Publications

A number of chronic dermatologic conditions may necessitate long-term adjunctive pain management in addition to treatment of the primary skin disease, such as hidradenitis suppurativa, lichen planus, and other systemic diseases associated with significant pain. Adequate management of chronic pain can represent a unique challenge, but remains an integral component of clinical treatment in relevant contexts. For nociceptive pain of moderate to severe intensity, opioid analgesics can be beneficial when other pain management strategies have failed to produce adequate relief. The decision to initiate long-term opioid therapy must be carefully weighed, and individualized treatment plans are often necessary to effectively treat pain while minimizing adverse effects. Part II of this 2-part continuing medical education article will describe the appropriate settings for initiation of opioid analgesia for dermatology patients and detail therapeutic strategies and patient monitoring guidelines.

BACKGROUND: Early clinical studies suggested that the anti-interleukin-17 receptor A monoclonal antibody brodalumab has efficacy in the treatment of psoriasis.

METHODS: In two phase 3 studies (AMAGINE-2 and AMAGINE-3), patients with moderate-to-severe psoriasis were randomly assigned to receive brodalumab (210 mg or 140 mg every 2 weeks), ustekinumab (45 mg for patients with a body weight ≤100 kg and 90 mg for patients >100 kg), or placebo. At week 12, patients receiving brodalumab were randomly assigned again to receive a brodalumab maintenance dose of 210 mg every 2 weeks or 140 mg every 2 weeks, every 4 weeks, or every 8 weeks; patients receiving ustekinumab continued to receive ustekinumab every 12 weeks, and patients receiving placebo received 210 mg of brodalumab every 2 weeks. The primary aims were to evaluate the superiority of brodalumab over placebo at week 12 with respect to at least a 75% reduction in the psoriasis area-and-severity index score (PASI 75) and a static physician's global assessment (sPGA) score of 0 or 1 (clear or almost clear skin), as well as the superiority of brodalumab over ustekinumab at week 12 with respect to a 100% reduction in PASI score (PASI 100).

RESULTS: At week 12, the PASI 75 response rates were higher with brodalumab at the 210-mg and 140-mg doses than with placebo (86% and 67%, respectively, vs. 8% [AMAGINE-2] and 85% and 69%, respectively, vs. 6% [AMAGINE-3]; P<0.001); the rates of sPGA scores of 0 or 1 were also higher with brodalumab (P<0.001). The week 12 PASI 100 response rates were significantly higher with 210 mg of brodalumab than with ustekinumab (44% vs. 22% [AMAGINE-2] and 37% vs. 19% [AMAGINE-3], P<0.001). The PASI 100 response rates with 140 mg of brodalumab were 26% in AMAGINE-2 (P=0.08 for the comparison with ustekinumab) and 27% in AMAGINE-3 (P=0.007). Rates of neutropenia were higher with brodalumab and with ustekinumab than with placebo. Mild or moderate candida infections were more frequent with brodalumab than with ustekinumab or placebo. Through week 52, the rates of serious infectious episodes were 1.0 (AMAGINE-2) and 1.3 (AMAGINE-3) per 100 patient-years of exposure to brodalumab.

CONCLUSIONS: Brodalumab treatment resulted in significant clinical improvements in patients with moderate-to-severe psoriasis. (Funded by Amgen; AMAGINE-2 and AMAGINE-3 ClinicalTrials.gov numbers, NCT01708603 and NCT01708629.).

BACKGROUND: Psoriasis is associated with risk of malignancy. Some psoriasis treatments may increase the risk of hospitalized infectious events (HIEs).

OBJECTIVES: To evaluate rates of malignancies and HIEs in patients with psoriasis.

METHODS: This retrospective cohort study utilized data from MarketScan(®) databases. Cohorts included adult general population (GP), patients with psoriasis, and patients with psoriasis treated with nonbiologics, adalimumab, etanercept, infliximab or phototherapy. Outcomes included incidence rates (IRs) per 10 000 person-years observation (PYO) for all malignancies excluding nonmelanoma skin cancer (NMSC), lymphoma, NMSC, and per 10 000 person-years of exposure (PYE) for HIEs.

