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Females with acne stay on spironolactone longer than antibiotics in real-world usage study
according to a retrospective study of women with acne published in the Journal of the American Academy of Dermatology.
Among those treated for at least a year, patients continued spironolactone for about 90 days longer on average, than those on antibiotic therapy, reported John S. Barbieri, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, and associates. “The extended drug usage survival of spironolactone suggests that, in routine clinical practice, spironolactone may have good long-term effectiveness and tolerability,” they wrote. “Since female patients often have persistent acne into adulthood and given concerns regarding antibiotic overuse among acne patients, it is possible that using spironolactone as a first-line agent before oral antibiotics could improve outcomes for female patients with acne,” they added.
In the study, they pointed out that spironolactone is emerging as a possible alternative to oral antibiotic therapy, but “little is known about long-term outcomes with spironolactone for those who have an initial positive response and how it compares to other alternatives.”
To examine the duration of acne treatment with spironolactone versus oral antibiotics, the researchers analyzed data during 2010-2016 in the Optum Clinformatics Data Mart. They included data on female patients aged 12-40 years, with at least two diagnosis codes for acne, who received spironolactone or oral antibiotics for at least 12 months. They used multivariate Cox proportional hazard models to assess differences in duration of therapy for spironolactone, compared with oral antibiotics.
The mean duration of a treatment course was significantly longer among the 4,321 patients treated with spironolactone than among the 7,517 patients treated with oral tetracycline-class antibiotics (697.8 days vs. 604.4 days; P less than .001). Compared with treatment with oral tetracyclines, the hazard ratio for discontinuing spironolactone treatment was 0.74, after researchers controlled for the age at diagnosis and treatment, history of polycystic ovarian syndrome, and history of combined oral contraceptive or topical retinoid treatment.
Patients who receive spironolactone and patients who receive oral antibiotics may represent different populations, the authors noted. In addition, guidelines advise limiting antibiotic treatment to 3-6 months, and antibiotic discontinuations may have been related to these recommendations. “It is not possible to determine whether medication discontinuation occurred due to lack of efficacy, cost, side effects, resolution of acne, or other factors,” they said, adding that prospective studies are needed “to identify the optimal treatment approaches for female patients with moderate to severe acne.”
The study was funded in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Barbieri is supported by NIAMS and receives partial salary support through a Pfizer Fellowship in Dermatology Patient Oriented Research grant to the Trustees of the University of Pennsylvania.
SOURCE: Barbieri JS et al. J Am Acad Dermatol. 2019 Mar 21. doi: 10.1016/j.jaad.2019.03.036.
according to a retrospective study of women with acne published in the Journal of the American Academy of Dermatology.
Among those treated for at least a year, patients continued spironolactone for about 90 days longer on average, than those on antibiotic therapy, reported John S. Barbieri, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, and associates. “The extended drug usage survival of spironolactone suggests that, in routine clinical practice, spironolactone may have good long-term effectiveness and tolerability,” they wrote. “Since female patients often have persistent acne into adulthood and given concerns regarding antibiotic overuse among acne patients, it is possible that using spironolactone as a first-line agent before oral antibiotics could improve outcomes for female patients with acne,” they added.
In the study, they pointed out that spironolactone is emerging as a possible alternative to oral antibiotic therapy, but “little is known about long-term outcomes with spironolactone for those who have an initial positive response and how it compares to other alternatives.”
To examine the duration of acne treatment with spironolactone versus oral antibiotics, the researchers analyzed data during 2010-2016 in the Optum Clinformatics Data Mart. They included data on female patients aged 12-40 years, with at least two diagnosis codes for acne, who received spironolactone or oral antibiotics for at least 12 months. They used multivariate Cox proportional hazard models to assess differences in duration of therapy for spironolactone, compared with oral antibiotics.
The mean duration of a treatment course was significantly longer among the 4,321 patients treated with spironolactone than among the 7,517 patients treated with oral tetracycline-class antibiotics (697.8 days vs. 604.4 days; P less than .001). Compared with treatment with oral tetracyclines, the hazard ratio for discontinuing spironolactone treatment was 0.74, after researchers controlled for the age at diagnosis and treatment, history of polycystic ovarian syndrome, and history of combined oral contraceptive or topical retinoid treatment.
Patients who receive spironolactone and patients who receive oral antibiotics may represent different populations, the authors noted. In addition, guidelines advise limiting antibiotic treatment to 3-6 months, and antibiotic discontinuations may have been related to these recommendations. “It is not possible to determine whether medication discontinuation occurred due to lack of efficacy, cost, side effects, resolution of acne, or other factors,” they said, adding that prospective studies are needed “to identify the optimal treatment approaches for female patients with moderate to severe acne.”
The study was funded in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Barbieri is supported by NIAMS and receives partial salary support through a Pfizer Fellowship in Dermatology Patient Oriented Research grant to the Trustees of the University of Pennsylvania.
SOURCE: Barbieri JS et al. J Am Acad Dermatol. 2019 Mar 21. doi: 10.1016/j.jaad.2019.03.036.
according to a retrospective study of women with acne published in the Journal of the American Academy of Dermatology.
Among those treated for at least a year, patients continued spironolactone for about 90 days longer on average, than those on antibiotic therapy, reported John S. Barbieri, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, and associates. “The extended drug usage survival of spironolactone suggests that, in routine clinical practice, spironolactone may have good long-term effectiveness and tolerability,” they wrote. “Since female patients often have persistent acne into adulthood and given concerns regarding antibiotic overuse among acne patients, it is possible that using spironolactone as a first-line agent before oral antibiotics could improve outcomes for female patients with acne,” they added.
In the study, they pointed out that spironolactone is emerging as a possible alternative to oral antibiotic therapy, but “little is known about long-term outcomes with spironolactone for those who have an initial positive response and how it compares to other alternatives.”
To examine the duration of acne treatment with spironolactone versus oral antibiotics, the researchers analyzed data during 2010-2016 in the Optum Clinformatics Data Mart. They included data on female patients aged 12-40 years, with at least two diagnosis codes for acne, who received spironolactone or oral antibiotics for at least 12 months. They used multivariate Cox proportional hazard models to assess differences in duration of therapy for spironolactone, compared with oral antibiotics.
The mean duration of a treatment course was significantly longer among the 4,321 patients treated with spironolactone than among the 7,517 patients treated with oral tetracycline-class antibiotics (697.8 days vs. 604.4 days; P less than .001). Compared with treatment with oral tetracyclines, the hazard ratio for discontinuing spironolactone treatment was 0.74, after researchers controlled for the age at diagnosis and treatment, history of polycystic ovarian syndrome, and history of combined oral contraceptive or topical retinoid treatment.
Patients who receive spironolactone and patients who receive oral antibiotics may represent different populations, the authors noted. In addition, guidelines advise limiting antibiotic treatment to 3-6 months, and antibiotic discontinuations may have been related to these recommendations. “It is not possible to determine whether medication discontinuation occurred due to lack of efficacy, cost, side effects, resolution of acne, or other factors,” they said, adding that prospective studies are needed “to identify the optimal treatment approaches for female patients with moderate to severe acne.”
The study was funded in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Barbieri is supported by NIAMS and receives partial salary support through a Pfizer Fellowship in Dermatology Patient Oriented Research grant to the Trustees of the University of Pennsylvania.
SOURCE: Barbieri JS et al. J Am Acad Dermatol. 2019 Mar 21. doi: 10.1016/j.jaad.2019.03.036.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
FDA approves Qternmet XR as adjunct therapy for glycemic improvement in type 2 diabetes
The Food and Drug Administration has approved Qternmet XR (dapagliflozin/saxagliptin/metformin) as an oral adjunct therapy to diet and exercise for the improvement of glycemic control in patients with type 2 diabetes, according to AstraZeneca.
FDA approval is based on results from a pair of phase 3 trials that tested different combinations of dapagliflozin and saxagliptin in patients with inadequately controlled type 2 diabetes who were also receiving metformin over a 24-week period. In both trials, treatment with dapagliflozin/saxagliptin/metformin decreased hemoglobin A1c by statistically significant amounts, and increased the number of patients with HbA1c levels below 7%
The safety results of Qternmet XR was consistent with each component medication’s known profile.
The Food and Drug Administration has approved Qternmet XR (dapagliflozin/saxagliptin/metformin) as an oral adjunct therapy to diet and exercise for the improvement of glycemic control in patients with type 2 diabetes, according to AstraZeneca.
FDA approval is based on results from a pair of phase 3 trials that tested different combinations of dapagliflozin and saxagliptin in patients with inadequately controlled type 2 diabetes who were also receiving metformin over a 24-week period. In both trials, treatment with dapagliflozin/saxagliptin/metformin decreased hemoglobin A1c by statistically significant amounts, and increased the number of patients with HbA1c levels below 7%
The safety results of Qternmet XR was consistent with each component medication’s known profile.
The Food and Drug Administration has approved Qternmet XR (dapagliflozin/saxagliptin/metformin) as an oral adjunct therapy to diet and exercise for the improvement of glycemic control in patients with type 2 diabetes, according to AstraZeneca.
FDA approval is based on results from a pair of phase 3 trials that tested different combinations of dapagliflozin and saxagliptin in patients with inadequately controlled type 2 diabetes who were also receiving metformin over a 24-week period. In both trials, treatment with dapagliflozin/saxagliptin/metformin decreased hemoglobin A1c by statistically significant amounts, and increased the number of patients with HbA1c levels below 7%
The safety results of Qternmet XR was consistent with each component medication’s known profile.
Bioimpedance spectroscopy may better identify lymphedema progression
Bioimpedance spectroscopy may better identify lymphedema progression in women at risk for breast cancer–related lymphedema over the traditionally used method of monitoring arm circumference with a tape measure, according to results from an interim analysis of the PREVENT trial presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.
“Despite advances in breast-conserving surgery, improved radiation protocol, the advent of sentinel [node] biopsies and recent improvement in chemotherapy regimens, breast cancer–related lymphedema ... remains a major source of morbidity and concern in this patient population,” Sheila Ridner, PhD, RN, FAAN, professor of nursing at the Vanderbilt University School of Nursing in Nashville, Tenn., said in her presentation. “Because it is thought that early identification of swelling in the limbs coupled with a compression intervention may reduce the risk of patients developing full-blown clinical lymphedema, clinicians are proposing to use a prospective surveillance model to follow breast cancer survivors post surgery in order to assess limbs in a routine fashion and perhaps instigate preventative mechanisms early.”
The larger randomized controlled Prevention of Lymphedema Following Locoregional Treatment for Breast Cancer (PREVENT) trial enrolled 1,201 patients, and 200 patients overall have completed the full protocol. The researchers plan to follow patients for 3 years after surgery. In this interim analysis, Dr. Ridner and colleagues analyzed data from 508 patients at eight sites in the United States and four sites in Sydney who had stage I through stage III or ductal carcinoma in situ (DCIS) breast cancer and underwent mastectomy, taxane-based chemotherapy, or an axillary treatment such as axillary radiation, axillary lymph node dissection, or sentinel lymph nose biopsy with more than 6 nodes.
The patients were randomized to be measured using either traditional tape measurement or bioimpedance spectroscopy (BIS). Patients were moved to a prevention intervention if there was a change in baseline volume of 5% or greater but less than 10% in the tape measure group and change from baseline L-Dex measurement of 6.5 or greater in the BIS group, which consisted of wearing an arm compression sleeve and chest gauntlet for 12 hours a day over 4 weeks. After surgery, the patients were followed up at 3 months, 6 months, 12 months, 18 months, and 24 months, with optional follow-up visits at 15 months and 21 months. Progression to full lymphedema was defined as a 10% or greater change in pretreatment baseline measurements in the tape measure group.
