Blog

We are all aware of the rising costs of medical care, especially for complex diseases such as psoriasis. The total cost of psoriasis in the United States is unknown. Brezinski et al (JAMA Dermatol. doi:10.1001/jamadermatol.2014.3593) sought to define the economic burden of psoriasis in the United States. They argued that this information is needed to provide the foundation for research, advocacy, and educational efforts within the disease.

The authors searched PubMed and MEDLINE databases for economic investigations on the costs of adult psoriasis in the United States. The primary objective of the analysis was to provide a comprehensive analysis of the literature on the economic burden of psoriasis in the United States. The direct, indirect, intangible, and comorbidity costs of psoriasis were reported based on this systematic literature review and adjusted to 2013 US dollars.

The direct costs included medical costs associated with (1) specialist medical evaluations, (2) hospitalization, (3) prescription medications, (4) phototherapy, (5) medication administration costs, (6) laboratory tests and monitoring studies, and (7) over-the-counter medications and self-care products. The indirect costs were determined by absenteeism and impaired work productivity. Intangible costs were calculated as a measure of the negative effect of psoriasis on quality of life. Finally, comorbidity costs measured the medical evaluations, treatment, and lab monitoring that were directly attributed to comorbid conditions associated with psoriasis.

An initial review of the literature generated 100 articles; 22 studies were included in the systematic review. The direct psoriasis costs ranged from $51.7 billion to $63.2 billion, the indirect costs ranged from $23.9 billion to $35.4 billion, and medical comorbidities were estimated to contribute $36.4 billion annually in 2013 US dollars. The annual cost of psoriasis in the United States amounted to approximately $112 billion in 2013.

The authors concluded that the economic burden of psoriasis was substantial and significant in the United States.

What’s the issue?

In the United States, the economic burden of psoriasis is substantial because this disease is associated with negative physical, psychiatric, and social consequences. In addition, treatment costs continue to rise. How will this analysis of cost influence your future management of psoriasis?

We want to know your views! Tell us what you think.

We are all aware of the rising costs of medical care, especially for complex diseases such as psoriasis. The total cost of psoriasis in the United States is unknown. Brezinski et al (JAMA Dermatol. doi:10.1001/jamadermatol.2014.3593) sought to define the economic burden of psoriasis in the United States. They argued that this information is needed to provide the foundation for research, advocacy, and educational efforts within the disease.

The authors searched PubMed and MEDLINE databases for economic investigations on the costs of adult psoriasis in the United States. The primary objective of the analysis was to provide a comprehensive analysis of the literature on the economic burden of psoriasis in the United States. The direct, indirect, intangible, and comorbidity costs of psoriasis were reported based on this systematic literature review and adjusted to 2013 US dollars.

The direct costs included medical costs associated with (1) specialist medical evaluations, (2) hospitalization, (3) prescription medications, (4) phototherapy, (5) medication administration costs, (6) laboratory tests and monitoring studies, and (7) over-the-counter medications and self-care products. The indirect costs were determined by absenteeism and impaired work productivity. Intangible costs were calculated as a measure of the negative effect of psoriasis on quality of life. Finally, comorbidity costs measured the medical evaluations, treatment, and lab monitoring that were directly attributed to comorbid conditions associated with psoriasis.

An initial review of the literature generated 100 articles; 22 studies were included in the systematic review. The direct psoriasis costs ranged from $51.7 billion to $63.2 billion, the indirect costs ranged from $23.9 billion to $35.4 billion, and medical comorbidities were estimated to contribute $36.4 billion annually in 2013 US dollars. The annual cost of psoriasis in the United States amounted to approximately $112 billion in 2013.

The authors concluded that the economic burden of psoriasis was substantial and significant in the United States.

What’s the issue?

In the United States, the economic burden of psoriasis is substantial because this disease is associated with negative physical, psychiatric, and social consequences. In addition, treatment costs continue to rise. How will this analysis of cost influence your future management of psoriasis?

We want to know your views! Tell us what you think.

We are all aware of the rising costs of medical care, especially for complex diseases such as psoriasis. The total cost of psoriasis in the United States is unknown. Brezinski et al (JAMA Dermatol. doi:10.1001/jamadermatol.2014.3593) sought to define the economic burden of psoriasis in the United States. They argued that this information is needed to provide the foundation for research, advocacy, and educational efforts within the disease.

The authors searched PubMed and MEDLINE databases for economic investigations on the costs of adult psoriasis in the United States. The primary objective of the analysis was to provide a comprehensive analysis of the literature on the economic burden of psoriasis in the United States. The direct, indirect, intangible, and comorbidity costs of psoriasis were reported based on this systematic literature review and adjusted to 2013 US dollars.

The direct costs included medical costs associated with (1) specialist medical evaluations, (2) hospitalization, (3) prescription medications, (4) phototherapy, (5) medication administration costs, (6) laboratory tests and monitoring studies, and (7) over-the-counter medications and self-care products. The indirect costs were determined by absenteeism and impaired work productivity. Intangible costs were calculated as a measure of the negative effect of psoriasis on quality of life. Finally, comorbidity costs measured the medical evaluations, treatment, and lab monitoring that were directly attributed to comorbid conditions associated with psoriasis.

An initial review of the literature generated 100 articles; 22 studies were included in the systematic review. The direct psoriasis costs ranged from $51.7 billion to $63.2 billion, the indirect costs ranged from $23.9 billion to $35.4 billion, and medical comorbidities were estimated to contribute $36.4 billion annually in 2013 US dollars. The annual cost of psoriasis in the United States amounted to approximately $112 billion in 2013.

The authors concluded that the economic burden of psoriasis was substantial and significant in the United States.

What’s the issue?

In the United States, the economic burden of psoriasis is substantial because this disease is associated with negative physical, psychiatric, and social consequences. In addition, treatment costs continue to rise. How will this analysis of cost influence your future management of psoriasis?

We want to know your views! Tell us what you think.

The role of diet in acne, both as a causative agent and therapeutic intervention, has been the topic of discussion in both the dermatology community as well as the laypress for decades. There is ample evidence highlighting the association of acne and high glycemic loads, certain dairy products, and refined sugar product ingestion. In the most recent edition to the repository, Grossi et al (J Eur Acad Dermatol Venereol. doi:10.1111/jdv.12878) reanalyzed data from their case-control study among young patients (age range, 10–24 years; N=563) with a diagnosis of moderate to severe acne versus control (participants with no or mild acne) between March 2009 and February 2010 that was originally published in 2012 (J Am Acad Dermatol. 2012;67:1129-1135). The unique element was how they evaluated the data. The investigators utilized a semantic connectivity map approach derived from artificial neural network computational models, which allowed for a better understanding of the complex connections between all of the studied variables. (The assumption of a given relation between any variables would not influence the results.) The data were presented on an Auto Semantic Connectivity Map that resembled a 4-leaf clover, representing “explanatory” information pertaining to the cases and controls and “residual” information of less importance. It is worth seeing in the manuscript to better appreciate the data.

What did they find? There is a close association between moderate to severe acne and a high intake of milk, other dairy products, sweets, and chocolate. Obesity and the low consumption of fish were linked to the presence of moderate to severe acne, while high consumption of fish (1 d/wk or more), high intake of fruits and vegetables, and body mass index lower than 18.5 were all associated with limited or no acne.

What’s the issue?

