By Gary M. White, MD
A single retrospective study of 16 patients with calciphylaxis at the Mayo clinic using an oral anticoagulant, the most common being apixaban, showed great promise in the treatment of calciphylaxis. At a follow up of 418 days, 9 of 16 were still alive and 5 of those 9 had complete resolution of their symptoms (study by Brian J. King, MD presented at the European Academy of Dermatology and Venereology as reported by Dermatology News, December, p. 8). Coumadin cannot be recommended as it may predispose to calciphylaxis.
Both the daily use of an emollient and the use of a hard water softener can reduce the risk of AD in high-risk infants. See here.
No need for CBC. Baseline and week 8 for SGPT and lipid panel.
A systematic literature review of 57 studies [Springerplus. 2016 Jul 22;5(1):1151] found ivermectin 1 % cream QD more effective than topical metronidazole and azelaic acid topical in the treatment of inflammatory rosacea.
Ustekinumab has worked well in several patients with atopic dermatitis [Clin Exp Dermatol. 2016 Aug;41(6):625-7, Ann Dermatol. 2013 Aug;25(3):368-370]. However, a study of 33 patients with moderate-to-severe AD compared did not find a difference between ustekinumab and placebo [Exp Dermatol. 2016 Jun 15].
Photodynamic therapy using 5-aminolevulinic acid (ALA-PDT) at 2 week intervals for 3 treatments was superior to clobetasol in one study of 43 women [Acta Dermato-Venereologica 2016 ahead of print] with Lichen Sclerosis. Of note, only 7% (1/14) of patients relapsed after 6 months in the ALA-PDT group vs 100% (7/7) of the clobetasol group.
In a recent meta study, lichen planus was significantly associated with an increased risk of dyslipidemia and higher triglyceride levels [Int J Dermatol. 2016 Feb 12].
Odomzo (sonidegib), a Hedgehog pathway inhibitor, has been approved by the FDA for patients with locally advanced basal cell carcinoma that has recurred following surgery or radiation therapy, or who are not candidates for surgery or radiation therapy. The dose is 200 mg daily. It has a boxed warning for pregnant women. The most common side effects of Odomzo were muscle spasms, alopecia, dysgeusia, fatigue, nausea, musculoskeletal pain, diarrhea, decreased weight, decreased appetite, myalgia, abdominal pain, headache, pain, vomiting and pruritus. Odomzo also has the potential to cause serious musculoskeletal-related side effects, including increased serum creatine kinase levels, with rare reports of rhabdomyolysis, muscle spasms, and myalgia.
A study was conducted of 770 individuals with Darier disease, compared with matched controls without Darier disease in Sweden. Individuals with Darier disease were found to have a sixfold increased risk of being diagnosed with intellectual disability [BJD 2015;173, 155–158].
A 53-year-old woman with vitiligo was nearly cleared after 5 months treatment with tofacitinib, a Janus kinase inhibitor. The initial dose was 5 mg every other day, increased after 3 weeks to 5 mg/day. There were no side effects and laboratory monitoring was normal. This single case report is very encouraging. More studies are being anticipated. JAMA Dermatol. Published online June 24, 2015.
A recent placebo-controlled study of 386 patients who had been diagnosed with at least two skin cancers, i.e. basal cell carcinoma and/or squamous cell carcinoma - in the past five years, showed that taking 500 milligrams twice daily of nicotinamide (not nicotinic acid) reduced the subsequent risk of non-melanoma skin cancers by 23 per cent. When patients stopped taking the supplements, their risk of getting skin cancer rose again about six months later.
An article from the Australasian Journal of Dermatology [Australas J Dermatol. 2015 Apr 20] reported that rod-shaped bacteria (RB--possibly fusobacteria) were detected in cases of perioral dermatitis at a high incidence. RB were detected on the surfaces of the roots of vellus hairs from lesions in nine of the 10 patients with perioral dermatitis. In contrast, RB were not detected in any of the eight patients with perioral corticosteroid-induced rosacea. No RB were found in the perioral areas of other types of facial dermatitis, including atopic dermatitis and seborrheic dermatitis or in 16 healthy controls.
A systemic review and meta-analysis showed that in North America and Asia (but not in Europe), atopic dermatitis (AD) is associated with being overweight/obese [JAAD 2015;72;606]. This brings up the idea of weight loss as a therapeutic intervention for AD (as is true for psoriasis).
