, easy-to-review material. This fact sheet reviews the most common neonatal blistering diseases and discusses their clinical features and management.

After, test your knowledge by answering the 5 practice questions.

Practice Questions

1. Which congenital blistering condition is caused by a mast cell growth factor receptor (KIT) mutation?

a. aplasia cutis congenita

b. bullous mastocytosis

c. congenital erosive and vesicular dermatosis

d. epidermolysis bullosa simplex

e. ichthyosis bullosa of Siemens

 

 

2. What gene mutation is present in acrodermatitis enteropathica?

a. collagen VII

b. keratin 2e

c. mast cell growth factor receptor

d. NF-κB essential modulator

e. solute carrier family 39 (zinc transporter), member 4

 

 

3. Which congenital blistering disease is associated with an increased risk of squamous cell carcinoma in adult patients?

a. aplasia cutis congenita

b. bullous mastocytosis

c. Kindler syndrome

d. pemphigus syphiliticus

e. varicella

 

 

4. Which congenital blistering condition can be caused by prenatal exposure to methimazole?

a. aplasia cutis congenita

b. bullous mastocytosis

c. dystrophic epidermolysis bullosa

d. Kindler syndrome

e. pemphigus syphiliticus

 

 

5. Which congenital blistering condition is caused by a mutation in transglutaminase 5?

a. acral peeling skin syndrome

b. aplasia cutis congenita

c. bullous mastocytosis

d. dystrophic epidermolysis bullosa

e. Kindler syndrome

 

 

1. Which congenital blistering condition is caused by a mast cell growth factor (KIT) receptor mutation?

a. aplasia cutis congenita

b. bullous mastocytosis

c. congenital erosive and vesicular dermatosis

d. epidermolysis bullosa simplex

e. ichthyosis bullosa of Siemens

 

2. What gene mutation is present in acrodermatitis enteropathica?

a. collagen VII

b. keratin 2e

c. mast cell growth factor receptor

d. NF-κB essential modulator

e. solute carrier family 39 (zinc transporter), member 4

 

3. Which congenital blistering disease is associated with an increased risk of squamous cell carcinoma in adult patients?

a. aplasia cutis congenita

b. bullous mastocytosis

c. Kindler syndrome

d. pemphigus syphiliticus

e. varicella

 

4. Which congenital blistering condition can be caused by prenatal exposure to methimazole?

a. aplasia cutis congenita

b. bullous mastocytosis

c. dystrophic epidermolysis bullosa

d. Kindler syndrome

e. pemphigus syphiliticus

 

5. Which congenital blistering condition is caused by a mutation in transglutaminase 5?

a. acral peeling skin syndrome

b. aplasia cutis congenita

c. bullous mastocytosis

d. dystrophic epidermolysis bullosa

e. Kindler syndrome

Article PDF
Author and Disclosure Information

Dr. Strowd is Assistant Professor of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The author reports no conflict of interest.

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Author and Disclosure Information

Dr. Strowd is Assistant Professor of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The author reports no conflict of interest.

Author and Disclosure Information

Dr. Strowd is Assistant Professor of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The author reports no conflict of interest.

Article PDF
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Review the PDF of the fact sheet on blistering diseases in newborns
with board-relevant, easy-to-review material. This fact sheet reviews the most common neonatal blistering diseases and discusses their clinical features and management.

After, test your knowledge by answering the 5 practice questions.

Practice Questions

1. Which congenital blistering condition is caused by a mast cell growth factor receptor (KIT) mutation?

a. aplasia cutis congenita

b. bullous mastocytosis

c. congenital erosive and vesicular dermatosis

d. epidermolysis bullosa simplex

e. ichthyosis bullosa of Siemens

 

 

2. What gene mutation is present in acrodermatitis enteropathica?

a. collagen VII

b. keratin 2e

c. mast cell growth factor receptor

d. NF-κB essential modulator

e. solute carrier family 39 (zinc transporter), member 4

 

 

3. Which congenital blistering disease is associated with an increased risk of squamous cell carcinoma in adult patients?

a. aplasia cutis congenita

b. bullous mastocytosis

c. Kindler syndrome

d. pemphigus syphiliticus

e. varicella

 

 

4. Which congenital blistering condition can be caused by prenatal exposure to methimazole?

a. aplasia cutis congenita

b. bullous mastocytosis

c. dystrophic epidermolysis bullosa

d. Kindler syndrome

e. pemphigus syphiliticus

 