By adopting a different analytic approach, it was shown once again that diet plays a substantial role in acne, indicating that some food items may stimulate selected acne-promoting pathways. But what now? Here is the evidence yet again, but where is the medicine of “evidence-based medicine”? It is time to recommend guidelines for screening and counseling. In a recent article, Bronsnick et al (J Am Acad Dermatol. 2014;71:1039.e1-1039.e12) found that the level of evidence supporting the benefit of a low-glycemic, low-carbohydrate diet was sufficient to recommend to acne patients. How many dermatologists feel comfortable providing dietary guidance to their acne patients? A consensus statement from relevant organizations such as the American Academy of Dermatology, the Society for Investigative Dermatology, and the American Acne & Rosacea Society that provides tangible and realistic screening tools to identify those who would benefit from dietary intervention and implementation and practice guidelines for Dr. Derm seeing 40 to 50 patients a day in Springfield, USA (homage to The Simpsons) based on the level of evidence available would be useful. What are your thoughts?

We want to know your views! Tell us what you think.

Suggested Readings

• Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63:124-141.
• Ferdowsian HR, Levin S. Does diet really affect acne? Skin Therapy Lett. 2010;15:1-2, 5.
• Melnik B. Dietary intervention in acne: attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol. 2012;4:20-32.
• Veith WB, Silverberg NB. The association of acne vulgaris with diet. Cutis. 2011;88:84-91.

The role of diet in acne, both as a causative agent and therapeutic intervention, has been the topic of discussion in both the dermatology community as well as the laypress for decades. There is ample evidence highlighting the association of acne and high glycemic loads, certain dairy products, and refined sugar product ingestion. In the most recent edition to the repository, Grossi et al (J Eur Acad Dermatol Venereol. doi:10.1111/jdv.12878) reanalyzed data from their case-control study among young patients (age range, 10–24 years; N=563) with a diagnosis of moderate to severe acne versus control (participants with no or mild acne) between March 2009 and February 2010 that was originally published in 2012 (J Am Acad Dermatol. 2012;67:1129-1135). The unique element was how they evaluated the data. The investigators utilized a semantic connectivity map approach derived from artificial neural network computational models, which allowed for a better understanding of the complex connections between all of the studied variables. (The assumption of a given relation between any variables would not influence the results.) The data were presented on an Auto Semantic Connectivity Map that resembled a 4-leaf clover, representing “explanatory” information pertaining to the cases and controls and “residual” information of less importance. It is worth seeing in the manuscript to better appreciate the data.

What did they find? There is a close association between moderate to severe acne and a high intake of milk, other dairy products, sweets, and chocolate. Obesity and the low consumption of fish were linked to the presence of moderate to severe acne, while high consumption of fish (1 d/wk or more), high intake of fruits and vegetables, and body mass index lower than 18.5 were all associated with limited or no acne.

What’s the issue?

By adopting a different analytic approach, it was shown once again that diet plays a substantial role in acne, indicating that some food items may stimulate selected acne-promoting pathways. But what now? Here is the evidence yet again, but where is the medicine of “evidence-based medicine”? It is time to recommend guidelines for screening and counseling. In a recent article, Bronsnick et al (J Am Acad Dermatol. 2014;71:1039.e1-1039.e12) found that the level of evidence supporting the benefit of a low-glycemic, low-carbohydrate diet was sufficient to recommend to acne patients. How many dermatologists feel comfortable providing dietary guidance to their acne patients? A consensus statement from relevant organizations such as the American Academy of Dermatology, the Society for Investigative Dermatology, and the American Acne & Rosacea Society that provides tangible and realistic screening tools to identify those who would benefit from dietary intervention and implementation and practice guidelines for Dr. Derm seeing 40 to 50 patients a day in Springfield, USA (homage to The Simpsons) based on the level of evidence available would be useful. What are your thoughts?

We want to know your views! Tell us what you think.

Suggested Readings

• Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63:124-141.
• Ferdowsian HR, Levin S. Does diet really affect acne? Skin Therapy Lett. 2010;15:1-2, 5.
• Melnik B. Dietary intervention in acne: attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol. 2012;4:20-32.
• Veith WB, Silverberg NB. The association of acne vulgaris with diet. Cutis. 2011;88:84-91.

The role of diet in acne, both as a causative agent and therapeutic intervention, has been the topic of discussion in both the dermatology community as well as the laypress for decades. There is ample evidence highlighting the association of acne and high glycemic loads, certain dairy products, and refined sugar product ingestion. In the most recent edition to the repository, Grossi et al (J Eur Acad Dermatol Venereol. doi:10.1111/jdv.12878) reanalyzed data from their case-control study among young patients (age range, 10–24 years; N=563) with a diagnosis of moderate to severe acne versus control (participants with no or mild acne) between March 2009 and February 2010 that was originally published in 2012 (J Am Acad Dermatol. 2012;67:1129-1135). The unique element was how they evaluated the data. The investigators utilized a semantic connectivity map approach derived from artificial neural network computational models, which allowed for a better understanding of the complex connections between all of the studied variables. (The assumption of a given relation between any variables would not influence the results.) The data were presented on an Auto Semantic Connectivity Map that resembled a 4-leaf clover, representing “explanatory” information pertaining to the cases and controls and “residual” information of less importance. It is worth seeing in the manuscript to better appreciate the data.

What did they find? There is a close association between moderate to severe acne and a high intake of milk, other dairy products, sweets, and chocolate. Obesity and the low consumption of fish were linked to the presence of moderate to severe acne, while high consumption of fish (1 d/wk or more), high intake of fruits and vegetables, and body mass index lower than 18.5 were all associated with limited or no acne.

What’s the issue?

By adopting a different analytic approach, it was shown once again that diet plays a substantial role in acne, indicating that some food items may stimulate selected acne-promoting pathways. But what now? Here is the evidence yet again, but where is the medicine of “evidence-based medicine”? It is time to recommend guidelines for screening and counseling. In a recent article, Bronsnick et al (J Am Acad Dermatol. 2014;71:1039.e1-1039.e12) found that the level of evidence supporting the benefit of a low-glycemic, low-carbohydrate diet was sufficient to recommend to acne patients. How many dermatologists feel comfortable providing dietary guidance to their acne patients? A consensus statement from relevant organizations such as the American Academy of Dermatology, the Society for Investigative Dermatology, and the American Acne & Rosacea Society that provides tangible and realistic screening tools to identify those who would benefit from dietary intervention and implementation and practice guidelines for Dr. Derm seeing 40 to 50 patients a day in Springfield, USA (homage to The Simpsons) based on the level of evidence available would be useful. What are your thoughts?

We want to know your views! Tell us what you think.

Suggested Readings

• Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63:124-141.
• Ferdowsian HR, Levin S. Does diet really affect acne? Skin Therapy Lett. 2010;15:1-2, 5.
• Melnik B. Dietary intervention in acne: attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol. 2012;4:20-32.
• Veith WB, Silverberg NB. The association of acne vulgaris with diet. Cutis. 2011;88:84-91.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

We are all aware that infections, particularly streptococcal infection, can be associated with psoriasis, especially the guttate variety. A logical question emanating from this fact is: Would tonsillectomy and adenoidectomy have any impact on psoriasis and its symptoms?