Hajar et al [JAAD 2015;72;541] have written a very interesting article on the Topical Steroid Withdrawal which has received much attention lately in social media. The most common situation is acute redness and edema of the face in a woman occurring after abrupt cessation of long term daily mid to high-potency topical corticosteroids. A review of internet blogs shows that many of these patients suffer for weeks to months with diffuse, burning, red, edematous skin. The authors discuss such issues as "Is this a new entity?" and "How is it distinct from just a flare of the underlying condition, e.g. eczema?"
The application of topical rapamycin improves the results and lessens the number of sessions for the treatment of port wine stains in Sturge-Weber Syndrome [JAAD 2015;72;151]. This study was a randomized, double-blind and placebo-controlled trial of 23 adults with SWS. The patients applied the 1% rapamycin cream daily after the first laser treatment and continued for 12 weeks. 1% rapamycin powder was dissolved in 3.8% benzyl alcohol and thoroughly mixed in a water-in-oil emulsion. Topical rapamycin alone does not seem to be effective. It is postulated that the rapamycin inhibits angioneogenesis which otherwise would occur post laser treatment. Studies in children have yet to be done.
An OTC product Elure contains lignin peroxidase and has been shown to be better than placebo at skin lightening and approximately equivalent in efficacy to hydroquinone when used BID for melasma [JAAD 2015;72;105-7]. 60 patients were studied with a split face design. Cohort 1: Elure vs. placebo. Cohort 2: Elure vs. 4% hydroquinone.
For a comparison of the PASI-75 efficacy rates for the latest treatments for psoriasis, click here.
With all the recent reports and lectures on field-therapy treatment of AKs, let's not forget the most important admonition, "daily morning sunscreen". Regular sunscreen use reduces the number of actinic keratoses (in this study for example over one summer--N Engl J Med. 1993 Oct 14;329(16):1147-51.). Another study of risk factors for the development of SCC and AKs [British Journal of Cancer (1996) 74, 1308-1312] found that those patients who spent "average" or "considerable" time in the sun in the previous two years were twice as likely to develop new AKs compared with those that spent vs "None/very little". Just as it is never to late to quit smoking, it is never too late to start using sunscreen.
Benzoyl peroxide is a key player in the fight against acne. Many patients, out of convenience, use the BP washes. But these products may only be on the skin for seconds before being washed off. Can they really be that effective with such a short contact time? Very little has been published on this subject. Below are this author's opinions after reading the available literature and speaking with experts.
Two JAK inhibitors have regrown hair in both mice and humans with alopecia areata. A patient with AU grew all his hair with tofacitinib at 10 mg daily [Journal of Investigative Dermatology]. Ruxolitinib completely restored hair growth in 3 patients with AA (more than 30% hair loss) within four to five months of starting treatment as well (link).
Afamelanotide is an implantable analog of alpha-melanocyte stimulating hormone that increases the efficacy of NB-UVB in the treatment of vitiligo. A multicenter, randomized, trial involving 55 patients with vitiligo treated with afamelanotide and NB-UVB or NB-UVB alone found that regimentation at day 168 was 48.6% in the combination group compared with 33.2% in the monotherapy group [JAMA Dermatol. 2015 Jan;151(1):42-50.]. One concern however is that the drug can cause darkening of the skin, increasing the overall visibility of the vitiligo.
There was a report of 10 patients using either 0.015% or 0.05% ingenol mebutate gel (Picato) or placebo as one application only. All warts cleared within 3-7 days where treated with IM. No sites treated with vehicle cleared. There were no recurrence in 3 months at sites which cleared. There was mild to moderate burning x 1-2 days. [J Invest Dermatol 2014;134:S90-107].
Gardasil 9 approved for HPV. Protection efficacy rate: 99% EGW, 97% genital SCCA, 75% anal SCCA.
The old idea that the port wine stain of Sturge-Weber Syndrome must involve the ophthalmic division of trigeminal nerve territory involvement in SWS should be abandoned. Instead, the PWSs of SWS in some way include the forehead [BJD 2014;171;4; 861–867]. Old vs. new classification which is defined as any PWS involving the forehead. from BJD 2014;171;4; 861–867
Philips BlueControl is a battery-powered wearable medical device that uses light-emitting diode blue light therapy to treat mild-to-moderate psoriasis. In a trial of patients with mild-to-moderate psoriasis vulgaris treated for 12 weeks, an average PASI reduction of 50% was obtained with no side effects.