Of the 508 patients analyzed, 10 patients had already progressed to full lymphedema, leaving 498 patients available for the interim analysis. There were 68 patients in the tape measure group (28.5%) and 41 patients in the BIS group (15.8%) who received the prevention intervention, and 10 patients in the tape measure group (14.7%) and 2 patients in the BIS group (4.9%) eventually progressed to full lymphedema. In the BIS group, there was a 10% absolute reduction and 67% relative reduction in lymphedema progression, compared with the tape measure group.
“We believe that the 10% absolute reduction is clinically significant for this patient population,” said Dr. Ridner. “We also believe that our interim results may support the concept of posttreatment surveillance using BIS for early detection of subclinical lymphedema coupled with early intervention as our preliminary data suggest this does have clinical advantages to the patient.”
The study was funded by ImpediMed. Dr. Ridner reports being the principal investigator for ImpediMed and Tactile Medical through work agreements contracted between the companies and her institution.
Bioimpedance spectroscopy may better identify lymphedema progression in women at risk for breast cancer–related lymphedema over the traditionally used method of monitoring arm circumference with a tape measure, according to results from an interim analysis of the PREVENT trial presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.
“Despite advances in breast-conserving surgery, improved radiation protocol, the advent of sentinel [node] biopsies and recent improvement in chemotherapy regimens, breast cancer–related lymphedema ... remains a major source of morbidity and concern in this patient population,” Sheila Ridner, PhD, RN, FAAN, professor of nursing at the Vanderbilt University School of Nursing in Nashville, Tenn., said in her presentation. “Because it is thought that early identification of swelling in the limbs coupled with a compression intervention may reduce the risk of patients developing full-blown clinical lymphedema, clinicians are proposing to use a prospective surveillance model to follow breast cancer survivors post surgery in order to assess limbs in a routine fashion and perhaps instigate preventative mechanisms early.”
The larger randomized controlled Prevention of Lymphedema Following Locoregional Treatment for Breast Cancer (PREVENT) trial enrolled 1,201 patients, and 200 patients overall have completed the full protocol. The researchers plan to follow patients for 3 years after surgery. In this interim analysis, Dr. Ridner and colleagues analyzed data from 508 patients at eight sites in the United States and four sites in Sydney who had stage I through stage III or ductal carcinoma in situ (DCIS) breast cancer and underwent mastectomy, taxane-based chemotherapy, or an axillary treatment such as axillary radiation, axillary lymph node dissection, or sentinel lymph nose biopsy with more than 6 nodes.
The patients were randomized to be measured using either traditional tape measurement or bioimpedance spectroscopy (BIS). Patients were moved to a prevention intervention if there was a change in baseline volume of 5% or greater but less than 10% in the tape measure group and change from baseline L-Dex measurement of 6.5 or greater in the BIS group, which consisted of wearing an arm compression sleeve and chest gauntlet for 12 hours a day over 4 weeks. After surgery, the patients were followed up at 3 months, 6 months, 12 months, 18 months, and 24 months, with optional follow-up visits at 15 months and 21 months. Progression to full lymphedema was defined as a 10% or greater change in pretreatment baseline measurements in the tape measure group.
Of the 508 patients analyzed, 10 patients had already progressed to full lymphedema, leaving 498 patients available for the interim analysis. There were 68 patients in the tape measure group (28.5%) and 41 patients in the BIS group (15.8%) who received the prevention intervention, and 10 patients in the tape measure group (14.7%) and 2 patients in the BIS group (4.9%) eventually progressed to full lymphedema. In the BIS group, there was a 10% absolute reduction and 67% relative reduction in lymphedema progression, compared with the tape measure group.
“We believe that the 10% absolute reduction is clinically significant for this patient population,” said Dr. Ridner. “We also believe that our interim results may support the concept of posttreatment surveillance using BIS for early detection of subclinical lymphedema coupled with early intervention as our preliminary data suggest this does have clinical advantages to the patient.”
The study was funded by ImpediMed. Dr. Ridner reports being the principal investigator for ImpediMed and Tactile Medical through work agreements contracted between the companies and her institution.
Bioimpedance spectroscopy may better identify lymphedema progression in women at risk for breast cancer–related lymphedema over the traditionally used method of monitoring arm circumference with a tape measure, according to results from an interim analysis of the PREVENT trial presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.
“Despite advances in breast-conserving surgery, improved radiation protocol, the advent of sentinel [node] biopsies and recent improvement in chemotherapy regimens, breast cancer–related lymphedema ... remains a major source of morbidity and concern in this patient population,” Sheila Ridner, PhD, RN, FAAN, professor of nursing at the Vanderbilt University School of Nursing in Nashville, Tenn., said in her presentation. “Because it is thought that early identification of swelling in the limbs coupled with a compression intervention may reduce the risk of patients developing full-blown clinical lymphedema, clinicians are proposing to use a prospective surveillance model to follow breast cancer survivors post surgery in order to assess limbs in a routine fashion and perhaps instigate preventative mechanisms early.”
The larger randomized controlled Prevention of Lymphedema Following Locoregional Treatment for Breast Cancer (PREVENT) trial enrolled 1,201 patients, and 200 patients overall have completed the full protocol. The researchers plan to follow patients for 3 years after surgery. In this interim analysis, Dr. Ridner and colleagues analyzed data from 508 patients at eight sites in the United States and four sites in Sydney who had stage I through stage III or ductal carcinoma in situ (DCIS) breast cancer and underwent mastectomy, taxane-based chemotherapy, or an axillary treatment such as axillary radiation, axillary lymph node dissection, or sentinel lymph nose biopsy with more than 6 nodes.
The patients were randomized to be measured using either traditional tape measurement or bioimpedance spectroscopy (BIS). Patients were moved to a prevention intervention if there was a change in baseline volume of 5% or greater but less than 10% in the tape measure group and change from baseline L-Dex measurement of 6.5 or greater in the BIS group, which consisted of wearing an arm compression sleeve and chest gauntlet for 12 hours a day over 4 weeks. After surgery, the patients were followed up at 3 months, 6 months, 12 months, 18 months, and 24 months, with optional follow-up visits at 15 months and 21 months. Progression to full lymphedema was defined as a 10% or greater change in pretreatment baseline measurements in the tape measure group.
Of the 508 patients analyzed, 10 patients had already progressed to full lymphedema, leaving 498 patients available for the interim analysis. There were 68 patients in the tape measure group (28.5%) and 41 patients in the BIS group (15.8%) who received the prevention intervention, and 10 patients in the tape measure group (14.7%) and 2 patients in the BIS group (4.9%) eventually progressed to full lymphedema. In the BIS group, there was a 10% absolute reduction and 67% relative reduction in lymphedema progression, compared with the tape measure group.
“We believe that the 10% absolute reduction is clinically significant for this patient population,” said Dr. Ridner. “We also believe that our interim results may support the concept of posttreatment surveillance using BIS for early detection of subclinical lymphedema coupled with early intervention as our preliminary data suggest this does have clinical advantages to the patient.”
The study was funded by ImpediMed. Dr. Ridner reports being the principal investigator for ImpediMed and Tactile Medical through work agreements contracted between the companies and her institution.
REPORTING FROM ASBS 2019
Patch testing in atopic dermatitis: when and how
WAIKOLOA, HAWAII – The according to Jonathan I. Silverberg, MD, PhD.
“What are atopic dermatitis patients allergic to? It’s all coming from their personal care products and the things being used to treat their atopic dermatitis,” Dr. Silverberg said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
Dr. Silverberg, of the department of dermatology at Northwestern University, Chicago, coauthored a systematic review and meta-analysis that examined the association between AD and contact sensitization. In their examination of 74 published studies, the investigators found that the likelihood of allergic contact dermatitis was 1.5-fold greater in adults and children with AD than in healthy individuals from the general population (J Am Acad Dermatol. 2017 Jul;77[1]:70-8).
This finding is at odds with an earlier widespread belief that AD patients should not be at increased risk because the immune profile of their primarily Th2-mediated disease would have a suppressant effect on Th1-mediated hypersensitivity.
“Recent data are calling into question old dogmas and reshaping the way we think about this. And this is not just an academic exercise, this is highly clinically relevant,” the dermatologist asserted.
The results of the meta-analysis prompted Dr. Silverberg and colleagues to conduct a retrospective study of more than 500 adults patch tested to an expanded allergen series at Northwestern’s patch test clinic with the purpose of identifying the common offending allergens in patients with AD. The key finding: The patients with AD were significantly more likely to have positive patch test reactions to ingredients in their repetitively used personal care products, topical corticosteroids, and topical antibiotics than the individuals without AD. The probable explanation for this results is that the skin barrier disruption inherent in AD allows for easier passage of weak allergens through the skin (J Am Acad Dermatol. 2018 Dec;79[6]:1028-33.e6).
Lanolin was identified as a particularly common allergen in the AD group. “Lanolin is found in one of the most commonly used moisturizers we recommend to patients: Aquaphor. It’s also found in tons of lip balms and emollients. Pretty much every soft soap out there contains lanolin, and it’s in a variety of other personal care products,” Dr. Silverberg noted.
Other common offenders in the AD population included fragrance mix II, cinnamal, quaternium-15, budesonide, tixocortol, carba mix, neomycin, bacitracin, rubber mix, and chlorhexidine. Relevance was established in more than 90% of the positive reactions.
“You can patch test them directly to their personal care products and make that connection beautifully and see how they’re reacting to them,” he said.
When to patch test atopic dermatitis patients
Dr. Silverberg was a coauthor of multidisciplinary expert consensus guidelines on when to consider patch testing in AD (Dermatitis. 2016 Jul-Aug;27[4]:186-92). “We had to go consensus because we don’t have nearly enough studies to provide true evidence-based recommendations,” he explained.
Because allergic contact dermatitis is a potentially curable comorbid condition in AD patients, it’s important to recognize the scenarios in which patch testing should be considered. These include AD refractory to topical therapy; adolescent- or adult-onset atopic dermatitis; and in AD patients with an atypical or evolving lesional distribution, such as localized dermatitis on the eyelids, head and neck, or hands and feet. Patch testing is also warranted before initiating systemic therapy for AD.
“If you’re about to put a patient on a biologic or phototherapy and step them up to a whole new class of risk of adverse events, that’s an ideal time to think about reversible options,” Dr. Silverberg advised.
Another situation in which he considers patch testing advisable, although this one isn’t covered in the consensus guidelines, is in AD patients with prominent nummular eczema lesions. “Widespread nummular eczema lesions may be a sign of allergic contact dermatitis in atopic dermatitis patients. I’m not saying everyone with nummular lesions is going to have a positive patch test, but it’s definitely a situation you want to think about,” he said.
How to patch test atopic dermatitis patients
Most of the common topical allergens in AD patients are not included in the T.R.U.E. Test. An expanded allergen series, such as the American Contact Dermatitis Society core 80 series, is the better way to go.
Once the dermatologist determines that a patient’s positive patch test reaction is relevant, it’s important to recommend the use of personal care products that are “pretty clean,” Dr. Silverberg said.
“Clean in my opinion is not a matter of ‘It should be all organic and all natural,’ ” he emphasized. “I’m not anti- any of that, but clean means having the fewest ingredients possible and trying to steer clear of those really common allergens that patients are highly likely to have been exposed to and potentially sensitized to over the many years of their tenure of atopic dermatitis.”
Dr. Silverberg reported receiving research grants from Galderma and GlaxoSmithKline and serving as a consultant to more than a dozen pharmaceutical companies.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – The according to Jonathan I. Silverberg, MD, PhD.
“What are atopic dermatitis patients allergic to? It’s all coming from their personal care products and the things being used to treat their atopic dermatitis,” Dr. Silverberg said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
Dr. Silverberg, of the department of dermatology at Northwestern University, Chicago, coauthored a systematic review and meta-analysis that examined the association between AD and contact sensitization. In their examination of 74 published studies, the investigators found that the likelihood of allergic contact dermatitis was 1.5-fold greater in adults and children with AD than in healthy individuals from the general population (J Am Acad Dermatol. 2017 Jul;77[1]:70-8).