In a November 2014 article published online in the Journal of the American Academy of Dermatology, Rachakonda et al (doi:10.1016/j.jaad.2014.10.013) performed an extensive literature review to evaluate if tonsillectomy reduces psoriasis severity. The authors searched the following sources: MEDLINE, CINAHL, Cochrane, Embase, Web of Science, and Ovid databases (August 1, 1960, to September 12, 2013). In addition, they executed a manual search of selected references. Through this process, they identified observational studies and clinical trials examining psoriasis after tonsillectomy.

In the analysis, the authors included data from 20 articles from the 53 years they examined. From this literature, they included 545 patients with psoriasis who were either evaluated for or underwent tonsillectomy. Of 410 patients with psoriasis who actually underwent tonsillectomy, 290 experienced improvement in their psoriasis. Although some individuals who underwent tonsillectomy experienced sustained improvement in their disease, others experienced relapse following the procedure. The authors noted that their study was limited. Fifteen of 20 analyzed publications were case reports or series that lacked control groups. In addition, they noted that a publication bias that favored the reporting of improved cases needs to be considered.

Based on this comprehensive systematic review on the effect of tonsillectomy on psoriasis, the authors concluded that although tonsillectomy is effective in ameliorating psoriasis in a subpopulation of patients, there are insufficient data to describe the differences in clinical characteristics between responders versus nonresponders. Tonsillectomy may be a potential option for patients with recalcitrant psoriasis that is associated with occurrences of tonsillitis. Studies with long-term follow-up are needed to elucidate more clearly the extent and persistence of benefit of tonsillectomy in psoriasis.

What’s the issue?

Tonsillectomy represents an intriguing option not commonly considered for those with resistant disease. Based on the current data, will you discuss tonsillectomy with your patients?

We want to know your views! Tell us what you think.

Reader Comment
This concept so intrigued me when I heard Dr. Susan Katz discuss it at the NYU Advances in Medicine conference last June that I had the discussion with one of my patients, and she opted to have tonsillectomy this past fall. So far, she seems to improving, but I have not yet discontinued her long-term biologic therapy. At the same conference, Dr. Katz presented the idea that delaying antibiotic treatment of streptococcal pharyngitis by a few days might actually improve strep clearance rates by allowing the immune system to mount a greater response to the infection. Waiting for culture results before initiating antibiotic therapy might be prudent not only because it might reduce the unnecessary use of antibiotics in non-streptococcal pharyngitis, but because it might actually improve the long-term prognosis of patients (with or without psoriasis) who do have strep by reducing the odds of a chronic carrier state. Thanks for highlighting this area of study. Fascinating to consider that there might be a surgical cure for some psoriatic patients.

—Jennifer Goldwasser, MD (Scarsdale, New York)

We are all aware that infections, particularly streptococcal infection, can be associated with psoriasis, especially the guttate variety. A logical question emanating from this fact is: Would tonsillectomy and adenoidectomy have any impact on psoriasis and its symptoms?

In a November 2014 article published online in the Journal of the American Academy of Dermatology, Rachakonda et al (doi:10.1016/j.jaad.2014.10.013) performed an extensive literature review to evaluate if tonsillectomy reduces psoriasis severity. The authors searched the following sources: MEDLINE, CINAHL, Cochrane, Embase, Web of Science, and Ovid databases (August 1, 1960, to September 12, 2013). In addition, they executed a manual search of selected references. Through this process, they identified observational studies and clinical trials examining psoriasis after tonsillectomy.

In the analysis, the authors included data from 20 articles from the 53 years they examined. From this literature, they included 545 patients with psoriasis who were either evaluated for or underwent tonsillectomy. Of 410 patients with psoriasis who actually underwent tonsillectomy, 290 experienced improvement in their psoriasis. Although some individuals who underwent tonsillectomy experienced sustained improvement in their disease, others experienced relapse following the procedure. The authors noted that their study was limited. Fifteen of 20 analyzed publications were case reports or series that lacked control groups. In addition, they noted that a publication bias that favored the reporting of improved cases needs to be considered.

Based on this comprehensive systematic review on the effect of tonsillectomy on psoriasis, the authors concluded that although tonsillectomy is effective in ameliorating psoriasis in a subpopulation of patients, there are insufficient data to describe the differences in clinical characteristics between responders versus nonresponders. Tonsillectomy may be a potential option for patients with recalcitrant psoriasis that is associated with occurrences of tonsillitis. Studies with long-term follow-up are needed to elucidate more clearly the extent and persistence of benefit of tonsillectomy in psoriasis.

What’s the issue?

Tonsillectomy represents an intriguing option not commonly considered for those with resistant disease. Based on the current data, will you discuss tonsillectomy with your patients?

We want to know your views! Tell us what you think.

Reader Comment
This concept so intrigued me when I heard Dr. Susan Katz discuss it at the NYU Advances in Medicine conference last June that I had the discussion with one of my patients, and she opted to have tonsillectomy this past fall. So far, she seems to improving, but I have not yet discontinued her long-term biologic therapy. At the same conference, Dr. Katz presented the idea that delaying antibiotic treatment of streptococcal pharyngitis by a few days might actually improve strep clearance rates by allowing the immune system to mount a greater response to the infection. Waiting for culture results before initiating antibiotic therapy might be prudent not only because it might reduce the unnecessary use of antibiotics in non-streptococcal pharyngitis, but because it might actually improve the long-term prognosis of patients (with or without psoriasis) who do have strep by reducing the odds of a chronic carrier state. Thanks for highlighting this area of study. Fascinating to consider that there might be a surgical cure for some psoriatic patients.

—Jennifer Goldwasser, MD (Scarsdale, New York)

We are all aware that infections, particularly streptococcal infection, can be associated with psoriasis, especially the guttate variety. A logical question emanating from this fact is: Would tonsillectomy and adenoidectomy have any impact on psoriasis and its symptoms?

In a November 2014 article published online in the Journal of the American Academy of Dermatology, Rachakonda et al (doi:10.1016/j.jaad.2014.10.013) performed an extensive literature review to evaluate if tonsillectomy reduces psoriasis severity. The authors searched the following sources: MEDLINE, CINAHL, Cochrane, Embase, Web of Science, and Ovid databases (August 1, 1960, to September 12, 2013). In addition, they executed a manual search of selected references. Through this process, they identified observational studies and clinical trials examining psoriasis after tonsillectomy.

In the analysis, the authors included data from 20 articles from the 53 years they examined. From this literature, they included 545 patients with psoriasis who were either evaluated for or underwent tonsillectomy. Of 410 patients with psoriasis who actually underwent tonsillectomy, 290 experienced improvement in their psoriasis. Although some individuals who underwent tonsillectomy experienced sustained improvement in their disease, others experienced relapse following the procedure. The authors noted that their study was limited. Fifteen of 20 analyzed publications were case reports or series that lacked control groups. In addition, they noted that a publication bias that favored the reporting of improved cases needs to be considered.

Based on this comprehensive systematic review on the effect of tonsillectomy on psoriasis, the authors concluded that although tonsillectomy is effective in ameliorating psoriasis in a subpopulation of patients, there are insufficient data to describe the differences in clinical characteristics between responders versus nonresponders. Tonsillectomy may be a potential option for patients with recalcitrant psoriasis that is associated with occurrences of tonsillitis. Studies with long-term follow-up are needed to elucidate more clearly the extent and persistence of benefit of tonsillectomy in psoriasis.

What’s the issue?

Tonsillectomy represents an intriguing option not commonly considered for those with resistant disease. Based on the current data, will you discuss tonsillectomy with your patients?