The Syphilis Health Check test which uses a finger stick blood sample has been approved by the FDA for use in the US by health care workers without special training. If the test is positive for syphilis, a confirmatory blood test should be drawn. The test is made by VEDA LAB for Diagnostics Direct, LLC.
Approximately 15% of patients with vitiligo have some sort of sensorineural hearing loss. Even in patients with normal hearing, bilateral cochlear dysfunction is common in both segmental and classic vitiligo [BJD 2015, 172: 406–411].
The FDA has approved topical ivermectin 1% cream (Soolantra) once daily for the treatment of rosacea. In two pivotal studies, the number of patients who were clear or almost clear at 12 weeks was 38%-40% for ivermectin vs. 12%-19% placebo. Side effects were actually less in the ivermectin group than the placebo group. In a separate study, ivermectin 1% cream was more effective for rosacea than metronidazole 0.75% topical cream.
Kenneth Katz in this month's Archives of Dermatology reviews the facts surrounding molluscum contagiosum and the treatment with imiquimod [JAMA Derm 2015;151;125]. Two large randomized clinical trials have shown that imiquimod does not have benefit in the treatment of molluscum contagiosum. Unfortunately, these two articles were never published. I also found interesting that he notes that imiquimod application to a least 10% body surface area led to leukopenia or neutropenia in 40% and 25% of patients, respectively.
Methotrexate has been used with benefit for alopecia areata in several small series of patients. It is usually combined with IL or oral steroids--often the steroids given early and then the patient treated with methotrexate alone or in combination with topical minoxidil. Hammerschmidt and Brenner reviewed treatment of 31 patients and found regrowth greater than 50% was observed in 67.7% of patients, with the best responses observed in those with <5 years of disease progression (79%), age over 40 years (73.3%), male patients (72.8%), cumulative dose of methotrexate 1000-1500 mg, and multifocal alopecia areata (93%) [An. Bras. Dermatol 89;5;Sept./Oct. 201].
Lattouf et al just published a study [JAAD 2015;72;359-61] of 29 patients with 40-70% hair loss from alopecia areata treated with the combination of simvastatin 40 mg and ezetimibe 10 mg daily for 24 weeks. Ten patients dropped out (3 of those before starting treatment), so 19 of 29 patients completed the study. 14 of those 19 (74%) were considered responders defined as more than 20% regrowth. (If you exclude the three that withdrew before starting treatment, but include the other 7 and count them as non-responders, then 14/26 or 54% responded.) After the 24 weeks, those 14 were randomized, half to continue for an additional 24 weeks and half to stop. 5 of the 7 treated continued with either more hair growth or stable disease. 5 of 7 who stopped the treatment relapsed. Of note, in a prior case report [J Drugs Dermatol. 2007 Sep;6(9):946-7], a 54 year old man with alopecia universalis grew dense scalp hair after being treated with the same combination. However, for 2 years previously, he had been on simvastatin alone without any benefit.
Although not double-blind, this study does seem to provide compelling evidence that the above combination may have benefit in a significant subset of patients with AA.
Simvastatin (Zocor) and ezetimibe (Zetia) are both lipid lowering agents. They are marketed together as Vytorin and Inegy.
Example patient from Treatment of alopecia areata with simvastatin/ezetimibe. JAAD 2015;72;359-60, before and after 40 weeks of treatment.
Secukinumab was recently approved for psoriasis. It is probably the most efficacious of the TNF agents currently available in the US. It is given 300 mg by subcutaneous injection with initial dosing at weeks 0, 1, 2 and 3 followed by monthly maintenance dosing starting at week 4. It is also effective for psoriatic arthritis.
See Mycoplasma Pneumoniae-Induced Rash And Mucositis
Dupilumab, a fully human monoclonal antibody that blocks interleukin-4 and interleukin-13--key drivers of type 2 helper T-cell (Th2)-mediated inflammation--was proven highly effective for atopic dermatitis. A 12-week DBPCT of dupilumab monotherapy found that 85% of patients on dupilumab, as compared with 35% of those on placebo, had a 50% reduction in the EASI score [N Engl J Med. 2014 Jul 10;371(2):130-9]. In combination with topical steroids, 100% of the subjects in the dupilumab group met the criterion for EASI-50, compared with 50% in the placebo group.