This finding is at odds with an earlier widespread belief that AD patients should not be at increased risk because the immune profile of their primarily Th2-mediated disease would have a suppressant effect on Th1-mediated hypersensitivity.
“Recent data are calling into question old dogmas and reshaping the way we think about this. And this is not just an academic exercise, this is highly clinically relevant,” the dermatologist asserted.
The results of the meta-analysis prompted Dr. Silverberg and colleagues to conduct a retrospective study of more than 500 adults patch tested to an expanded allergen series at Northwestern’s patch test clinic with the purpose of identifying the common offending allergens in patients with AD. The key finding: The patients with AD were significantly more likely to have positive patch test reactions to ingredients in their repetitively used personal care products, topical corticosteroids, and topical antibiotics than the individuals without AD. The probable explanation for this results is that the skin barrier disruption inherent in AD allows for easier passage of weak allergens through the skin (J Am Acad Dermatol. 2018 Dec;79[6]:1028-33.e6).
Lanolin was identified as a particularly common allergen in the AD group. “Lanolin is found in one of the most commonly used moisturizers we recommend to patients: Aquaphor. It’s also found in tons of lip balms and emollients. Pretty much every soft soap out there contains lanolin, and it’s in a variety of other personal care products,” Dr. Silverberg noted.
Other common offenders in the AD population included fragrance mix II, cinnamal, quaternium-15, budesonide, tixocortol, carba mix, neomycin, bacitracin, rubber mix, and chlorhexidine. Relevance was established in more than 90% of the positive reactions.
“You can patch test them directly to their personal care products and make that connection beautifully and see how they’re reacting to them,” he said.
When to patch test atopic dermatitis patients
Dr. Silverberg was a coauthor of multidisciplinary expert consensus guidelines on when to consider patch testing in AD (Dermatitis. 2016 Jul-Aug;27[4]:186-92). “We had to go consensus because we don’t have nearly enough studies to provide true evidence-based recommendations,” he explained.
Because allergic contact dermatitis is a potentially curable comorbid condition in AD patients, it’s important to recognize the scenarios in which patch testing should be considered. These include AD refractory to topical therapy; adolescent- or adult-onset atopic dermatitis; and in AD patients with an atypical or evolving lesional distribution, such as localized dermatitis on the eyelids, head and neck, or hands and feet. Patch testing is also warranted before initiating systemic therapy for AD.
“If you’re about to put a patient on a biologic or phototherapy and step them up to a whole new class of risk of adverse events, that’s an ideal time to think about reversible options,” Dr. Silverberg advised.
Another situation in which he considers patch testing advisable, although this one isn’t covered in the consensus guidelines, is in AD patients with prominent nummular eczema lesions. “Widespread nummular eczema lesions may be a sign of allergic contact dermatitis in atopic dermatitis patients. I’m not saying everyone with nummular lesions is going to have a positive patch test, but it’s definitely a situation you want to think about,” he said.
How to patch test atopic dermatitis patients
Most of the common topical allergens in AD patients are not included in the T.R.U.E. Test. An expanded allergen series, such as the American Contact Dermatitis Society core 80 series, is the better way to go.
Once the dermatologist determines that a patient’s positive patch test reaction is relevant, it’s important to recommend the use of personal care products that are “pretty clean,” Dr. Silverberg said.
“Clean in my opinion is not a matter of ‘It should be all organic and all natural,’ ” he emphasized. “I’m not anti- any of that, but clean means having the fewest ingredients possible and trying to steer clear of those really common allergens that patients are highly likely to have been exposed to and potentially sensitized to over the many years of their tenure of atopic dermatitis.”
Dr. Silverberg reported receiving research grants from Galderma and GlaxoSmithKline and serving as a consultant to more than a dozen pharmaceutical companies.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – The according to Jonathan I. Silverberg, MD, PhD.
“What are atopic dermatitis patients allergic to? It’s all coming from their personal care products and the things being used to treat their atopic dermatitis,” Dr. Silverberg said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
Dr. Silverberg, of the department of dermatology at Northwestern University, Chicago, coauthored a systematic review and meta-analysis that examined the association between AD and contact sensitization. In their examination of 74 published studies, the investigators found that the likelihood of allergic contact dermatitis was 1.5-fold greater in adults and children with AD than in healthy individuals from the general population (J Am Acad Dermatol. 2017 Jul;77[1]:70-8).
This finding is at odds with an earlier widespread belief that AD patients should not be at increased risk because the immune profile of their primarily Th2-mediated disease would have a suppressant effect on Th1-mediated hypersensitivity.
“Recent data are calling into question old dogmas and reshaping the way we think about this. And this is not just an academic exercise, this is highly clinically relevant,” the dermatologist asserted.
The results of the meta-analysis prompted Dr. Silverberg and colleagues to conduct a retrospective study of more than 500 adults patch tested to an expanded allergen series at Northwestern’s patch test clinic with the purpose of identifying the common offending allergens in patients with AD. The key finding: The patients with AD were significantly more likely to have positive patch test reactions to ingredients in their repetitively used personal care products, topical corticosteroids, and topical antibiotics than the individuals without AD. The probable explanation for this results is that the skin barrier disruption inherent in AD allows for easier passage of weak allergens through the skin (J Am Acad Dermatol. 2018 Dec;79[6]:1028-33.e6).
Lanolin was identified as a particularly common allergen in the AD group. “Lanolin is found in one of the most commonly used moisturizers we recommend to patients: Aquaphor. It’s also found in tons of lip balms and emollients. Pretty much every soft soap out there contains lanolin, and it’s in a variety of other personal care products,” Dr. Silverberg noted.
Other common offenders in the AD population included fragrance mix II, cinnamal, quaternium-15, budesonide, tixocortol, carba mix, neomycin, bacitracin, rubber mix, and chlorhexidine. Relevance was established in more than 90% of the positive reactions.
“You can patch test them directly to their personal care products and make that connection beautifully and see how they’re reacting to them,” he said.
When to patch test atopic dermatitis patients
Dr. Silverberg was a coauthor of multidisciplinary expert consensus guidelines on when to consider patch testing in AD (Dermatitis. 2016 Jul-Aug;27[4]:186-92). “We had to go consensus because we don’t have nearly enough studies to provide true evidence-based recommendations,” he explained.
Because allergic contact dermatitis is a potentially curable comorbid condition in AD patients, it’s important to recognize the scenarios in which patch testing should be considered. These include AD refractory to topical therapy; adolescent- or adult-onset atopic dermatitis; and in AD patients with an atypical or evolving lesional distribution, such as localized dermatitis on the eyelids, head and neck, or hands and feet. Patch testing is also warranted before initiating systemic therapy for AD.
“If you’re about to put a patient on a biologic or phototherapy and step them up to a whole new class of risk of adverse events, that’s an ideal time to think about reversible options,” Dr. Silverberg advised.
Another situation in which he considers patch testing advisable, although this one isn’t covered in the consensus guidelines, is in AD patients with prominent nummular eczema lesions. “Widespread nummular eczema lesions may be a sign of allergic contact dermatitis in atopic dermatitis patients. I’m not saying everyone with nummular lesions is going to have a positive patch test, but it’s definitely a situation you want to think about,” he said.
How to patch test atopic dermatitis patients
Most of the common topical allergens in AD patients are not included in the T.R.U.E. Test. An expanded allergen series, such as the American Contact Dermatitis Society core 80 series, is the better way to go.
Once the dermatologist determines that a patient’s positive patch test reaction is relevant, it’s important to recommend the use of personal care products that are “pretty clean,” Dr. Silverberg said.
“Clean in my opinion is not a matter of ‘It should be all organic and all natural,’ ” he emphasized. “I’m not anti- any of that, but clean means having the fewest ingredients possible and trying to steer clear of those really common allergens that patients are highly likely to have been exposed to and potentially sensitized to over the many years of their tenure of atopic dermatitis.”
Dr. Silverberg reported receiving research grants from Galderma and GlaxoSmithKline and serving as a consultant to more than a dozen pharmaceutical companies.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
The art of selecting an MS therapy
DALLAS – , said Mark Freedman, MD, MSc, in a presentation at ACTRIMS Forum 2019, the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. “Right now, we are probably dealing with more of an imprecise medicine,” said Dr. Freedman.
Information such as a patient’s ability to recover from relapses may indicate MS severity or the likelihood of disease progression, but selecting a therapy remains “an art of medicine,” said Dr. Freedman, professor of neurology at the University of Ottawa, director of the multiple sclerosis research unit at Ottawa Hospital, and senior scientist at the Ottawa Hospital Research Institute.
When prescribing a DMT, neurologists tend to consider three key elements: the disease, the treatment, and patient expectations. “Focus on these three aspects,” Dr. Freedman said.
It is no longer sufficient for neurologists to diagnose MS, hand the patient a drug, and “expect that things are going to go the way you want them to go,” he said.
Immunomodulating, anti–cell trafficking, or cell-depleting therapy?
Genetics, sex, types of relapses, recovery from relapses, response to therapy, MRI burden, and other biomarkers such as oligoclonal bands and neurofilaments may indicate which patients have severe disease and should receive aggressive treatment.
Determining the phase of the disease is a crucial first step “that is going to drive your choice of therapy,” he said.
Dr. Freedman likened the development of progressive MS to approaching the edge of a cliff. If patients appear to be nearing the progressive phase, “then your choice of therapy has to be an aggressive one – one that will hopefully hold them back from falling,” he said. In the earlier phases of MS, on the other hand, “you are looking at a long-term treatment that should probably be safe and still able to contain the disease,” such as an immunomodulator. If a patient is “about to fall off, you may want to go for temporary use of an antitrafficker to control things, and then eventually deplete the cells that are going to be causing the patient to fall off the cliff.”
Prognostic factors
Disease activity over time, and whether the disease is progressing faster or slower than would be expected, may be important prognostic factors. A patient’s sex also may be a factor because women tend to have more attacks and to have their attacks at a younger age, Dr. Freedman said.
The types of relapses and a patient’s ability to recover from them may provide important information. “Some attacks are quite mild. Others tend to build up disease,” Dr. Freedman said. “Some people are better healers than others. We have all seen people who have been quadriplegic in an ICU on a ventilator walk out of the hospital without even a numb toe. And other people who have a little bit of weakness in one leg seem to never be able to recover from that. Exactly what drives repair is still not clear.” Most patients do recover, however, “and the inability to recover early on is a bad omen,” Dr. Freedman said.
When researchers examined the relationship between functional components of the Expanded Disability Status Scale (EDSS) and disability progression, “not surprisingly ... pyramidal and spinal cord and cerebellar [functioning] are more associated with earlier progression” (Neuroepidemiology. 2015;44[1]:16-23).
A study by Lublin et al. found that patients with MS whose attacks left them with residual deficits had more EDSS accumulation over time (Neurology. 2003 Dec 9;61[11]:1528-32.).
Response to immunomodulators
“The inability to control the disease with an immunomodulator is a bad sign,” Dr. Freedman said. He pointed to data from a trial of teriflunomide that included patients who had had suboptimal responses to first-line therapy as well as patients who were treatment naive (Mult Scler. 2018 Apr;24[4]:535-9.). Some of the patients who had received prior MS therapy were randomized to placebo, which “is not something that would happen today,” he said.
“If you just focus on the [patients who received placebo] and look at the rate of attack in patients who had no prior DMT, at least one prior DMT, or two or more prior DMTs, the attack rates are much higher in those individuals who tried and failed first-line therapies,” Dr. Freedman said. These patients also had more EDSS progression. “The majority of people do respond [to first-line treatment], but those who do not you need to worry about a little bit more than those who do respond.”
MRI lesions and brain reserve
MRI activity over time tends to predict disease progression, and lesion location is important. One cohort study found that the likelihood of developing secondary progressive MS was lower among patients who did not develop new spinal cord or brainstem lesions in the first three years of the disease, compared with those who did.
