Publications

BACKGROUND: Because Mohs fellowship training typically incorporates a research component, as required by the Mohs College for fellowship certification, we evaluated whether Mohs microscopic surgery fellowship-trained (MMSFT) dermatologic surgeons were more likely to join academic institutions and demonstrate greater activity in teaching, research, and scientific writing than non-fellowship-trained surgeons (NMMSFT).

METHODS: Responses to the 2002 and 2005 American Academy of Dermatology Practice Profile survey comparing practice settings, proportion of time spent in various practice settings, and professional roles were compared between the two groups.

RESULTS: MMSFT dermatologic surgeons were 5 times as likely to be in full-time academic practice and 3 times as likely to be in part-time academia as NMMSFT dermatologic surgeons. Consistent with their greater presence in academia, in 2004, 47% of MMSFT dermatologist surgeons participated in teaching, compared with 19% of NMMSFT surgeons (p=.001) and 16% of all dermatologists (p=.001). Twenty-two percent of MMSFT dermatologic surgeons were involved in research, compared with only 4% of NMMSFT dermatologic surgeons (p=.001) and 8% of all dermatologists (p<.05).

CONCLUSIONS: Academic productivity of dermatologic surgeons appears to be associated with Mohs fellowship training. The level of teaching and research was significant even in MMSFT surgeons who were not in full- or part-time academic faculty positions. This suggests a strong tradition of academic productivity for dermatologic surgeons outside traditional academic institutions.

BACKGROUND: Adalimumab is a fully human monoclonal antibody that binds tumor necrosis factor, a key proinflammatory cytokine involved in the pathogenesis of psoriasis.

OBJECTIVE: We sought to evaluate clinical efficacy and safety of adalimumab for moderate to severe psoriasis and investigate continuous versus interrupted therapy.

METHODS: We conducted a 52-week, multicenter study of 1212 patients randomized to receive adalimumab (40 mg) or placebo every other week for the first 15 weeks. At least 75% improvement in the Psoriasis Area and Severity Index (PASI) score was the criterion for advancement through this multiphase study.

RESULTS: At week 16, 71% (578 of 814) of adalimumab- and 7% (26 of 398) of placebo-treated patients achieved greater than or equal to 75% improvement in the PASI score. During weeks 33 to 52, the percentage of patients rerandomized to placebo who lost adequate response (defined as <50% improvement in the PASI response relative to baseline and at least a 6-point increase in PASI score from week 33) was 28% compared with 5% of patients treated continuously with adalimumab.

LIMITATIONS: Lack of an active comparator and evaluation of maintenance of response beyond week 52 are limitations.

CONCLUSION: Adalimumab is efficacious and well-tolerated in the treatment of chronic plaque psoriasis.

TRIAL REGISTRATION: Clinical trials.gov. NCT00237887.

INTRODUCTION: Five to forty percent of patients with cutaneous psoriasis develop an inflammatory, oligoarticular spondyloarthropathy known as psoriatic arthritis.

OBJECTIVE: To compare health-related quality of life (QOL) between cutaneous psoriatic patients with and without psoriatic arthritis.

METHOD: Secondary cross-sectional analysis of data obtained from the 2005 Spring US National Psoriasis Foundation Quality of Life Telephone/Internet Survey. 426 patients with psoriasis and/or psoriatic arthritis were included in the 2005 survey. Among these respondents, the self-reported disease histories of 140 patients with cutaneous psoriasis and psoriatic arthritis were compared with those of 278 patients with cutaneous psoriasis only. Both groups were compared with respect to demographics, skin disease severity, treatment history and satisfaction, and QOL using previously validated assessment scales.

RESULTS: Compared with those with skin psoriasis only, respondents with cutaneous psoriasis and psoriatic arthritis were slightly older, more likely to be female and members of the National Psoriasis Foundation, and more likely to report a younger age of disease onset. They were also more likely to be unemployed, to report their job was affected by their condition, and to report a higher mean estimate of lost annual wages. On both univariate and multivariate analysis, however, no significant differences between groups were detected in skin disease severity, overall QOL, and satisfaction with current treatment options. At the same time, individuals with skin psoriasis and psoriatic arthritis were more likely to be taking systemic agents. They also reported higher mean scores for pain, while those with cutaneous psoriasis reported higher mean scores for self-consciousness only.

CONCLUSION: In contrast to previous reports that did not control for skin disease severity, this study demonstrates that patients with cutaneous psoriasis and psoriatic arthritis do not report significantly worse health-related QOL compared with patients with cutaneous psoriasis only. Nor do they report significantly greater dissatisfaction with current treatment options. These findings may reflect the intrinsic inadequacy of the QOL instruments used in this study for capturing the additional burden of joint disease. Alternatively, these findings may reflect the existence of a threshold of joint disease in patients with skin psoriasis and psoriatic arthritis below which joint symptoms are perceived as negligible relative to cutaneous disease.

BACKGROUND: Biologics are widely used in the treatment of psoriasis and psoriatic arthritis.

OBJECTIVE: Our aim was to arrive at a consensus on the kind of monitoring and the vaccinations that should be performed before and during biologic therapy.