RESULTS: Incidence rates [95% confidence interval (CI)] for all malignancies except NMSC were 129 (127-130) and 142 (135-149) for GP (PYO = 51 071 587) and psoriasis (PYO = 119 432) cohorts, respectively; 10·9 (10·5-11·3) and 12·9 (10·9-14·8) for lymphoma; and 145 (144-147) and 180 (173-188) for NMSC. Rates for all malignancies excluding NMSC were similar among treatments but variable for lymphoma and NMSC. IRs (95% CI) for HIEs were 332 (256-408) for the nonbiologic cohort (PYE = 3528); 288 (206-370) for etanercept (PYE = 6563); 325 (196-455) for adalimumab (PYE = 2772); 521 (278-765) for infliximab (PYE = 1058); and 334 (242-427) for phototherapy (PYE = 1797). IRs for HIEs were lowest for etanercept and higher in patients on baseline systemic corticosteroids across treatment cohorts.

CONCLUSIONS: Malignancy rates were higher in patients with psoriasis than the GP, but these treatments did not appear to increase malignancy risk.

Hidradenitis suppurativa (HS) is a progressive, inflammatory disease that affects mostly young women and appears to be caused by inflammation of hair follicles in areas of friction in the body (eg, the axillae, groin, perineum, and medial aspects of the thighs). Given this pathophysiology, one might expect comorbidities that contribute to inflammation and friction. Observed comorbidities fall into several categories: obesity and the metabolic syndrome, hormone-related disorders, deleterious health habits and mood, autoimmune disease, inflammatory disease and finally, the risk of skin cancer and sequelae of nonhealing wounds. The available literature on comorbid diseases of HS is limited but rapidly increasing. In this review, we summarize recent and major studies of HS disease association.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving painful, deep abscesses and chronic, draining sinus tracts. Because of the variable signs and symptoms displayed by patients, it remains widely unrecognized and difficult to treat, resulting in significant diagnostic delay and inconsistent treatment process. No medical specialty has successfully designated a criterion standard of treatment, resulting in variable care and unmet patient needs. Widespread causes and effects of HS are difficult to determine because the prevalence is dependent on a variety of things, including how and where data are collected, resulting in significant bias. Therefore, the task must be to assess existing studies to produce a best estimate of prevalence. In addition, the 3 types of studies available for HS (ie, self-report, registry-based, and group examination studies) must be evaluated because each offers important insights into who is impacted by this disease. The exact prevalence of HS remains unknown because of the difficulty in collecting and extrapolating data and the usefulness of studies; however, high comorbidity and disease severity is observed, resulting in increased hospital visits for patients with HS–nearly double that of other diseases. Finally, comparisons between HS and psoriasis are worth mentioning because the similarities are clear, but the severity of HS appears to be more debilitating in many aspects of life. This article will address the epidemiology of HS through current available research.

Psoriasis is a systemic inflammatory disease that confers significant risk of metabolic derangements and adverse cardiovascular outcomes. Early detection and treatment of modifiable risk factors and modulation of the systemic inflammatory response are important treatment goals. Studies have shown that there is a significant lack of awareness of the relationship between psoriasis and cardiovascular disease, so future considerations should focus on education of and collaboration with health care providers, especially those in primary care, and development of updated, rigorous screening guidelines. In addition, targeted biologic therapies such as TNF-a inhibitors have shown immense promise in targeting the systemic inflammation associated with psoriatic disease, but whether they will impact long-term cardiovascular outcomes remains to be seen.

BACKGROUND: Psoriasis is a chronic, inflammatory skin disorder that is associated with obesity. Independently, both psoriasis and obesity likely impose impressive physical and psychosocial burdens on affected patients.

OBJECTIVE: The purpose of this study was to evaluate the relative impact of body mass index (BMI) on the socioeconomic status, medical co-morbidities, and current and chronic quality of life of psoriasis patients.

METHODS: Overall, 114 subjects were examined and asked to complete a self-administered questionnaire regarding disabilities, relationships, education, as well as medical and economic outcomes. Participants also answered the ten questions used in the Dermatology Life Quality Index modified to ask 'over the last week', 'over the last year' and 'over your lifetime with psoriasis'. Survey responses were compared amongst the three patient groups based on BMI (normal, overweight, obese).

RESULTS: Patients with elevated BMI were more likely to rate their general health lower (P < 0.001), believe that psoriasis caused their weight gain (P = 0.014), experience sleep problems over their lifetime (P = 0.016), hide their psoriasis over their lifetime (P = 0.010), have their self-confidence affected by their psoriasis over their lifetime (P = 0.011) and avoid common activities over their lifetime (P = 0.012).

CONCLUSION: There are long-term negative effects of elevated BMI that impose additional burdens on psoriasis patients, including impairments in sleep quality and increased social anxiety.