In addition, patients who presented with more lesions were more likely to reach an EDSS score 3 or 6 over 10 years (Brain. 2008 Mar;131[Pt 3]:808-17.).
Brain reserve also may be important. Among 52 treatment-naive Serbian adults with MS, Sumowski et al. found that maximal lifetime brain growth as estimated with intracranial volume was associated with risk of disability progression over 5 years (Neurology. 2016 May 24;86[21]:2006-9.). “Those who had a greater reserve had a much lower risk of disease progression,” Dr. Freedman said. The results suggest that patients with more brain reserve may be better able to sustain damage as the disease progresses and they age, he said.
Comorbidities
In the past, neurologists may have left it up to general practitioners “to sort out the rest of the patient’s health,” Dr. Freedman said. “But we now recognize that having certain comorbidities already puts a higher burden onto the disease. And those patients who have more comorbidities ... are going to do worse. But not only are they going to do worse ... it turns out that patients who have more comorbidities are going to have less of a response to your various therapies.” Vascular comorbidities, in particular, may affect treatment response (Neurology. 2017 Nov 28;89[22]:2222-9.).
If hypertension or diabetes clinics can help control those conditions in patients with MS, “it will help us a lot in getting what we are expecting from the [MS] medications,” Dr. Freedman said.
Adherence, expectations, and symptomatic treatment
Ultimately, selecting an MS therapy is a decision that doctors share with their patients. “You’re going to have a discussion with them,” he said. “You can see what fits their lifestyle.” For example, a world traveler might not be a good candidate for a drug that requires regular monitoring. A patient’s risk averseness also may influence treatment choice.
If you involve patients in the selection process, it may improve medication adherence. In addition, patients need to understand what you aim to accomplish with a DMT, said Dr. Freedman. “That may sound like a trivial thing. But how many times has the patient come in and said, ‘The drug is not working. ... My eye is not better’” when that was not the goal of treatment to begin with. Let patients know that symptomatic treatments may address problems apart from MS DMT. This personalized but imprecise approach to treatment is “probably the best we can do for now,” Dr. Freedman said.
Dr. Freedman has received a research grant from Genzyme and is on the company’s speakers bureau. He has received honoraria and consulting fees from various pharmaceutical companies and serves on companies’ advisory boards.
SOURCE: Freedman MS. ACTRIMS Forum 2019, Session 2.
DALLAS – , said Mark Freedman, MD, MSc, in a presentation at ACTRIMS Forum 2019, the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. “Right now, we are probably dealing with more of an imprecise medicine,” said Dr. Freedman.
Information such as a patient’s ability to recover from relapses may indicate MS severity or the likelihood of disease progression, but selecting a therapy remains “an art of medicine,” said Dr. Freedman, professor of neurology at the University of Ottawa, director of the multiple sclerosis research unit at Ottawa Hospital, and senior scientist at the Ottawa Hospital Research Institute.
When prescribing a DMT, neurologists tend to consider three key elements: the disease, the treatment, and patient expectations. “Focus on these three aspects,” Dr. Freedman said.
It is no longer sufficient for neurologists to diagnose MS, hand the patient a drug, and “expect that things are going to go the way you want them to go,” he said.
Immunomodulating, anti–cell trafficking, or cell-depleting therapy?
Genetics, sex, types of relapses, recovery from relapses, response to therapy, MRI burden, and other biomarkers such as oligoclonal bands and neurofilaments may indicate which patients have severe disease and should receive aggressive treatment.
Determining the phase of the disease is a crucial first step “that is going to drive your choice of therapy,” he said.
Dr. Freedman likened the development of progressive MS to approaching the edge of a cliff. If patients appear to be nearing the progressive phase, “then your choice of therapy has to be an aggressive one – one that will hopefully hold them back from falling,” he said. In the earlier phases of MS, on the other hand, “you are looking at a long-term treatment that should probably be safe and still able to contain the disease,” such as an immunomodulator. If a patient is “about to fall off, you may want to go for temporary use of an antitrafficker to control things, and then eventually deplete the cells that are going to be causing the patient to fall off the cliff.”
Prognostic factors
Disease activity over time, and whether the disease is progressing faster or slower than would be expected, may be important prognostic factors. A patient’s sex also may be a factor because women tend to have more attacks and to have their attacks at a younger age, Dr. Freedman said.
The types of relapses and a patient’s ability to recover from them may provide important information. “Some attacks are quite mild. Others tend to build up disease,” Dr. Freedman said. “Some people are better healers than others. We have all seen people who have been quadriplegic in an ICU on a ventilator walk out of the hospital without even a numb toe. And other people who have a little bit of weakness in one leg seem to never be able to recover from that. Exactly what drives repair is still not clear.” Most patients do recover, however, “and the inability to recover early on is a bad omen,” Dr. Freedman said.
When researchers examined the relationship between functional components of the Expanded Disability Status Scale (EDSS) and disability progression, “not surprisingly ... pyramidal and spinal cord and cerebellar [functioning] are more associated with earlier progression” (Neuroepidemiology. 2015;44[1]:16-23).
A study by Lublin et al. found that patients with MS whose attacks left them with residual deficits had more EDSS accumulation over time (Neurology. 2003 Dec 9;61[11]:1528-32.).
Response to immunomodulators
“The inability to control the disease with an immunomodulator is a bad sign,” Dr. Freedman said. He pointed to data from a trial of teriflunomide that included patients who had had suboptimal responses to first-line therapy as well as patients who were treatment naive (Mult Scler. 2018 Apr;24[4]:535-9.). Some of the patients who had received prior MS therapy were randomized to placebo, which “is not something that would happen today,” he said.
“If you just focus on the [patients who received placebo] and look at the rate of attack in patients who had no prior DMT, at least one prior DMT, or two or more prior DMTs, the attack rates are much higher in those individuals who tried and failed first-line therapies,” Dr. Freedman said. These patients also had more EDSS progression. “The majority of people do respond [to first-line treatment], but those who do not you need to worry about a little bit more than those who do respond.”
MRI lesions and brain reserve
MRI activity over time tends to predict disease progression, and lesion location is important. One cohort study found that the likelihood of developing secondary progressive MS was lower among patients who did not develop new spinal cord or brainstem lesions in the first three years of the disease, compared with those who did.
In addition, patients who presented with more lesions were more likely to reach an EDSS score 3 or 6 over 10 years (Brain. 2008 Mar;131[Pt 3]:808-17.).
Brain reserve also may be important. Among 52 treatment-naive Serbian adults with MS, Sumowski et al. found that maximal lifetime brain growth as estimated with intracranial volume was associated with risk of disability progression over 5 years (Neurology. 2016 May 24;86[21]:2006-9.). “Those who had a greater reserve had a much lower risk of disease progression,” Dr. Freedman said. The results suggest that patients with more brain reserve may be better able to sustain damage as the disease progresses and they age, he said.
Comorbidities
In the past, neurologists may have left it up to general practitioners “to sort out the rest of the patient’s health,” Dr. Freedman said. “But we now recognize that having certain comorbidities already puts a higher burden onto the disease. And those patients who have more comorbidities ... are going to do worse. But not only are they going to do worse ... it turns out that patients who have more comorbidities are going to have less of a response to your various therapies.” Vascular comorbidities, in particular, may affect treatment response (Neurology. 2017 Nov 28;89[22]:2222-9.).
If hypertension or diabetes clinics can help control those conditions in patients with MS, “it will help us a lot in getting what we are expecting from the [MS] medications,” Dr. Freedman said.
Adherence, expectations, and symptomatic treatment
Ultimately, selecting an MS therapy is a decision that doctors share with their patients. “You’re going to have a discussion with them,” he said. “You can see what fits their lifestyle.” For example, a world traveler might not be a good candidate for a drug that requires regular monitoring. A patient’s risk averseness also may influence treatment choice.
If you involve patients in the selection process, it may improve medication adherence. In addition, patients need to understand what you aim to accomplish with a DMT, said Dr. Freedman. “That may sound like a trivial thing. But how many times has the patient come in and said, ‘The drug is not working. ... My eye is not better’” when that was not the goal of treatment to begin with. Let patients know that symptomatic treatments may address problems apart from MS DMT. This personalized but imprecise approach to treatment is “probably the best we can do for now,” Dr. Freedman said.
Dr. Freedman has received a research grant from Genzyme and is on the company’s speakers bureau. He has received honoraria and consulting fees from various pharmaceutical companies and serves on companies’ advisory boards.
SOURCE: Freedman MS. ACTRIMS Forum 2019, Session 2.
DALLAS – , said Mark Freedman, MD, MSc, in a presentation at ACTRIMS Forum 2019, the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. “Right now, we are probably dealing with more of an imprecise medicine,” said Dr. Freedman.
Information such as a patient’s ability to recover from relapses may indicate MS severity or the likelihood of disease progression, but selecting a therapy remains “an art of medicine,” said Dr. Freedman, professor of neurology at the University of Ottawa, director of the multiple sclerosis research unit at Ottawa Hospital, and senior scientist at the Ottawa Hospital Research Institute.
When prescribing a DMT, neurologists tend to consider three key elements: the disease, the treatment, and patient expectations. “Focus on these three aspects,” Dr. Freedman said.
It is no longer sufficient for neurologists to diagnose MS, hand the patient a drug, and “expect that things are going to go the way you want them to go,” he said.
Immunomodulating, anti–cell trafficking, or cell-depleting therapy?
Genetics, sex, types of relapses, recovery from relapses, response to therapy, MRI burden, and other biomarkers such as oligoclonal bands and neurofilaments may indicate which patients have severe disease and should receive aggressive treatment.
Determining the phase of the disease is a crucial first step “that is going to drive your choice of therapy,” he said.
Dr. Freedman likened the development of progressive MS to approaching the edge of a cliff. If patients appear to be nearing the progressive phase, “then your choice of therapy has to be an aggressive one – one that will hopefully hold them back from falling,” he said. In the earlier phases of MS, on the other hand, “you are looking at a long-term treatment that should probably be safe and still able to contain the disease,” such as an immunomodulator. If a patient is “about to fall off, you may want to go for temporary use of an antitrafficker to control things, and then eventually deplete the cells that are going to be causing the patient to fall off the cliff.”
Prognostic factors
Disease activity over time, and whether the disease is progressing faster or slower than would be expected, may be important prognostic factors. A patient’s sex also may be a factor because women tend to have more attacks and to have their attacks at a younger age, Dr. Freedman said.
The types of relapses and a patient’s ability to recover from them may provide important information. “Some attacks are quite mild. Others tend to build up disease,” Dr. Freedman said. “Some people are better healers than others. We have all seen people who have been quadriplegic in an ICU on a ventilator walk out of the hospital without even a numb toe. And other people who have a little bit of weakness in one leg seem to never be able to recover from that. Exactly what drives repair is still not clear.” Most patients do recover, however, “and the inability to recover early on is a bad omen,” Dr. Freedman said.
When researchers examined the relationship between functional components of the Expanded Disability Status Scale (EDSS) and disability progression, “not surprisingly ... pyramidal and spinal cord and cerebellar [functioning] are more associated with earlier progression” (Neuroepidemiology. 2015;44[1]:16-23).
A study by Lublin et al. found that patients with MS whose attacks left them with residual deficits had more EDSS accumulation over time (Neurology. 2003 Dec 9;61[11]:1528-32.).
Response to immunomodulators
“The inability to control the disease with an immunomodulator is a bad sign,” Dr. Freedman said. He pointed to data from a trial of teriflunomide that included patients who had had suboptimal responses to first-line therapy as well as patients who were treatment naive (Mult Scler. 2018 Apr;24[4]:535-9.). Some of the patients who had received prior MS therapy were randomized to placebo, which “is not something that would happen today,” he said.