We want to know your views! Tell us what you think.

Reader Comment
This concept so intrigued me when I heard Dr. Susan Katz discuss it at the NYU Advances in Medicine conference last June that I had the discussion with one of my patients, and she opted to have tonsillectomy this past fall. So far, she seems to improving, but I have not yet discontinued her long-term biologic therapy. At the same conference, Dr. Katz presented the idea that delaying antibiotic treatment of streptococcal pharyngitis by a few days might actually improve strep clearance rates by allowing the immune system to mount a greater response to the infection. Waiting for culture results before initiating antibiotic therapy might be prudent not only because it might reduce the unnecessary use of antibiotics in non-streptococcal pharyngitis, but because it might actually improve the long-term prognosis of patients (with or without psoriasis) who do have strep by reducing the odds of a chronic carrier state. Thanks for highlighting this area of study. Fascinating to consider that there might be a surgical cure for some psoriatic patients.

—Jennifer Goldwasser, MD (Scarsdale, New York)

There are anecdotal reports of dogs detecting melanoma and studies of canines being able to not only detect but also distinguish cancer from noncancer. Analysis of volatile compounds or metabolites from exhaled human breath and excreted urine also has been shown to differentiate between patients with certain cancers and healthy individuals. In addition, investigators have demonstrated that melanoma tissue has a volatile profile that is distinct from healthy nonneoplastic skin and nevi.

Abaffy et al (Metabolomics. 2013;9:998-1008) conducted a study that gives further support to the potential for analyzing volatile organic compounds as biomarkers of melanoma. They used the headspace solid phase microextraction method followed by gas chromatography and mass spectrometry to compare the volatile metabolic profiles of melanoma and nonneoplastic healthy-appearing adjacent skin from the same patient. They discovered increased levels of lauric acid (C12:0) and palmitic acid (C16:0) in melanoma and they postulated that the increased levels of these fatty acids were due to cancer-associated upregulation of de novo lipid synthesis.

What’s the issue?

In the 1980s, nail fold capillary microscopy using an ophthalmoscope was occasionally performed to evaluate for disease-associated vascular changes in patients who were being evaluated for connective tissue disorders. Within 2 decades, a dermoscope to assist in the evaluation of not only nail folds but also pigmented and other lesions replaced the ophthalmoscope. The US Food and Drug Administration recently approved a software-driven optical imaging and data analysis device that can be used to obtain additional information to assist the clinician in making a decision whether to biopsy a pigmented lesion.

As our ability to develop more sensitive and specific methods to diagnose melanoma and differentiate it from benign lesions advances, our approach to the evaluation of patients with pigmented lesions shall continue to be modified. Based on the detection of melanoma-associated volatile organic compounds coupled with their potential use as readily accessible tumor-related biomarkers, it is reasonable to speculate: (1) that a handheld office-based device, a dermatoscenter, that can identify melanoma-induced volatile tumor markers shall be developed to evaluate whether pigmented lesions are malignant or benign, and (2) that this device will eventually become an integral component of the dermatologist’s diagnostic armamentarium. Does your dermatology center need a dermatoscenter?

We want to know your views! Tell us what you think.

There are anecdotal reports of dogs detecting melanoma and studies of canines being able to not only detect but also distinguish cancer from noncancer. Analysis of volatile compounds or metabolites from exhaled human breath and excreted urine also has been shown to differentiate between patients with certain cancers and healthy individuals. In addition, investigators have demonstrated that melanoma tissue has a volatile profile that is distinct from healthy nonneoplastic skin and nevi.

Abaffy et al (Metabolomics. 2013;9:998-1008) conducted a study that gives further support to the potential for analyzing volatile organic compounds as biomarkers of melanoma. They used the headspace solid phase microextraction method followed by gas chromatography and mass spectrometry to compare the volatile metabolic profiles of melanoma and nonneoplastic healthy-appearing adjacent skin from the same patient. They discovered increased levels of lauric acid (C12:0) and palmitic acid (C16:0) in melanoma and they postulated that the increased levels of these fatty acids were due to cancer-associated upregulation of de novo lipid synthesis.

What’s the issue?

In the 1980s, nail fold capillary microscopy using an ophthalmoscope was occasionally performed to evaluate for disease-associated vascular changes in patients who were being evaluated for connective tissue disorders. Within 2 decades, a dermoscope to assist in the evaluation of not only nail folds but also pigmented and other lesions replaced the ophthalmoscope. The US Food and Drug Administration recently approved a software-driven optical imaging and data analysis device that can be used to obtain additional information to assist the clinician in making a decision whether to biopsy a pigmented lesion.

As our ability to develop more sensitive and specific methods to diagnose melanoma and differentiate it from benign lesions advances, our approach to the evaluation of patients with pigmented lesions shall continue to be modified. Based on the detection of melanoma-associated volatile organic compounds coupled with their potential use as readily accessible tumor-related biomarkers, it is reasonable to speculate: (1) that a handheld office-based device, a dermatoscenter, that can identify melanoma-induced volatile tumor markers shall be developed to evaluate whether pigmented lesions are malignant or benign, and (2) that this device will eventually become an integral component of the dermatologist’s diagnostic armamentarium. Does your dermatology center need a dermatoscenter?

We want to know your views! Tell us what you think.

There are anecdotal reports of dogs detecting melanoma and studies of canines being able to not only detect but also distinguish cancer from noncancer. Analysis of volatile compounds or metabolites from exhaled human breath and excreted urine also has been shown to differentiate between patients with certain cancers and healthy individuals. In addition, investigators have demonstrated that melanoma tissue has a volatile profile that is distinct from healthy nonneoplastic skin and nevi.

Abaffy et al (Metabolomics. 2013;9:998-1008) conducted a study that gives further support to the potential for analyzing volatile organic compounds as biomarkers of melanoma. They used the headspace solid phase microextraction method followed by gas chromatography and mass spectrometry to compare the volatile metabolic profiles of melanoma and nonneoplastic healthy-appearing adjacent skin from the same patient. They discovered increased levels of lauric acid (C12:0) and palmitic acid (C16:0) in melanoma and they postulated that the increased levels of these fatty acids were due to cancer-associated upregulation of de novo lipid synthesis.

What’s the issue?

In the 1980s, nail fold capillary microscopy using an ophthalmoscope was occasionally performed to evaluate for disease-associated vascular changes in patients who were being evaluated for connective tissue disorders. Within 2 decades, a dermoscope to assist in the evaluation of not only nail folds but also pigmented and other lesions replaced the ophthalmoscope. The US Food and Drug Administration recently approved a software-driven optical imaging and data analysis device that can be used to obtain additional information to assist the clinician in making a decision whether to biopsy a pigmented lesion.

As our ability to develop more sensitive and specific methods to diagnose melanoma and differentiate it from benign lesions advances, our approach to the evaluation of patients with pigmented lesions shall continue to be modified. Based on the detection of melanoma-associated volatile organic compounds coupled with their potential use as readily accessible tumor-related biomarkers, it is reasonable to speculate: (1) that a handheld office-based device, a dermatoscenter, that can identify melanoma-induced volatile tumor markers shall be developed to evaluate whether pigmented lesions are malignant or benign, and (2) that this device will eventually become an integral component of the dermatologist’s diagnostic armamentarium. Does your dermatology center need a dermatoscenter?

We want to know your views! Tell us what you think.