METHODS: Medical literature and data presented at meetings were reviewed and a consensus conference was held by members of the Medical Board of the National Psoriasis Foundation.

RESULTS: Consensus was established on monitoring and vaccination practices that included discussion and recognition of variations in those practices. History, physical examination, chemistry screen with liver function tests, complete blood cell count, and platelet count and tuberculosis testing are widely obtained at baseline and with variable frequencies thereafter. Patients treated with efalizumab have platelet counts checked more often; liver function tests are repeated more frequently in patients treated with infliximab; patients taking tumor necrosis factor blockers undergo tuberculosis testing more often; and patients treated with alefacept have CD4 counts checked approximately every 2 weeks. Avoidance of live vaccines during biologic therapy and administration of essential vaccines before biologic therapy were discussed, although vaccination is performed only to a variable degree. There was no consistency in the measurement of antinuclear antibodies among the experts.

LIMITATIONS: There are few evidence-based studies on monitoring practices for patients with psoriasis taking biologic therapies.

CONCLUSIONS: In patients taking biologic therapies for psoriasis, monitoring of blood chemistries, blood counts, CD4 counts, antinuclear antibodies, tuberculin skin tests, history, and physical examination may be warranted depending on the particular therapy and the particular patient. Vaccination practices are also addressed.

BACKGROUND: The US dermatology workforce, which is affected by a physician shortage, has reportedly seen a rapid and substantial influx of physician assistants (PAs) and nurse practitioners (NPs). Little is known about which dermatology practices use these practitioners, how they are supervised, and the services they are providing.

METHODS: We analyzed results of the American Academy of Dermatology's 2007 practice profile survey to learn more about patterns of nonphysician clinician (NPC) use. Of 3965 surveys mailed, responses were obtained from 1243 dermatologists (31% response rate). Comparison data were drawn from previous surveys conducted with a similar methodology in 2002 (35% response rate) and 2005 (30% response rate).

RESULTS: Overall, 325 responding dermatologists (29.6%) reported using PAs, NPs, or both in their practices in 2007, a 43% increase from the proportion in 2002 (20.7%). PAs were more prevalent than NPs (23% vs 10%). By the year 2010, 36.2% of respondents plan to hire these NPCs. Younger cohorts of dermatologists were significantly more likely to use NPCs (P = .006), as were those in group and academic practices (P < .0001). Respondents seeking to hire additional dermatologists (P < .0001) and those with surgical or cosmetically focused practices (P < .001) were much more likely to use NPCs. Respondents reported supervising their NPCs on-site 92.8% of the time, but 31% were off-site 10% of the time or more. Most dermatologists allowed their NPCs to see new patients and established patients with new problems, and a minority of these patients were formally presented to a physician during extender visits. NPCs spent the majority of their time seeing medical dermatology patients, even if their supervising dermatologist was primarily engaged in surgical or cosmetic dermatology.

LIMITATIONS: Survey respondents might have inaccurately reported practice characteristics or might not be representative of all US dermatologists.

CONCLUSIONS: In the setting of persistently long patient wait times and difficulty recruiting new physician staff, dermatologists have rapidly turned to PAs and NPs to help meet patient demand for care. These NPCs are primarily caring for new and established medical dermatology patients under indirect supervision. In the absence of explicit consensus or policy as to how the field should ensure future access to care for patients with skin disease, growth in the use of NPCs has continued, with significant variation in use and supervision patterns.

To assess the effect of exercise-induced sweat on truncal acne, a prospective, single-blinded, randomized, controlled, institution review board-approved clinical trial was conducted on physically active males. Subjects were instructed to exercise long enough to break a sweat 5 days a week for 2 weeks. Group 1 did not exercise (n = 7), group 2 showered within 1 hour of exercise (n = 8), and group 3 waited at least 4 hours to shower after exercising (n = 8). No statistically significant differences in truncal acne were noted between (p = 0.84) nor within (p = 0.74 for group 1, 0.07 for group 2, and 0.09 for group 3) study groups at the end of the study period.

BACKGROUND: Cardiovascular diseases or risk factors (CVDR) seem to be more common in psoriasis patients than in the general population.

OBJECTIVE: We assessed the relationship of psoriasis with CVDR by analysis of healthcare claims data using a cross-sectional, prevalence-based study design.

PATIENTS AND METHODS: The IMS Health and MarketScan claims databases were used to identify adults with psoriasis diagnostic codes. Non-psoriasis controls were matched 3:1 based on age, gender, census region and previous medical insurance coverage. Odds ratios evaluated the relative prevalence of CVDR, and Mantel-Haenszel confidence intervals were estimated.

RESULTS: CVDR prevalence was generally higher in psoriasis patients than controls in both datasets. Odds ratios for atherosclerosis, congestive heart failure, type 2 diabetes, and peripheral vascular disease were >or=1.20 for psoriasis patients. Elevated disease severity was associated with a higher rate of CVDR, but varied somewhat by dataset and condition.

CONCLUSIONS: Elevated CVDR rates were found in psoriasis patients compared with controls. This pattern merits further examination.