“If you just focus on the [patients who received placebo] and look at the rate of attack in patients who had no prior DMT, at least one prior DMT, or two or more prior DMTs, the attack rates are much higher in those individuals who tried and failed first-line therapies,” Dr. Freedman said. These patients also had more EDSS progression. “The majority of people do respond [to first-line treatment], but those who do not you need to worry about a little bit more than those who do respond.”
MRI lesions and brain reserve
MRI activity over time tends to predict disease progression, and lesion location is important. One cohort study found that the likelihood of developing secondary progressive MS was lower among patients who did not develop new spinal cord or brainstem lesions in the first three years of the disease, compared with those who did.
In addition, patients who presented with more lesions were more likely to reach an EDSS score 3 or 6 over 10 years (Brain. 2008 Mar;131[Pt 3]:808-17.).
Brain reserve also may be important. Among 52 treatment-naive Serbian adults with MS, Sumowski et al. found that maximal lifetime brain growth as estimated with intracranial volume was associated with risk of disability progression over 5 years (Neurology. 2016 May 24;86[21]:2006-9.). “Those who had a greater reserve had a much lower risk of disease progression,” Dr. Freedman said. The results suggest that patients with more brain reserve may be better able to sustain damage as the disease progresses and they age, he said.
Comorbidities
In the past, neurologists may have left it up to general practitioners “to sort out the rest of the patient’s health,” Dr. Freedman said. “But we now recognize that having certain comorbidities already puts a higher burden onto the disease. And those patients who have more comorbidities ... are going to do worse. But not only are they going to do worse ... it turns out that patients who have more comorbidities are going to have less of a response to your various therapies.” Vascular comorbidities, in particular, may affect treatment response (Neurology. 2017 Nov 28;89[22]:2222-9.).
If hypertension or diabetes clinics can help control those conditions in patients with MS, “it will help us a lot in getting what we are expecting from the [MS] medications,” Dr. Freedman said.
Adherence, expectations, and symptomatic treatment
Ultimately, selecting an MS therapy is a decision that doctors share with their patients. “You’re going to have a discussion with them,” he said. “You can see what fits their lifestyle.” For example, a world traveler might not be a good candidate for a drug that requires regular monitoring. A patient’s risk averseness also may influence treatment choice.
If you involve patients in the selection process, it may improve medication adherence. In addition, patients need to understand what you aim to accomplish with a DMT, said Dr. Freedman. “That may sound like a trivial thing. But how many times has the patient come in and said, ‘The drug is not working. ... My eye is not better’” when that was not the goal of treatment to begin with. Let patients know that symptomatic treatments may address problems apart from MS DMT. This personalized but imprecise approach to treatment is “probably the best we can do for now,” Dr. Freedman said.
Dr. Freedman has received a research grant from Genzyme and is on the company’s speakers bureau. He has received honoraria and consulting fees from various pharmaceutical companies and serves on companies’ advisory boards.
SOURCE: Freedman MS. ACTRIMS Forum 2019, Session 2.
EXPERT ANALYSIS FROM ACTRIMS
Most pregnancy-related deaths are preventable
according to the Centers for Disease Control and Prevention.
Deaths from pregnancy-related complications can occur “up to a year after delivery,” the CDC emphasized in a report released May 7. Indeed, 31% of pregnancy-related deaths happen during pregnancy, 36% happen at delivery or in the week after, and 33% happen 1 week to 1 year post partum. Yet detailed data from 13 state maternal mortality review committees (MMRCs) showed that 60% of such deaths are preventable.
There were 17 pregnancy-related deaths per 100,000 live births during 2011-2015, based on another data source: 3,410 pregnancy-related deaths (an average of 682 deaths per year) in the CDC’s Pregnancy Mortality Surveillance System. That pregnancy-related mortality ratio varied by race/ethnicity, Emily E. Peterson, MD, and the other CDC investigators reported in Morbidity and Mortality Weekly Report: Hispanic (11 deaths per 100,000), white (13), Asian/Pacific Islander (14), American Indian/Alaska Native (33), and black (43).
One aspect of the disparity was addressed by Wanda Barfield, MD, MPH, director of the CDC’s division of reproductive health and assistant surgeon general in the U.S. Public Health Service. “Recent studies have shown that racial and ethnic minority women deliver at different and lower-quality hospitals than white women and that these hospitals disproportionately care for black women at delivery,” she said at a CDC telebriefing.
Analysis of the timing of 2,990 deaths from the Pregnancy Mortality Surveillance System showed that almost a third (31.3%) occurred during pregnancy and 16.9% occurred on the day of delivery. Dr. Peterson and her CDC associates noted that more than half of pregnancy-related deaths, however, took place later: 1-6 days post partum (18.6%), 7-42 days (21.4%), and 43-365 days (11.7%).
The data on preventability were collected by the state MMRCs and included 232 deaths that occurred during 2013-2017. The MMRCs considered deaths preventable if they could be “averted by one or more reasonable changes to patient, community, provider, health facility, and/or system factors.”
“Our new analysis underscores the need for access to quality services, risk awareness, and early diagnosis, but it also highlights opportunities for preventing future pregnancy-related deaths,” Dr. Barfield said. “By identifying and promptly responding to warning signs not just during pregnancy, but even up to a year after delivery, we can save lives.”
according to the Centers for Disease Control and Prevention.
Deaths from pregnancy-related complications can occur “up to a year after delivery,” the CDC emphasized in a report released May 7. Indeed, 31% of pregnancy-related deaths happen during pregnancy, 36% happen at delivery or in the week after, and 33% happen 1 week to 1 year post partum. Yet detailed data from 13 state maternal mortality review committees (MMRCs) showed that 60% of such deaths are preventable.
There were 17 pregnancy-related deaths per 100,000 live births during 2011-2015, based on another data source: 3,410 pregnancy-related deaths (an average of 682 deaths per year) in the CDC’s Pregnancy Mortality Surveillance System. That pregnancy-related mortality ratio varied by race/ethnicity, Emily E. Peterson, MD, and the other CDC investigators reported in Morbidity and Mortality Weekly Report: Hispanic (11 deaths per 100,000), white (13), Asian/Pacific Islander (14), American Indian/Alaska Native (33), and black (43).
One aspect of the disparity was addressed by Wanda Barfield, MD, MPH, director of the CDC’s division of reproductive health and assistant surgeon general in the U.S. Public Health Service. “Recent studies have shown that racial and ethnic minority women deliver at different and lower-quality hospitals than white women and that these hospitals disproportionately care for black women at delivery,” she said at a CDC telebriefing.
Analysis of the timing of 2,990 deaths from the Pregnancy Mortality Surveillance System showed that almost a third (31.3%) occurred during pregnancy and 16.9% occurred on the day of delivery. Dr. Peterson and her CDC associates noted that more than half of pregnancy-related deaths, however, took place later: 1-6 days post partum (18.6%), 7-42 days (21.4%), and 43-365 days (11.7%).
The data on preventability were collected by the state MMRCs and included 232 deaths that occurred during 2013-2017. The MMRCs considered deaths preventable if they could be “averted by one or more reasonable changes to patient, community, provider, health facility, and/or system factors.”
“Our new analysis underscores the need for access to quality services, risk awareness, and early diagnosis, but it also highlights opportunities for preventing future pregnancy-related deaths,” Dr. Barfield said. “By identifying and promptly responding to warning signs not just during pregnancy, but even up to a year after delivery, we can save lives.”
according to the Centers for Disease Control and Prevention.
Deaths from pregnancy-related complications can occur “up to a year after delivery,” the CDC emphasized in a report released May 7. Indeed, 31% of pregnancy-related deaths happen during pregnancy, 36% happen at delivery or in the week after, and 33% happen 1 week to 1 year post partum. Yet detailed data from 13 state maternal mortality review committees (MMRCs) showed that 60% of such deaths are preventable.
There were 17 pregnancy-related deaths per 100,000 live births during 2011-2015, based on another data source: 3,410 pregnancy-related deaths (an average of 682 deaths per year) in the CDC’s Pregnancy Mortality Surveillance System. That pregnancy-related mortality ratio varied by race/ethnicity, Emily E. Peterson, MD, and the other CDC investigators reported in Morbidity and Mortality Weekly Report: Hispanic (11 deaths per 100,000), white (13), Asian/Pacific Islander (14), American Indian/Alaska Native (33), and black (43).
One aspect of the disparity was addressed by Wanda Barfield, MD, MPH, director of the CDC’s division of reproductive health and assistant surgeon general in the U.S. Public Health Service. “Recent studies have shown that racial and ethnic minority women deliver at different and lower-quality hospitals than white women and that these hospitals disproportionately care for black women at delivery,” she said at a CDC telebriefing.
Analysis of the timing of 2,990 deaths from the Pregnancy Mortality Surveillance System showed that almost a third (31.3%) occurred during pregnancy and 16.9% occurred on the day of delivery. Dr. Peterson and her CDC associates noted that more than half of pregnancy-related deaths, however, took place later: 1-6 days post partum (18.6%), 7-42 days (21.4%), and 43-365 days (11.7%).
The data on preventability were collected by the state MMRCs and included 232 deaths that occurred during 2013-2017. The MMRCs considered deaths preventable if they could be “averted by one or more reasonable changes to patient, community, provider, health facility, and/or system factors.”
“Our new analysis underscores the need for access to quality services, risk awareness, and early diagnosis, but it also highlights opportunities for preventing future pregnancy-related deaths,” Dr. Barfield said. “By identifying and promptly responding to warning signs not just during pregnancy, but even up to a year after delivery, we can save lives.”
PCV13 vaccine reduces frequency of otitis media visits
The mean number of office visits for otitis media in children younger than 5 years dropped significantly after the introduction of the 13-valent pneumococcal conjugate vaccine, according to findings published in the International Journal of Pediatric Otorhinolaryngology.
Previous studies have shown that more than half of children with otitis media (OM) have serotypes included in the PCV7 vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F), wrote Xiaofeng Zhou, MD, of Pfizer, New York, and colleagues.
To assess the impact of PCV13, with the additional serotypes 1, 3, 5, 6A, 7F, and 19A, the researchers analyzed data from the U.S. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for three time periods: pre-PCV7 (1997-1999), after the introduction of PCV7 (2001-2009), and after the introduction of PCV13 (2011-2013).
Between the pre-PCV7 and PCV13 time periods, the researchers found significant reductions in the mean rates of OM visits of 48% and 41% among children younger than 2 years and younger than 5 years, respectively; reductions were 24% and 22%, respectively, when comparing PCV13 and PCV7. Ambulatory care visits for skin rash and trauma were not significantly different among the study periods.
Comparing the PCV7 and PCV13 time periods, the mean number of OM visits per 100 children declined from 84 to 64 per 100 children younger than 2 years, 41 to 34 per 100 children between ages 2 and 5 years, and from 59 to 46 per 100 children younger than 5 years.
The study findings were limited by several factors including the use of an ecologic study design, which was chosen to help reduce selection bias, but that did not show evidence of the field effectiveness of the PCV13 vaccine. Another limitation was the potential misclassification of patients with OM given clinician variability in diagnostic criteria, the researchers noted.
“Our results in this study, while not providing direct evidence of causality, nonetheless suggest a significant and positive impact of the PCV13 vaccination program on otitis media for children less than 5 years of age in the U.S., with further reductions in OM visits observed in PCV13 period following a decade of PCV7 use,” Dr. Zhou and associates said.
The investigators are employed by Pfizer, which funded the study.
SOURCE: Zhou X et al. Int J Pediatr Otorhinolaryngol. 2019 Apr. 119:96-102.
The mean number of office visits for otitis media in children younger than 5 years dropped significantly after the introduction of the 13-valent pneumococcal conjugate vaccine, according to findings published in the International Journal of Pediatric Otorhinolaryngology.
Previous studies have shown that more than half of children with otitis media (OM) have serotypes included in the PCV7 vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F), wrote Xiaofeng Zhou, MD, of Pfizer, New York, and colleagues.