In summer 2014, the US Food and Drug Administration (FDA) approved 2 new topical medications for onychomycosis. In recent months, the Journal of Clinical and Aesthetic Dermatology (2014;7:10-18) and Medscape provided review materials to assist in sifting through this topic. In summary, efinaconazole, a triazole antifungal in a 10% solution recommended for daily application for 48 weeks, exhibited 17.8% complete and 55.2% mycological cure rates compared to vehicle (5.5% and 16.9%, respectively). Tavaborole, an oxaborole antifungal in a 5% solution recommended for daily application for 48 weeks, displayed 9.1% complete and 35.9% mycological cure rates versus vehicle (1.5% and 12.2%, respectively). To complete the discussion, ciclopirox nail lacquer, FDA approved in 1999 for onychomycosis for daily application for 48 weeks, heralded 8.5% complete and 36% mycological cure rates compared to vehicle (0% and 9%, respectively). Ciclopirox requires nail debridement periodically, and the newer agents do not.

What’s the issue?

Do you agree that nary a day goes by without an e-mailed article or continuing medical education opportunity tasked at “getting to know” new topical onychomycosis therapies? That being said, how often have you summarily deleted them, assuming that topicals just don’t work? I know I have, though I paused this week after thinking to myself, “How often have I written a prescription for ciclopirox nail lacquer to appease a patient who would prefer nonsystemic therapy?” And then I read on. Based on the data above, perhaps these medications, particularly efinaconazole, at least deserve perusal compared to our current meager topical and systemic options. What has your experience been with these novel topicals, their insurance coverage, and their tolerability and efficacy in your practice?

We want to know your views! Tell us what you think.

In summer 2014, the US Food and Drug Administration (FDA) approved 2 new topical medications for onychomycosis. In recent months, the Journal of Clinical and Aesthetic Dermatology (2014;7:10-18) and Medscape provided review materials to assist in sifting through this topic. In summary, efinaconazole, a triazole antifungal in a 10% solution recommended for daily application for 48 weeks, exhibited 17.8% complete and 55.2% mycological cure rates compared to vehicle (5.5% and 16.9%, respectively). Tavaborole, an oxaborole antifungal in a 5% solution recommended for daily application for 48 weeks, displayed 9.1% complete and 35.9% mycological cure rates versus vehicle (1.5% and 12.2%, respectively). To complete the discussion, ciclopirox nail lacquer, FDA approved in 1999 for onychomycosis for daily application for 48 weeks, heralded 8.5% complete and 36% mycological cure rates compared to vehicle (0% and 9%, respectively). Ciclopirox requires nail debridement periodically, and the newer agents do not.

What’s the issue?

Do you agree that nary a day goes by without an e-mailed article or continuing medical education opportunity tasked at “getting to know” new topical onychomycosis therapies? That being said, how often have you summarily deleted them, assuming that topicals just don’t work? I know I have, though I paused this week after thinking to myself, “How often have I written a prescription for ciclopirox nail lacquer to appease a patient who would prefer nonsystemic therapy?” And then I read on. Based on the data above, perhaps these medications, particularly efinaconazole, at least deserve perusal compared to our current meager topical and systemic options. What has your experience been with these novel topicals, their insurance coverage, and their tolerability and efficacy in your practice?

We want to know your views! Tell us what you think.

In summer 2014, the US Food and Drug Administration (FDA) approved 2 new topical medications for onychomycosis. In recent months, the Journal of Clinical and Aesthetic Dermatology (2014;7:10-18) and Medscape provided review materials to assist in sifting through this topic. In summary, efinaconazole, a triazole antifungal in a 10% solution recommended for daily application for 48 weeks, exhibited 17.8% complete and 55.2% mycological cure rates compared to vehicle (5.5% and 16.9%, respectively). Tavaborole, an oxaborole antifungal in a 5% solution recommended for daily application for 48 weeks, displayed 9.1% complete and 35.9% mycological cure rates versus vehicle (1.5% and 12.2%, respectively). To complete the discussion, ciclopirox nail lacquer, FDA approved in 1999 for onychomycosis for daily application for 48 weeks, heralded 8.5% complete and 36% mycological cure rates compared to vehicle (0% and 9%, respectively). Ciclopirox requires nail debridement periodically, and the newer agents do not.

What’s the issue?

Do you agree that nary a day goes by without an e-mailed article or continuing medical education opportunity tasked at “getting to know” new topical onychomycosis therapies? That being said, how often have you summarily deleted them, assuming that topicals just don’t work? I know I have, though I paused this week after thinking to myself, “How often have I written a prescription for ciclopirox nail lacquer to appease a patient who would prefer nonsystemic therapy?” And then I read on. Based on the data above, perhaps these medications, particularly efinaconazole, at least deserve perusal compared to our current meager topical and systemic options. What has your experience been with these novel topicals, their insurance coverage, and their tolerability and efficacy in your practice?

We want to know your views! Tell us what you think.

Over the last several years, we have come to understand that patients with inflammatory diseases may be at higher risk for major adverse cardiovascular events (MACEs) and cardiovascular death. In an article published online on October 28 in the Annals of the Rheumatic Diseases, Ogdie et al reported on a study of the risk for MACEs among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.

The authors performed a population-based longitudinal cohort study (1994-2010) in The Health Improvement Network (THIN), a primary care medical record database in the United Kingdom. Patients aged 18 to 89 years with the applicable diagnoses were included. Up to 10 unexposed controls were selected for each patient with PsA, matched on practice and index date.

The study outcomes included the following: cardiovascular death, myocardial infarction, cerebrovascular accidents, and the composite outcome (MACE). Cox proportional hazards models were utilized to calculate the hazard ratios (HRs) for each of the outcomes after adjusting for traditional risk factors. The authors’ preliminary hypothesis was that there was an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.

In the analysis, the authors identified individuals with PsA (N=8706), RA (N=41,752), psoriasis (N=138,424), and unexposed controls (N=81,573). After adjusting for traditional risk factors, the risk for MACE was higher in the following populations: patients with PsA not prescribed a DMARD (HR, 1.24; 95% confidence interval [CI], 1.03-1.49), patients with RA (no DMARD: HR, 1.39; 95% CI, 1.28-1.50; DMARD: HR, 1.58; 95% CI, 1.46-1.70), patients with psoriasis not prescribed a DMARD (HR, 1.08; 95% CI, 1.02-1.15), and patients with severe psoriasis (DMARD: HR, 1.42; 95% CI, 1.17-1.73).

The authors concluded that cardiovascular risk should be addressed with all patients affected by psoriasis, PsA, or RA. These results suggest the need for improved screening and management of traditional cardiovascular risk factors in patients with inflammatory diseases.

What’s the issue?

Although there has been literature on MACE in these diseases, existing studies have not examined the risk for incident MACE including myocardial infarction, cerebrovascular accidents, and cardiovascular death in PsA compared with matched internal controls from a population-based perspective after accounting for the presence of traditional cardiovascular risk factors. This study is an additional piece of evidence that supports the need for comprehensive management of these patients. How do you currently address the concern for MACE?

We want to know your views! Tell us what you think.

Over the last several years, we have come to understand that patients with inflammatory diseases may be at higher risk for major adverse cardiovascular events (MACEs) and cardiovascular death. In an article published online on October 28 in the Annals of the Rheumatic Diseases, Ogdie et al reported on a study of the risk for MACEs among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.