 

5. Which congenital blistering condition is caused by a mutation in transglutaminase 5?

a. acral peeling skin syndrome

b. aplasia cutis congenita

c. bullous mastocytosis

d. dystrophic epidermolysis bullosa

e. Kindler syndrome

 

 

1. Which congenital blistering condition is caused by a mast cell growth factor (KIT) receptor mutation?

a. aplasia cutis congenita

b. bullous mastocytosis

c. congenital erosive and vesicular dermatosis

d. epidermolysis bullosa simplex

e. ichthyosis bullosa of Siemens

 

2. What gene mutation is present in acrodermatitis enteropathica?

a. collagen VII

b. keratin 2e

c. mast cell growth factor receptor

d. NF-κB essential modulator

e. solute carrier family 39 (zinc transporter), member 4

 

3. Which congenital blistering disease is associated with an increased risk of squamous cell carcinoma in adult patients?

a. aplasia cutis congenita

b. bullous mastocytosis

c. Kindler syndrome

d. pemphigus syphiliticus

e. varicella

 

4. Which congenital blistering condition can be caused by prenatal exposure to methimazole?

a. aplasia cutis congenita

b. bullous mastocytosis

c. dystrophic epidermolysis bullosa

d. Kindler syndrome

e. pemphigus syphiliticus

 

5. Which congenital blistering condition is caused by a mutation in transglutaminase 5?

a. acral peeling skin syndrome

b. aplasia cutis congenita

c. bullous mastocytosis

d. dystrophic epidermolysis bullosa

e. Kindler syndrome

Review the PDF of the fact sheet on blistering diseases in newborns
with board-relevant, easy-to-review material. This fact sheet reviews the most common neonatal blistering diseases and discusses their clinical features and management.

After, test your knowledge by answering the 5 practice questions.

Practice Questions

1. Which congenital blistering condition is caused by a mast cell growth factor receptor (KIT) mutation?

a. aplasia cutis congenita

b. bullous mastocytosis

c. congenital erosive and vesicular dermatosis

d. epidermolysis bullosa simplex

e. ichthyosis bullosa of Siemens

 

 

2. What gene mutation is present in acrodermatitis enteropathica?

a. collagen VII

b. keratin 2e

c. mast cell growth factor receptor

d. NF-κB essential modulator

e. solute carrier family 39 (zinc transporter), member 4

 

 

3. Which congenital blistering disease is associated with an increased risk of squamous cell carcinoma in adult patients?

a. aplasia cutis congenita

b. bullous mastocytosis

c. Kindler syndrome

d. pemphigus syphiliticus

e. varicella

 

 

4. Which congenital blistering condition can be caused by prenatal exposure to methimazole?

a. aplasia cutis congenita

b. bullous mastocytosis

c. dystrophic epidermolysis bullosa

d. Kindler syndrome

e. pemphigus syphiliticus

 

 

5. Which congenital blistering condition is caused by a mutation in transglutaminase 5?

a. acral peeling skin syndrome

b. aplasia cutis congenita

c. bullous mastocytosis

d. dystrophic epidermolysis bullosa

e. Kindler syndrome

 

 

1. Which congenital blistering condition is caused by a mast cell growth factor (KIT) receptor mutation?

a. aplasia cutis congenita

b. bullous mastocytosis

c. congenital erosive and vesicular dermatosis

d. epidermolysis bullosa simplex

e. ichthyosis bullosa of Siemens

 

2. What gene mutation is present in acrodermatitis enteropathica?

a. collagen VII

b. keratin 2e

c. mast cell growth factor receptor

d. NF-κB essential modulator

e. solute carrier family 39 (zinc transporter), member 4

 

3. Which congenital blistering disease is associated with an increased risk of squamous cell carcinoma in adult patients?

a. aplasia cutis congenita

b. bullous mastocytosis

c. Kindler syndrome

d. pemphigus syphiliticus

e. varicella

 

4. Which congenital blistering condition can be caused by prenatal exposure to methimazole?

a. aplasia cutis congenita

b. bullous mastocytosis

c. dystrophic epidermolysis bullosa

d. Kindler syndrome

e. pemphigus syphiliticus

 

5. Which congenital blistering condition is caused by a mutation in transglutaminase 5?

a. acral peeling skin syndrome

b. aplasia cutis congenita

c. bullous mastocytosis

d. dystrophic epidermolysis bullosa

e. Kindler syndrome

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Blistering Diseases in Newborns
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