To assess the impact of PCV13, with the additional serotypes 1, 3, 5, 6A, 7F, and 19A, the researchers analyzed data from the U.S. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for three time periods: pre-PCV7 (1997-1999), after the introduction of PCV7 (2001-2009), and after the introduction of PCV13 (2011-2013).
Between the pre-PCV7 and PCV13 time periods, the researchers found significant reductions in the mean rates of OM visits of 48% and 41% among children younger than 2 years and younger than 5 years, respectively; reductions were 24% and 22%, respectively, when comparing PCV13 and PCV7. Ambulatory care visits for skin rash and trauma were not significantly different among the study periods.
Comparing the PCV7 and PCV13 time periods, the mean number of OM visits per 100 children declined from 84 to 64 per 100 children younger than 2 years, 41 to 34 per 100 children between ages 2 and 5 years, and from 59 to 46 per 100 children younger than 5 years.
The study findings were limited by several factors including the use of an ecologic study design, which was chosen to help reduce selection bias, but that did not show evidence of the field effectiveness of the PCV13 vaccine. Another limitation was the potential misclassification of patients with OM given clinician variability in diagnostic criteria, the researchers noted.
“Our results in this study, while not providing direct evidence of causality, nonetheless suggest a significant and positive impact of the PCV13 vaccination program on otitis media for children less than 5 years of age in the U.S., with further reductions in OM visits observed in PCV13 period following a decade of PCV7 use,” Dr. Zhou and associates said.
The investigators are employed by Pfizer, which funded the study.
SOURCE: Zhou X et al. Int J Pediatr Otorhinolaryngol. 2019 Apr. 119:96-102.
The mean number of office visits for otitis media in children younger than 5 years dropped significantly after the introduction of the 13-valent pneumococcal conjugate vaccine, according to findings published in the International Journal of Pediatric Otorhinolaryngology.
Previous studies have shown that more than half of children with otitis media (OM) have serotypes included in the PCV7 vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F), wrote Xiaofeng Zhou, MD, of Pfizer, New York, and colleagues.
To assess the impact of PCV13, with the additional serotypes 1, 3, 5, 6A, 7F, and 19A, the researchers analyzed data from the U.S. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for three time periods: pre-PCV7 (1997-1999), after the introduction of PCV7 (2001-2009), and after the introduction of PCV13 (2011-2013).
Between the pre-PCV7 and PCV13 time periods, the researchers found significant reductions in the mean rates of OM visits of 48% and 41% among children younger than 2 years and younger than 5 years, respectively; reductions were 24% and 22%, respectively, when comparing PCV13 and PCV7. Ambulatory care visits for skin rash and trauma were not significantly different among the study periods.
Comparing the PCV7 and PCV13 time periods, the mean number of OM visits per 100 children declined from 84 to 64 per 100 children younger than 2 years, 41 to 34 per 100 children between ages 2 and 5 years, and from 59 to 46 per 100 children younger than 5 years.
The study findings were limited by several factors including the use of an ecologic study design, which was chosen to help reduce selection bias, but that did not show evidence of the field effectiveness of the PCV13 vaccine. Another limitation was the potential misclassification of patients with OM given clinician variability in diagnostic criteria, the researchers noted.
“Our results in this study, while not providing direct evidence of causality, nonetheless suggest a significant and positive impact of the PCV13 vaccination program on otitis media for children less than 5 years of age in the U.S., with further reductions in OM visits observed in PCV13 period following a decade of PCV7 use,” Dr. Zhou and associates said.
The investigators are employed by Pfizer, which funded the study.
SOURCE: Zhou X et al. Int J Pediatr Otorhinolaryngol. 2019 Apr. 119:96-102.
FROM THE INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
Coalescing Papules on Bilateral Mastectomy Scars
The Diagnosis: Scar Sarcoidosis
Although scars on both breasts were involved, the decision was made to biopsy the right breast because the patient reported more pain on the left breast. Biopsy showed noncaseating granulomas consistent with scar sarcoidosis (Figure). Additional screening tests were performed to evaluate for any systemic involvement of sarcoidosis, including a complete blood cell count, comprehensive metabolic panel, angiotensin-converting enzyme level, tuberculosis serology screening, electrocardiogram, chest radiograph, and pulmonary function tests. She also was referred to rheumatology and ophthalmology for consultation. The results of all screenings were within reference range, and no sign of systemic sarcoidosis was found. She was treated with hydrocortisone ointment 2.5% for several weeks without notable improvement. She elected not to pursue any additional treatment and to monitor the symptoms with close follow-up only. One year after the initial visit, the skin lesions spontaneously and notably improved.
Sarcoidosis is a systemic granulomatous disorder of unknown etiology that most commonly affects the lungs. It also can involve the lymph nodes, liver, spleen, bones, gastrointestinal tract, eyes, and skin. Cutaneous sarcoidosis has been documented in the literature since the late 1800s and occurs in up to one-third of sarcoid patients.1 Cutaneous lesions developing within a preexisting scar is a well-known variant, occurring in 29% of patients with cutaneous sarcoidosis in one clinical study (N=818).2 There have been many reports describing scar sarcoidosis, with its development at prior sites of surgery, trauma, acne, or venipuncture.3 Other case reports have described variants of scar sarcoidosis developing at sites of hyaluronic acid injection, laser surgery, ritual scarification, tattoos, and desensitization injections, as well as prior herpes zoster infections.4-9
Cutaneous sarcoidosis has a wide range of clinical presentations. Lesions can be described as specific or nonspecific. Specific lesions demonstrate the typical sarcoid granuloma on histology and more often are seen in chronic disease, while nonspecific lesions more often are seen in acute disease.3,10 Scar sarcoidosis is an example of a specific lesion in which old scars become infiltrated with noncaseating granulomas. The granulomas typically are in the superficial dermis but may involve the full thickness of the dermis, extending into the subcutaneous tissue.11 The cause of granulomas developing in scars is unknown. Prior contamination of the scar with foreign material, possibly at the time of the trauma, is a possible underlying cause.12
Typical scar sarcoidosis presents as swollen, erythematous, indurated lesions with a purple-red hue that may become brown.3,12 Tenderness or pruritus also may be present.13 Interestingly, our patient's scar sarcoidosis presented with a yellow hue at both mastectomy sites.
Diagnosing scar sarcoidosis can be challenging. Patients are diagnosed with sarcoidosis when a compatible clinical or radiologic picture is present along with histologic evidence of a noncaseating granuloma and other potential causes are excluded.11 The differential includes an infectious etiology, other types of granulomatous dermatitis, hypertrophic scar, keloid, or foreign body granuloma.
Scar sarcoidosis can be isolated in occurrence. It also can precede or occur concomitantly or during a relapse of systemic sarcoidosis.10 Most commonly, patients with scar sarcoidosis also have systemic manifestations of sarcoidosis, and changing scars may be an indicator of disease exacerbation or relapse.10 For patients who only demonstrate specific skin lesions of cutaneous sarcoidosis, approximately 30% develop systemic involvement later in life.3 For this reason, close monitoring and regular follow-up are necessary.
Treatment of scar sarcoidosis is dependent on the extent of the disease and presence of systemic sarcoidosis. Topical and systemic corticosteroids, hydroxychloroquine, chloroquine phosphate, and methotrexate all have been shown to be helpful in treating cutaneous sarcoidosis.3 For scar sarcoidosis that is limited to only the scar site, as seen in our case, monitoring and close follow-up is acceptable. Topical steroids can be prescribed for symptomatic relief. Scar sarcoidosis can resolve slowly and spontaneously over time.10 Our patient notably improved 1 year after the initial presentation without treatment.
Scar sarcoidosis is a well-documented variant of cutaneous sarcoidosis that can have important implications for diagnosing systemic sarcoidosis. Although there are typical lesions that represent scar sarcoidosis, it is important to have a high degree of suspicion with any changing scar. Once diagnosed through biopsy, a thorough investigation for systemic signs of sarcoidosis needs to be performed to guide treatment.
- Bolognia JL, Jorizzo JL, Shaffer JV, eds. Dermatology. 3rd ed. Vol 2. Philadelphia, PA: Elsevier/Saunders; 2012.
- Neville E, Walker AN, James DG. Prognostic factors predicting the outcome of sarcoidosis: an analysis of 818 patients. Q J Med. 1983;52:525-533.
- Mañá J, Marcoval J, Graells J, et al. Cutaneous involvement in sarcoidosis: relationship to systemic disease. Arch Dermatol. 1997;133:882-888.
- Dal Sacco D, Cozzani E, Parodi A, et al. Scar sarcoidosis after hyaluronic acid injection. Int J Dermatol. 2005;44:411-412.
- Kormeili T, Neel V, Moy RL. Cutaneous sarcoidosis at sites of previous laser surgery. Cutis. 2004;73:53-55.
- Nayar M. Sarcoidosis on ritual scarification. Int J Dermatol. 1993;32:116-118.
- James WD, Elston DM, Berger TG, et al. Andrews' Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, PA: Elsevier/Saunders; 2011.
- Healsmith MF, Hutchinson PE. The development of scar sarcoidosis at the site of desensitization injections. Clin Exp Dermatol. 1992;17:369-370.
- Singal A, Vij A, Pandhi D. Post herpes-zoster scar sarcoidosis with pulmonary involvement. Indian Dermatol Online J. 2014;5:77-79.
- Chudomirova K, Velichkova L, Anavi B, et al. Recurrent sarcoidosis in skin scars accompanying systemic sarcoidosis. J Eur Acad Dermatol Venereol. 2003;17:360-361.
- Selim A, Ehrsam E, Atassi MB, et al. Scar sarcoidosis: a case report and brief review. Cutis. 2006;78:418-422.
- Singal A, Thami GP, Goraya JS. Scar sarcoidosis in childhood: case report and review of the literature. Clin Exp Dermatol. 2005;30:244-246.
- Marchell RM, Judson MA. Chronic cutaneous lesions of sarcoidosis. Clin Dermatol. 2007;25:295-302.
The Diagnosis: Scar Sarcoidosis
Although scars on both breasts were involved, the decision was made to biopsy the right breast because the patient reported more pain on the left breast. Biopsy showed noncaseating granulomas consistent with scar sarcoidosis (Figure). Additional screening tests were performed to evaluate for any systemic involvement of sarcoidosis, including a complete blood cell count, comprehensive metabolic panel, angiotensin-converting enzyme level, tuberculosis serology screening, electrocardiogram, chest radiograph, and pulmonary function tests. She also was referred to rheumatology and ophthalmology for consultation. The results of all screenings were within reference range, and no sign of systemic sarcoidosis was found. She was treated with hydrocortisone ointment 2.5% for several weeks without notable improvement. She elected not to pursue any additional treatment and to monitor the symptoms with close follow-up only. One year after the initial visit, the skin lesions spontaneously and notably improved.
Sarcoidosis is a systemic granulomatous disorder of unknown etiology that most commonly affects the lungs. It also can involve the lymph nodes, liver, spleen, bones, gastrointestinal tract, eyes, and skin. Cutaneous sarcoidosis has been documented in the literature since the late 1800s and occurs in up to one-third of sarcoid patients.1 Cutaneous lesions developing within a preexisting scar is a well-known variant, occurring in 29% of patients with cutaneous sarcoidosis in one clinical study (N=818).2 There have been many reports describing scar sarcoidosis, with its development at prior sites of surgery, trauma, acne, or venipuncture.3 Other case reports have described variants of scar sarcoidosis developing at sites of hyaluronic acid injection, laser surgery, ritual scarification, tattoos, and desensitization injections, as well as prior herpes zoster infections.4-9
Cutaneous sarcoidosis has a wide range of clinical presentations. Lesions can be described as specific or nonspecific. Specific lesions demonstrate the typical sarcoid granuloma on histology and more often are seen in chronic disease, while nonspecific lesions more often are seen in acute disease.3,10 Scar sarcoidosis is an example of a specific lesion in which old scars become infiltrated with noncaseating granulomas. The granulomas typically are in the superficial dermis but may involve the full thickness of the dermis, extending into the subcutaneous tissue.11 The cause of granulomas developing in scars is unknown. Prior contamination of the scar with foreign material, possibly at the time of the trauma, is a possible underlying cause.12
Typical scar sarcoidosis presents as swollen, erythematous, indurated lesions with a purple-red hue that may become brown.3,12 Tenderness or pruritus also may be present.13 Interestingly, our patient's scar sarcoidosis presented with a yellow hue at both mastectomy sites.