The authors performed a population-based longitudinal cohort study (1994-2010) in The Health Improvement Network (THIN), a primary care medical record database in the United Kingdom. Patients aged 18 to 89 years with the applicable diagnoses were included. Up to 10 unexposed controls were selected for each patient with PsA, matched on practice and index date.

The study outcomes included the following: cardiovascular death, myocardial infarction, cerebrovascular accidents, and the composite outcome (MACE). Cox proportional hazards models were utilized to calculate the hazard ratios (HRs) for each of the outcomes after adjusting for traditional risk factors. The authors’ preliminary hypothesis was that there was an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.

In the analysis, the authors identified individuals with PsA (N=8706), RA (N=41,752), psoriasis (N=138,424), and unexposed controls (N=81,573). After adjusting for traditional risk factors, the risk for MACE was higher in the following populations: patients with PsA not prescribed a DMARD (HR, 1.24; 95% confidence interval [CI], 1.03-1.49), patients with RA (no DMARD: HR, 1.39; 95% CI, 1.28-1.50; DMARD: HR, 1.58; 95% CI, 1.46-1.70), patients with psoriasis not prescribed a DMARD (HR, 1.08; 95% CI, 1.02-1.15), and patients with severe psoriasis (DMARD: HR, 1.42; 95% CI, 1.17-1.73).

The authors concluded that cardiovascular risk should be addressed with all patients affected by psoriasis, PsA, or RA. These results suggest the need for improved screening and management of traditional cardiovascular risk factors in patients with inflammatory diseases.

What’s the issue?

Although there has been literature on MACE in these diseases, existing studies have not examined the risk for incident MACE including myocardial infarction, cerebrovascular accidents, and cardiovascular death in PsA compared with matched internal controls from a population-based perspective after accounting for the presence of traditional cardiovascular risk factors. This study is an additional piece of evidence that supports the need for comprehensive management of these patients. How do you currently address the concern for MACE?

We want to know your views! Tell us what you think.

Over the last several years, we have come to understand that patients with inflammatory diseases may be at higher risk for major adverse cardiovascular events (MACEs) and cardiovascular death. In an article published online on October 28 in the Annals of the Rheumatic Diseases, Ogdie et al reported on a study of the risk for MACEs among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.

The authors performed a population-based longitudinal cohort study (1994-2010) in The Health Improvement Network (THIN), a primary care medical record database in the United Kingdom. Patients aged 18 to 89 years with the applicable diagnoses were included. Up to 10 unexposed controls were selected for each patient with PsA, matched on practice and index date.

The study outcomes included the following: cardiovascular death, myocardial infarction, cerebrovascular accidents, and the composite outcome (MACE). Cox proportional hazards models were utilized to calculate the hazard ratios (HRs) for each of the outcomes after adjusting for traditional risk factors. The authors’ preliminary hypothesis was that there was an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.

In the analysis, the authors identified individuals with PsA (N=8706), RA (N=41,752), psoriasis (N=138,424), and unexposed controls (N=81,573). After adjusting for traditional risk factors, the risk for MACE was higher in the following populations: patients with PsA not prescribed a DMARD (HR, 1.24; 95% confidence interval [CI], 1.03-1.49), patients with RA (no DMARD: HR, 1.39; 95% CI, 1.28-1.50; DMARD: HR, 1.58; 95% CI, 1.46-1.70), patients with psoriasis not prescribed a DMARD (HR, 1.08; 95% CI, 1.02-1.15), and patients with severe psoriasis (DMARD: HR, 1.42; 95% CI, 1.17-1.73).

The authors concluded that cardiovascular risk should be addressed with all patients affected by psoriasis, PsA, or RA. These results suggest the need for improved screening and management of traditional cardiovascular risk factors in patients with inflammatory diseases.

What’s the issue?

Although there has been literature on MACE in these diseases, existing studies have not examined the risk for incident MACE including myocardial infarction, cerebrovascular accidents, and cardiovascular death in PsA compared with matched internal controls from a population-based perspective after accounting for the presence of traditional cardiovascular risk factors. This study is an additional piece of evidence that supports the need for comprehensive management of these patients. How do you currently address the concern for MACE?

We want to know your views! Tell us what you think.

Hamilton and Dover (Dermatol Surg. 2014;40:1173-1174) discussed the use of checklists for improving laser and light-based procedures in their November 2014 editorial. The authors discussed how the use of checklists has become pervasive in many fields of medicine, including surgery. However, they also highlighted that the utility of checklists and their success do not come from just checking off boxes but rather from actively performing the tasks. The implementation of a laser checklist can seem daunting, but Hamilton and Dover proposed that for a dermatology practice or dermatology department it becomes easier because the dermatologist and staff work closely already, making communication less of a challenge. Also, the procedure lends itself to a systematic approach. In doing so, one can routinely ensure that the necessary practices are being done to ensure both patient and staff safety. 

What’s the issue?

The implementation of checklists for medical procedures may seem straightforward; however, to be effective there has to be pertinent information gathered or actions taken. Our department utilizes checklists for our laser procedures. The different steps that we have included help to ensure that the nurses who prepare the patients will communicate the pertinent information to the physician. Our checklist starts with ensuring proper setup, such as connecting the necessary pieces, before starting the laser. Next is making sure all the necessary equipment is in place, such as the correct laser goggles for the patient and staff. We label all of our goggles with the name of the laser on them so it is readily apparent what to use. We also have a check box that ensures the proper signage is outside on the door and the laser shades are drawn. There also is a section relating to the patient. Depending on the type of laser being utilized the checklist may include the following: skin type, recent history of tanning, history of oral herpes, isotretinoin use, and time since last treatment. The next check box ensures consent is signed and pretreatment photographs are taken. Any prior complications also are noted. We have a section for treatment parameters used during the current visit and then another section for posttreatment instructions.

Although a checklist may seem like unnecessary work, we found that it actually helps to enhance productivity and ensures proper laser safety for the physician and patient. We have a different one for each laser, as it also serves as a documentation tool for the procedure. Do you utilize checklists for your laser procedures? If so, what else do you include?

We want to know your views! Tell us what you think.

Hamilton and Dover (Dermatol Surg. 2014;40:1173-1174) discussed the use of checklists for improving laser and light-based procedures in their November 2014 editorial. The authors discussed how the use of checklists has become pervasive in many fields of medicine, including surgery. However, they also highlighted that the utility of checklists and their success do not come from just checking off boxes but rather from actively performing the tasks. The implementation of a laser checklist can seem daunting, but Hamilton and Dover proposed that for a dermatology practice or dermatology department it becomes easier because the dermatologist and staff work closely already, making communication less of a challenge. Also, the procedure lends itself to a systematic approach. In doing so, one can routinely ensure that the necessary practices are being done to ensure both patient and staff safety. 

What’s the issue?

The implementation of checklists for medical procedures may seem straightforward; however, to be effective there has to be pertinent information gathered or actions taken. Our department utilizes checklists for our laser procedures. The different steps that we have included help to ensure that the nurses who prepare the patients will communicate the pertinent information to the physician. Our checklist starts with ensuring proper setup, such as connecting the necessary pieces, before starting the laser. Next is making sure all the necessary equipment is in place, such as the correct laser goggles for the patient and staff. We label all of our goggles with the name of the laser on them so it is readily apparent what to use. We also have a check box that ensures the proper signage is outside on the door and the laser shades are drawn. There also is a section relating to the patient. Depending on the type of laser being utilized the checklist may include the following: skin type, recent history of tanning, history of oral herpes, isotretinoin use, and time since last treatment. The next check box ensures consent is signed and pretreatment photographs are taken. Any prior complications also are noted. We have a section for treatment parameters used during the current visit and then another section for posttreatment instructions.