Diagnosing scar sarcoidosis can be challenging. Patients are diagnosed with sarcoidosis when a compatible clinical or radiologic picture is present along with histologic evidence of a noncaseating granuloma and other potential causes are excluded.11 The differential includes an infectious etiology, other types of granulomatous dermatitis, hypertrophic scar, keloid, or foreign body granuloma.
Scar sarcoidosis can be isolated in occurrence. It also can precede or occur concomitantly or during a relapse of systemic sarcoidosis.10 Most commonly, patients with scar sarcoidosis also have systemic manifestations of sarcoidosis, and changing scars may be an indicator of disease exacerbation or relapse.10 For patients who only demonstrate specific skin lesions of cutaneous sarcoidosis, approximately 30% develop systemic involvement later in life.3 For this reason, close monitoring and regular follow-up are necessary.
Treatment of scar sarcoidosis is dependent on the extent of the disease and presence of systemic sarcoidosis. Topical and systemic corticosteroids, hydroxychloroquine, chloroquine phosphate, and methotrexate all have been shown to be helpful in treating cutaneous sarcoidosis.3 For scar sarcoidosis that is limited to only the scar site, as seen in our case, monitoring and close follow-up is acceptable. Topical steroids can be prescribed for symptomatic relief. Scar sarcoidosis can resolve slowly and spontaneously over time.10 Our patient notably improved 1 year after the initial presentation without treatment.
Scar sarcoidosis is a well-documented variant of cutaneous sarcoidosis that can have important implications for diagnosing systemic sarcoidosis. Although there are typical lesions that represent scar sarcoidosis, it is important to have a high degree of suspicion with any changing scar. Once diagnosed through biopsy, a thorough investigation for systemic signs of sarcoidosis needs to be performed to guide treatment.
The Diagnosis: Scar Sarcoidosis
Although scars on both breasts were involved, the decision was made to biopsy the right breast because the patient reported more pain on the left breast. Biopsy showed noncaseating granulomas consistent with scar sarcoidosis (Figure). Additional screening tests were performed to evaluate for any systemic involvement of sarcoidosis, including a complete blood cell count, comprehensive metabolic panel, angiotensin-converting enzyme level, tuberculosis serology screening, electrocardiogram, chest radiograph, and pulmonary function tests. She also was referred to rheumatology and ophthalmology for consultation. The results of all screenings were within reference range, and no sign of systemic sarcoidosis was found. She was treated with hydrocortisone ointment 2.5% for several weeks without notable improvement. She elected not to pursue any additional treatment and to monitor the symptoms with close follow-up only. One year after the initial visit, the skin lesions spontaneously and notably improved.
Sarcoidosis is a systemic granulomatous disorder of unknown etiology that most commonly affects the lungs. It also can involve the lymph nodes, liver, spleen, bones, gastrointestinal tract, eyes, and skin. Cutaneous sarcoidosis has been documented in the literature since the late 1800s and occurs in up to one-third of sarcoid patients.1 Cutaneous lesions developing within a preexisting scar is a well-known variant, occurring in 29% of patients with cutaneous sarcoidosis in one clinical study (N=818).2 There have been many reports describing scar sarcoidosis, with its development at prior sites of surgery, trauma, acne, or venipuncture.3 Other case reports have described variants of scar sarcoidosis developing at sites of hyaluronic acid injection, laser surgery, ritual scarification, tattoos, and desensitization injections, as well as prior herpes zoster infections.4-9
Cutaneous sarcoidosis has a wide range of clinical presentations. Lesions can be described as specific or nonspecific. Specific lesions demonstrate the typical sarcoid granuloma on histology and more often are seen in chronic disease, while nonspecific lesions more often are seen in acute disease.3,10 Scar sarcoidosis is an example of a specific lesion in which old scars become infiltrated with noncaseating granulomas. The granulomas typically are in the superficial dermis but may involve the full thickness of the dermis, extending into the subcutaneous tissue.11 The cause of granulomas developing in scars is unknown. Prior contamination of the scar with foreign material, possibly at the time of the trauma, is a possible underlying cause.12
Typical scar sarcoidosis presents as swollen, erythematous, indurated lesions with a purple-red hue that may become brown.3,12 Tenderness or pruritus also may be present.13 Interestingly, our patient's scar sarcoidosis presented with a yellow hue at both mastectomy sites.
Diagnosing scar sarcoidosis can be challenging. Patients are diagnosed with sarcoidosis when a compatible clinical or radiologic picture is present along with histologic evidence of a noncaseating granuloma and other potential causes are excluded.11 The differential includes an infectious etiology, other types of granulomatous dermatitis, hypertrophic scar, keloid, or foreign body granuloma.
Scar sarcoidosis can be isolated in occurrence. It also can precede or occur concomitantly or during a relapse of systemic sarcoidosis.10 Most commonly, patients with scar sarcoidosis also have systemic manifestations of sarcoidosis, and changing scars may be an indicator of disease exacerbation or relapse.10 For patients who only demonstrate specific skin lesions of cutaneous sarcoidosis, approximately 30% develop systemic involvement later in life.3 For this reason, close monitoring and regular follow-up are necessary.
Treatment of scar sarcoidosis is dependent on the extent of the disease and presence of systemic sarcoidosis. Topical and systemic corticosteroids, hydroxychloroquine, chloroquine phosphate, and methotrexate all have been shown to be helpful in treating cutaneous sarcoidosis.3 For scar sarcoidosis that is limited to only the scar site, as seen in our case, monitoring and close follow-up is acceptable. Topical steroids can be prescribed for symptomatic relief. Scar sarcoidosis can resolve slowly and spontaneously over time.10 Our patient notably improved 1 year after the initial presentation without treatment.
Scar sarcoidosis is a well-documented variant of cutaneous sarcoidosis that can have important implications for diagnosing systemic sarcoidosis. Although there are typical lesions that represent scar sarcoidosis, it is important to have a high degree of suspicion with any changing scar. Once diagnosed through biopsy, a thorough investigation for systemic signs of sarcoidosis needs to be performed to guide treatment.
- Bolognia JL, Jorizzo JL, Shaffer JV, eds. Dermatology. 3rd ed. Vol 2. Philadelphia, PA: Elsevier/Saunders; 2012.
- Neville E, Walker AN, James DG. Prognostic factors predicting the outcome of sarcoidosis: an analysis of 818 patients. Q J Med. 1983;52:525-533.
- Mañá J, Marcoval J, Graells J, et al. Cutaneous involvement in sarcoidosis: relationship to systemic disease. Arch Dermatol. 1997;133:882-888.
- Dal Sacco D, Cozzani E, Parodi A, et al. Scar sarcoidosis after hyaluronic acid injection. Int J Dermatol. 2005;44:411-412.
- Kormeili T, Neel V, Moy RL. Cutaneous sarcoidosis at sites of previous laser surgery. Cutis. 2004;73:53-55.
- Nayar M. Sarcoidosis on ritual scarification. Int J Dermatol. 1993;32:116-118.
- James WD, Elston DM, Berger TG, et al. Andrews' Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, PA: Elsevier/Saunders; 2011.
- Healsmith MF, Hutchinson PE. The development of scar sarcoidosis at the site of desensitization injections. Clin Exp Dermatol. 1992;17:369-370.
- Singal A, Vij A, Pandhi D. Post herpes-zoster scar sarcoidosis with pulmonary involvement. Indian Dermatol Online J. 2014;5:77-79.
- Chudomirova K, Velichkova L, Anavi B, et al. Recurrent sarcoidosis in skin scars accompanying systemic sarcoidosis. J Eur Acad Dermatol Venereol. 2003;17:360-361.
- Selim A, Ehrsam E, Atassi MB, et al. Scar sarcoidosis: a case report and brief review. Cutis. 2006;78:418-422.
- Singal A, Thami GP, Goraya JS. Scar sarcoidosis in childhood: case report and review of the literature. Clin Exp Dermatol. 2005;30:244-246.
- Marchell RM, Judson MA. Chronic cutaneous lesions of sarcoidosis. Clin Dermatol. 2007;25:295-302.
- Bolognia JL, Jorizzo JL, Shaffer JV, eds. Dermatology. 3rd ed. Vol 2. Philadelphia, PA: Elsevier/Saunders; 2012.
- Neville E, Walker AN, James DG. Prognostic factors predicting the outcome of sarcoidosis: an analysis of 818 patients. Q J Med. 1983;52:525-533.
- Mañá J, Marcoval J, Graells J, et al. Cutaneous involvement in sarcoidosis: relationship to systemic disease. Arch Dermatol. 1997;133:882-888.
- Dal Sacco D, Cozzani E, Parodi A, et al. Scar sarcoidosis after hyaluronic acid injection. Int J Dermatol. 2005;44:411-412.
- Kormeili T, Neel V, Moy RL. Cutaneous sarcoidosis at sites of previous laser surgery. Cutis. 2004;73:53-55.
- Nayar M. Sarcoidosis on ritual scarification. Int J Dermatol. 1993;32:116-118.
- James WD, Elston DM, Berger TG, et al. Andrews' Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, PA: Elsevier/Saunders; 2011.
- Healsmith MF, Hutchinson PE. The development of scar sarcoidosis at the site of desensitization injections. Clin Exp Dermatol. 1992;17:369-370.
- Singal A, Vij A, Pandhi D. Post herpes-zoster scar sarcoidosis with pulmonary involvement. Indian Dermatol Online J. 2014;5:77-79.
- Chudomirova K, Velichkova L, Anavi B, et al. Recurrent sarcoidosis in skin scars accompanying systemic sarcoidosis. J Eur Acad Dermatol Venereol. 2003;17:360-361.
- Selim A, Ehrsam E, Atassi MB, et al. Scar sarcoidosis: a case report and brief review. Cutis. 2006;78:418-422.
- Singal A, Thami GP, Goraya JS. Scar sarcoidosis in childhood: case report and review of the literature. Clin Exp Dermatol. 2005;30:244-246.
- Marchell RM, Judson MA. Chronic cutaneous lesions of sarcoidosis. Clin Dermatol. 2007;25:295-302.
A 57-year-old woman with triple-negative ductal breast cancer presented with a mildly pruritic rash on bilateral mastectomy scars of 3 to 4 months' duration. More than a year prior to presentation, she was diagnosed with breast cancer and treated with a bilateral mastectomy and chemotherapy. On physical examination, faintly yellow, slightly indurated, coalescing papules with red rims were present on the bilateral mastectomy scars, with the scar on the left side appearing worse than the right. She previously had not sought treatment.
Patients describe significant impact of epilepsy on their lives
PHILADELPHIA – said Jacqueline French, MD, a professor at the Comprehensive Epilepsy Center at New York University.
“This underscores the need to consider these experiences, and potentially the stage of disease, when developing patient-reported outcome measures,” she said at the annual meeting of the American Academy of Neurology.
To describe the patient’s experience of living with epilepsy, including the occurrence of disease-related signs and symptoms and impact on daily life at different disease stages, Dr. French conducted qualitative, semistructured interviews with adults with focal epilepsy at the following stages: early (1 year or less since diagnosis), middle (1-5 years since diagnosis), and late (more than 5 years since diagnosis). The patients had varying seizure frequency and treatment experiences. They were asked to describe the symptoms and functional impact they had experienced related to epilepsy, and then to rate the degree to which each symptom and impact “bothered” them, using a disturbance rating scale from 0 (not at all) to 10 (extremely).
A total of 62 patients who were aged 18-60 years (mean age, 37 years; 73% female) were interviewed. In all, 19 of the patients had early-stage disease, 17 had middle-stage, and 26 had late-stage disease. Symptoms reported with the highest frequency and highest average disturbance (AD) ratings across all cohorts included twitching/tremors (80% of patients; AD, 5.3), confusion (78%; AD, 7.8), difficulty talking (75%; AD, 8.1), impaired/loss of consciousness (70%; AD, 6.8), stiffening (65%; AD, 5.4), déjà vu (62%; AD, 5.1), difficulty remembering (60%; AD, 8.5), and dizziness/light-headedness (58%; AD, 6.4).
The high-frequency/high-disturbance daily impact of epilepsy included the inability to drive (74%; AD, 7.1), limited ability to work and/or go to school (61%; AD, 6.7), limitations on leisure and social activities (58%; AD, 6.3), and memory loss (47%; AD, 8.4).
Dr French noted that, although disease experiences were similar among the cohorts, some heterogeneity across patient subgroups was observed.
Eisai sponsored the study.
PHILADELPHIA – said Jacqueline French, MD, a professor at the Comprehensive Epilepsy Center at New York University.
“This underscores the need to consider these experiences, and potentially the stage of disease, when developing patient-reported outcome measures,” she said at the annual meeting of the American Academy of Neurology.
To describe the patient’s experience of living with epilepsy, including the occurrence of disease-related signs and symptoms and impact on daily life at different disease stages, Dr. French conducted qualitative, semistructured interviews with adults with focal epilepsy at the following stages: early (1 year or less since diagnosis), middle (1-5 years since diagnosis), and late (more than 5 years since diagnosis). The patients had varying seizure frequency and treatment experiences. They were asked to describe the symptoms and functional impact they had experienced related to epilepsy, and then to rate the degree to which each symptom and impact “bothered” them, using a disturbance rating scale from 0 (not at all) to 10 (extremely).
A total of 62 patients who were aged 18-60 years (mean age, 37 years; 73% female) were interviewed. In all, 19 of the patients had early-stage disease, 17 had middle-stage, and 26 had late-stage disease. Symptoms reported with the highest frequency and highest average disturbance (AD) ratings across all cohorts included twitching/tremors (80% of patients; AD, 5.3), confusion (78%; AD, 7.8), difficulty talking (75%; AD, 8.1), impaired/loss of consciousness (70%; AD, 6.8), stiffening (65%; AD, 5.4), déjà vu (62%; AD, 5.1), difficulty remembering (60%; AD, 8.5), and dizziness/light-headedness (58%; AD, 6.4).
The high-frequency/high-disturbance daily impact of epilepsy included the inability to drive (74%; AD, 7.1), limited ability to work and/or go to school (61%; AD, 6.7), limitations on leisure and social activities (58%; AD, 6.3), and memory loss (47%; AD, 8.4).
Dr French noted that, although disease experiences were similar among the cohorts, some heterogeneity across patient subgroups was observed.
Eisai sponsored the study.
PHILADELPHIA – said Jacqueline French, MD, a professor at the Comprehensive Epilepsy Center at New York University.
“This underscores the need to consider these experiences, and potentially the stage of disease, when developing patient-reported outcome measures,” she said at the annual meeting of the American Academy of Neurology.
To describe the patient’s experience of living with epilepsy, including the occurrence of disease-related signs and symptoms and impact on daily life at different disease stages, Dr. French conducted qualitative, semistructured interviews with adults with focal epilepsy at the following stages: early (1 year or less since diagnosis), middle (1-5 years since diagnosis), and late (more than 5 years since diagnosis). The patients had varying seizure frequency and treatment experiences. They were asked to describe the symptoms and functional impact they had experienced related to epilepsy, and then to rate the degree to which each symptom and impact “bothered” them, using a disturbance rating scale from 0 (not at all) to 10 (extremely).
A total of 62 patients who were aged 18-60 years (mean age, 37 years; 73% female) were interviewed. In all, 19 of the patients had early-stage disease, 17 had middle-stage, and 26 had late-stage disease. Symptoms reported with the highest frequency and highest average disturbance (AD) ratings across all cohorts included twitching/tremors (80% of patients; AD, 5.3), confusion (78%; AD, 7.8), difficulty talking (75%; AD, 8.1), impaired/loss of consciousness (70%; AD, 6.8), stiffening (65%; AD, 5.4), déjà vu (62%; AD, 5.1), difficulty remembering (60%; AD, 8.5), and dizziness/light-headedness (58%; AD, 6.4).
The high-frequency/high-disturbance daily impact of epilepsy included the inability to drive (74%; AD, 7.1), limited ability to work and/or go to school (61%; AD, 6.7), limitations on leisure and social activities (58%; AD, 6.3), and memory loss (47%; AD, 8.4).
Dr French noted that, although disease experiences were similar among the cohorts, some heterogeneity across patient subgroups was observed.
Eisai sponsored the study.
REPORTING FROM AAN 2019
Key clinical point: Adults with focal epilepsy report a range of high-disturbance symptoms and impacts on daily life.
Major finding: The high-frequency/high-disturbance daily impact of epilepsy included the inability to drive (reported by 74% of respondents), limited ability to work and/or go to school (61%), limitations on leisure and social activities (58%), and memory loss (47%).
Study details: Qualitative, semistructured interviews with 62 adults with focal epilepsy at different stages of illness: early, middle, and late.
Disclosures: Eisai sponsored the study.
Physical activity slows cognitive decline in patients with Parkinson’s disease
PHILADELPHIA – according to Sneha Mantri, MD, of Duke University in Durham, N.C., and colleagues, who presented the results of their study at the annual meeting of the American Academy of Neurology.
Physical activity is an important component of the management of Parkinson’s disease and is shown to mitigate cognitive decline among patients with moderate disease, said Dr. Mantri and colleagues. “Exercise levels in de novo and early disease may influence risk of future cognitive decline; early disease also presents an opportunity for early intervention and possible disease modification,” Dr. Mantri said.
Physical activity levels in early disease are known to be low, but the effects of activity on cognition are currently unclear. To assess the relationship between physical activity and cognition, Dr. Mantri and colleagues examined patients with Parkinson’s disease who were enrolled in the prospective Parkinson’s Progression Markers Initiative (PPMI) cohort. At annual study visits, participants completed the Physical Activity Scale for the Elderly (PASE), a validated self-reported questionnaire assessing household, leisure, and work activities over the previous 7 days. The researchers used a linear mixed-effects model to compare rates of change in the Montreal Cognitive Assessment (MoCA) according to PASE scores; covariates included age, sex, Unified Parkinson’s Disease Rating Scale (UPDRS) part III score, and baseline MoCA.
A total of 379 patients completed at least one PASE questionnaire over the course of the study. PASE scores in this cohort have been previously described (Mantri S et al. J Park Dis. 2018;8[1]:107-11). Although overall rates of cognitive decline are known to be modest in this early cohort, PASE over time has a significant effect on MoCA during follow-up (P = 0.02) which suggest that higher levels of activity throughout disease are associated with better cognitive performance.
Dr. Mantri had nothing to disclose. Among her coauthors, Dr. Tropea received personal compensation from Genzyme and Medtronics and research support from Sanofi. Dr. Morley had nothing to disclose.
SOURCE: Mantri S et al. AAN 2019, Abstract P2.8-021.
PHILADELPHIA – according to Sneha Mantri, MD, of Duke University in Durham, N.C., and colleagues, who presented the results of their study at the annual meeting of the American Academy of Neurology.
Physical activity is an important component of the management of Parkinson’s disease and is shown to mitigate cognitive decline among patients with moderate disease, said Dr. Mantri and colleagues. “Exercise levels in de novo and early disease may influence risk of future cognitive decline; early disease also presents an opportunity for early intervention and possible disease modification,” Dr. Mantri said.
Physical activity levels in early disease are known to be low, but the effects of activity on cognition are currently unclear. To assess the relationship between physical activity and cognition, Dr. Mantri and colleagues examined patients with Parkinson’s disease who were enrolled in the prospective Parkinson’s Progression Markers Initiative (PPMI) cohort. At annual study visits, participants completed the Physical Activity Scale for the Elderly (PASE), a validated self-reported questionnaire assessing household, leisure, and work activities over the previous 7 days. The researchers used a linear mixed-effects model to compare rates of change in the Montreal Cognitive Assessment (MoCA) according to PASE scores; covariates included age, sex, Unified Parkinson’s Disease Rating Scale (UPDRS) part III score, and baseline MoCA.
A total of 379 patients completed at least one PASE questionnaire over the course of the study. PASE scores in this cohort have been previously described (Mantri S et al. J Park Dis. 2018;8[1]:107-11). Although overall rates of cognitive decline are known to be modest in this early cohort, PASE over time has a significant effect on MoCA during follow-up (P = 0.02) which suggest that higher levels of activity throughout disease are associated with better cognitive performance.
Dr. Mantri had nothing to disclose. Among her coauthors, Dr. Tropea received personal compensation from Genzyme and Medtronics and research support from Sanofi. Dr. Morley had nothing to disclose.
SOURCE: Mantri S et al. AAN 2019, Abstract P2.8-021.
PHILADELPHIA – according to Sneha Mantri, MD, of Duke University in Durham, N.C., and colleagues, who presented the results of their study at the annual meeting of the American Academy of Neurology.
Physical activity is an important component of the management of Parkinson’s disease and is shown to mitigate cognitive decline among patients with moderate disease, said Dr. Mantri and colleagues. “Exercise levels in de novo and early disease may influence risk of future cognitive decline; early disease also presents an opportunity for early intervention and possible disease modification,” Dr. Mantri said.
Physical activity levels in early disease are known to be low, but the effects of activity on cognition are currently unclear. To assess the relationship between physical activity and cognition, Dr. Mantri and colleagues examined patients with Parkinson’s disease who were enrolled in the prospective Parkinson’s Progression Markers Initiative (PPMI) cohort. At annual study visits, participants completed the Physical Activity Scale for the Elderly (PASE), a validated self-reported questionnaire assessing household, leisure, and work activities over the previous 7 days. The researchers used a linear mixed-effects model to compare rates of change in the Montreal Cognitive Assessment (MoCA) according to PASE scores; covariates included age, sex, Unified Parkinson’s Disease Rating Scale (UPDRS) part III score, and baseline MoCA.
A total of 379 patients completed at least one PASE questionnaire over the course of the study. PASE scores in this cohort have been previously described (Mantri S et al. J Park Dis. 2018;8[1]:107-11). Although overall rates of cognitive decline are known to be modest in this early cohort, PASE over time has a significant effect on MoCA during follow-up (P = 0.02) which suggest that higher levels of activity throughout disease are associated with better cognitive performance.
Dr. Mantri had nothing to disclose. Among her coauthors, Dr. Tropea received personal compensation from Genzyme and Medtronics and research support from Sanofi. Dr. Morley had nothing to disclose.
SOURCE: Mantri S et al. AAN 2019, Abstract P2.8-021.
REPORTING FROM AAN 2019
Key clinical point: Physical activity is associated with slower cognitive decline in patients with de novo Parkinson’s disease.
Major finding: Higher scores on the Physical Activity Scale for the Elderly over time had a significant effect on cognitive function.
Study details: A prospective study of 379 patients enrolled in the Parkinson’s Progression Markers Initiative.
Disclosures: Dr. Mantri had no relevant financial disclosures. Among her coauthors, Dr. Tropea received personal compensation from Genzyme and Medtronics and research support from Sanofi. Dr. Morley had nothing to disclose.
Source: Mantri S et al. AAN 2019, Abstract P2.8-021.