Although a checklist may seem like unnecessary work, we found that it actually helps to enhance productivity and ensures proper laser safety for the physician and patient. We have a different one for each laser, as it also serves as a documentation tool for the procedure. Do you utilize checklists for your laser procedures? If so, what else do you include?

We want to know your views! Tell us what you think.

Hamilton and Dover (Dermatol Surg. 2014;40:1173-1174) discussed the use of checklists for improving laser and light-based procedures in their November 2014 editorial. The authors discussed how the use of checklists has become pervasive in many fields of medicine, including surgery. However, they also highlighted that the utility of checklists and their success do not come from just checking off boxes but rather from actively performing the tasks. The implementation of a laser checklist can seem daunting, but Hamilton and Dover proposed that for a dermatology practice or dermatology department it becomes easier because the dermatologist and staff work closely already, making communication less of a challenge. Also, the procedure lends itself to a systematic approach. In doing so, one can routinely ensure that the necessary practices are being done to ensure both patient and staff safety. 

What’s the issue?

The implementation of checklists for medical procedures may seem straightforward; however, to be effective there has to be pertinent information gathered or actions taken. Our department utilizes checklists for our laser procedures. The different steps that we have included help to ensure that the nurses who prepare the patients will communicate the pertinent information to the physician. Our checklist starts with ensuring proper setup, such as connecting the necessary pieces, before starting the laser. Next is making sure all the necessary equipment is in place, such as the correct laser goggles for the patient and staff. We label all of our goggles with the name of the laser on them so it is readily apparent what to use. We also have a check box that ensures the proper signage is outside on the door and the laser shades are drawn. There also is a section relating to the patient. Depending on the type of laser being utilized the checklist may include the following: skin type, recent history of tanning, history of oral herpes, isotretinoin use, and time since last treatment. The next check box ensures consent is signed and pretreatment photographs are taken. Any prior complications also are noted. We have a section for treatment parameters used during the current visit and then another section for posttreatment instructions.

Although a checklist may seem like unnecessary work, we found that it actually helps to enhance productivity and ensures proper laser safety for the physician and patient. We have a different one for each laser, as it also serves as a documentation tool for the procedure. Do you utilize checklists for your laser procedures? If so, what else do you include?

We want to know your views! Tell us what you think.

In the October 2014 issue of the Journal of Clinical and Aesthetic Dermatology (2014;7:10-19), Wu et al published the top 100 most-cited psoriasis articles in clinical dermatologic journals from 1970 to 2012. Given the explosion of literature in this area, I was very excited to rush to find the list online.  

The authors conducted a citation analysis of major clinical dermatologic journals from 1970 to 2012 limited to the subject of psoriasis. They used the search term psoriasis in the Science Citation Index from 1970 to 2012 and included articles that have received 100 or more citations. The top 100 articles were further stratified by country, institution, and study type.

The authors found that half of the top 100 cited articles were from the United States; 81 of them were original articles. The majority of the top 100 articles were from dermatology programs in the United States, but institutions in the United Kingdom and Germany also made notable contributions.

There were 2 periods of particular note in their analysis. The high numbers of citations from 1985 to 1989 correlated with the elucidation of the immune-mediated pathogenesis of psoriasis at that time. The high number of top citations from 2000 to 2004 correlated with the development of biologic agents in psoriasis therapy.

What’s the issue?

It is interesting to see which studies have been most influential in this highly active area of dermatology. What articles have most influenced your approach to psoriasis?

We want to know your views! Tell us what you think.

In the October 2014 issue of the Journal of Clinical and Aesthetic Dermatology (2014;7:10-19), Wu et al published the top 100 most-cited psoriasis articles in clinical dermatologic journals from 1970 to 2012. Given the explosion of literature in this area, I was very excited to rush to find the list online.  

The authors conducted a citation analysis of major clinical dermatologic journals from 1970 to 2012 limited to the subject of psoriasis. They used the search term psoriasis in the Science Citation Index from 1970 to 2012 and included articles that have received 100 or more citations. The top 100 articles were further stratified by country, institution, and study type.

The authors found that half of the top 100 cited articles were from the United States; 81 of them were original articles. The majority of the top 100 articles were from dermatology programs in the United States, but institutions in the United Kingdom and Germany also made notable contributions.

There were 2 periods of particular note in their analysis. The high numbers of citations from 1985 to 1989 correlated with the elucidation of the immune-mediated pathogenesis of psoriasis at that time. The high number of top citations from 2000 to 2004 correlated with the development of biologic agents in psoriasis therapy.

What’s the issue?

It is interesting to see which studies have been most influential in this highly active area of dermatology. What articles have most influenced your approach to psoriasis?

We want to know your views! Tell us what you think.

In the October 2014 issue of the Journal of Clinical and Aesthetic Dermatology (2014;7:10-19), Wu et al published the top 100 most-cited psoriasis articles in clinical dermatologic journals from 1970 to 2012. Given the explosion of literature in this area, I was very excited to rush to find the list online.  

The authors conducted a citation analysis of major clinical dermatologic journals from 1970 to 2012 limited to the subject of psoriasis. They used the search term psoriasis in the Science Citation Index from 1970 to 2012 and included articles that have received 100 or more citations. The top 100 articles were further stratified by country, institution, and study type.

The authors found that half of the top 100 cited articles were from the United States; 81 of them were original articles. The majority of the top 100 articles were from dermatology programs in the United States, but institutions in the United Kingdom and Germany also made notable contributions.

There were 2 periods of particular note in their analysis. The high numbers of citations from 1985 to 1989 correlated with the elucidation of the immune-mediated pathogenesis of psoriasis at that time. The high number of top citations from 2000 to 2004 correlated with the development of biologic agents in psoriasis therapy.

What’s the issue?

It is interesting to see which studies have been most influential in this highly active area of dermatology. What articles have most influenced your approach to psoriasis?

We want to know your views! Tell us what you think.

In a June 29 article published online in Molecular Carcinogenesis, Fenton et al demonstrated that topical dasatinib treatment of UVB-exposed SKH1 hairless mice reduced the total tumor burden (ie, benign tumors, atypical benign tumors, squamous cell carcinomas) per mouse.

Dasatinib is a tyrosine kinase inhibitor currently used to treat imatinib-resistant chronic myeloid leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia. Its mechanism of action is to block the activity of tyrosine kinases by attaching to their adenosine triphosphate–binding site. It can inhibit the activity of the following tyrosine kinases: Src family kinases (SFK), break point cluster region-Abelson (Bcr-Abl), Ephrin type-A receptor 2 (EphA2), platelet-derived growth factor receptor, and mast/stem cell factor receptor (also called CD117 or c-Kit).

Src family kinases are associated with transformation of cells and progression of cancer. Elevated Src family kinases activity is present in the majority of human carcinomas.

Fyn, a nonreceptor tyrosine kinase, is a member of the Src family kinases. Cell growth, cell migration, and protein kinase B (Akt)–mediated inhibition of apoptosis are influenced by Fyn activity. In addition, Fyn activity is overexpressed in cutaneous squamous cell carcinoma.

In conclusion, dasatinib—an Src family kinases inhibitor—was able to inhibit Fyn activity and thereby reduce UV-induced skin carcinogenesis.

What’s the issue?

In 1962, Falkson and Schulz (Br J Dermatol. 1962;74:229-236) noted not only inflammation and subsequent resolution of actinic keratoses after exposure to sunlight in a woman with colon cancer being treated with systemic 5-fluorouracil but also several other patients whose keratoses were seen to disappear during therapy without preceding erythema. Omura and Torre (JAMA. 1969;208:150-151) confirmed these observations in a woman with breast cancer whose actinic keratoses became inflamed after receiving intravenous 5-fluorouracil and subsequently faded. The route of drug administration was modified and 5-fluorouracil was applied topically. Today topical 5-fluorouracil is still used for the treatment of actinic keratoses.

Topical application of nitrogen mustard is used in the treatment of cutaneous T-cell lymphoma. In addition, intralesional administration of systemic antineoplastic agents has been used to treat cutaneous neoplasms: methotrexate for keratoacanthomas and rituximab for primary cutaneous B-cell lymphomas.

The Fenton et al study suggests that topical dasatinib may be a potential therapeutic intervention for the treatment of cutaneous squamous cell carcinoma. The investigators not only demonstrate laboratory data from mouse studies but also provide a potential molecular mechanism for drug-associated tumor suppression. Indeed, dasatinib solution, dasatinib cream, or both may be the next innovative therapy for the suppression of cutaneous squamous cell carcinoma in organ transplant and immunocompromised patients and for the potential management of this skin cancer in immunocompetent individuals. What do you think?

We want to know your views! Tell us what you think.

In a June 29 article published online in Molecular Carcinogenesis, Fenton et al demonstrated that topical dasatinib treatment of UVB-exposed SKH1 hairless mice reduced the total tumor burden (ie, benign tumors, atypical benign tumors, squamous cell carcinomas) per mouse.

Dasatinib is a tyrosine kinase inhibitor currently used to treat imatinib-resistant chronic myeloid leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia. Its mechanism of action is to block the activity of tyrosine kinases by attaching to their adenosine triphosphate–binding site. It can inhibit the activity of the following tyrosine kinases: Src family kinases (SFK), break point cluster region-Abelson (Bcr-Abl), Ephrin type-A receptor 2 (EphA2), platelet-derived growth factor receptor, and mast/stem cell factor receptor (also called CD117 or c-Kit).

Src family kinases are associated with transformation of cells and progression of cancer. Elevated Src family kinases activity is present in the majority of human carcinomas.

Fyn, a nonreceptor tyrosine kinase, is a member of the Src family kinases. Cell growth, cell migration, and protein kinase B (Akt)–mediated inhibition of apoptosis are influenced by Fyn activity. In addition, Fyn activity is overexpressed in cutaneous squamous cell carcinoma.

In conclusion, dasatinib—an Src family kinases inhibitor—was able to inhibit Fyn activity and thereby reduce UV-induced skin carcinogenesis.

What’s the issue?

In 1962, Falkson and Schulz (Br J Dermatol. 1962;74:229-236) noted not only inflammation and subsequent resolution of actinic keratoses after exposure to sunlight in a woman with colon cancer being treated with systemic 5-fluorouracil but also several other patients whose keratoses were seen to disappear during therapy without preceding erythema. Omura and Torre (JAMA. 1969;208:150-151) confirmed these observations in a woman with breast cancer whose actinic keratoses became inflamed after receiving intravenous 5-fluorouracil and subsequently faded. The route of drug administration was modified and 5-fluorouracil was applied topically. Today topical 5-fluorouracil is still used for the treatment of actinic keratoses.

Topical application of nitrogen mustard is used in the treatment of cutaneous T-cell lymphoma. In addition, intralesional administration of systemic antineoplastic agents has been used to treat cutaneous neoplasms: methotrexate for keratoacanthomas and rituximab for primary cutaneous B-cell lymphomas.

The Fenton et al study suggests that topical dasatinib may be a potential therapeutic intervention for the treatment of cutaneous squamous cell carcinoma. The investigators not only demonstrate laboratory data from mouse studies but also provide a potential molecular mechanism for drug-associated tumor suppression. Indeed, dasatinib solution, dasatinib cream, or both may be the next innovative therapy for the suppression of cutaneous squamous cell carcinoma in organ transplant and immunocompromised patients and for the potential management of this skin cancer in immunocompetent individuals. What do you think?

We want to know your views! Tell us what you think.

In a June 29 article published online in Molecular Carcinogenesis, Fenton et al demonstrated that topical dasatinib treatment of UVB-exposed SKH1 hairless mice reduced the total tumor burden (ie, benign tumors, atypical benign tumors, squamous cell carcinomas) per mouse.

Dasatinib is a tyrosine kinase inhibitor currently used to treat imatinib-resistant chronic myeloid leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia. Its mechanism of action is to block the activity of tyrosine kinases by attaching to their adenosine triphosphate–binding site. It can inhibit the activity of the following tyrosine kinases: Src family kinases (SFK), break point cluster region-Abelson (Bcr-Abl), Ephrin type-A receptor 2 (EphA2), platelet-derived growth factor receptor, and mast/stem cell factor receptor (also called CD117 or c-Kit).

Src family kinases are associated with transformation of cells and progression of cancer. Elevated Src family kinases activity is present in the majority of human carcinomas.

Fyn, a nonreceptor tyrosine kinase, is a member of the Src family kinases. Cell growth, cell migration, and protein kinase B (Akt)–mediated inhibition of apoptosis are influenced by Fyn activity. In addition, Fyn activity is overexpressed in cutaneous squamous cell carcinoma.

In conclusion, dasatinib—an Src family kinases inhibitor—was able to inhibit Fyn activity and thereby reduce UV-induced skin carcinogenesis.

What’s the issue?

In 1962, Falkson and Schulz (Br J Dermatol. 1962;74:229-236) noted not only inflammation and subsequent resolution of actinic keratoses after exposure to sunlight in a woman with colon cancer being treated with systemic 5-fluorouracil but also several other patients whose keratoses were seen to disappear during therapy without preceding erythema. Omura and Torre (JAMA. 1969;208:150-151) confirmed these observations in a woman with breast cancer whose actinic keratoses became inflamed after receiving intravenous 5-fluorouracil and subsequently faded. The route of drug administration was modified and 5-fluorouracil was applied topically. Today topical 5-fluorouracil is still used for the treatment of actinic keratoses.

Topical application of nitrogen mustard is used in the treatment of cutaneous T-cell lymphoma. In addition, intralesional administration of systemic antineoplastic agents has been used to treat cutaneous neoplasms: methotrexate for keratoacanthomas and rituximab for primary cutaneous B-cell lymphomas.

The Fenton et al study suggests that topical dasatinib may be a potential therapeutic intervention for the treatment of cutaneous squamous cell carcinoma. The investigators not only demonstrate laboratory data from mouse studies but also provide a potential molecular mechanism for drug-associated tumor suppression. Indeed, dasatinib solution, dasatinib cream, or both may be the next innovative therapy for the suppression of cutaneous squamous cell carcinoma in organ transplant and immunocompromised patients and for the potential management of this skin cancer in immunocompetent individuals. What do you think?

We want to know your views! Tell us what you think.