Multifocal Myositis and Elevated CPK associated with the use of Ustekinumab for Hidradenitis Suppurativa

ustekinumab (UST) is a human interleukin (IL)-12/IL-23 monoclonal antibody that has been approved by the Food and Drug Administration (FDA) to treat moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn\u27s disease. Off-label use of UST has shown promising results for hidradenitis suppurativa (HS) in patients that have failed therapy with adalimumab, the only FDA approved treatment for HS

26914 Ustekinumab-induced myositis: A case series

Ustekinumab (UST) is a monoclonal antibody that blocks proinflammatory cytokines IL-12 and IL-23. Off-label use of UST has shown promising results for moderate to severe hidradenitis suppurativa (HS) in patients who have failed to respond to or unable to tolerate adalimumab, the only Food and Drug Administration (FDA) approved treatment for HS. Previously, myositis has not been reported as an adverse effect of UST. We present two patients with poorly controlled HS who experienced new onset myositis shortly after beginning treatment with UST. Abnormal electromyography (EMG) demonstrated myopathic appearing motor units in the bilateral biceps in patient 1. Creatinine kinase was elevated greater than three times normal in patient 1, and normal in patient 2. Patient 2 had marked reduction in ambulation requiring use of a cane. Both patients experienced a sequela of symptoms such as generalized muscle weakness, muscle swelling with warmth to the areas, and myalgias with improvement of symptoms shortly after discontinuation of UST. A proposed mechanism may be related to the overexpression of IL-12 and IL-23 secondary to UST’s receptor blockade. IL-12 can initiate IL-32 production, a cytokine that has been shown to be overexpressed in HS.3 Il-32 induces the production of IFNy and IL-17, byproducts of TH1 and TH17 helper cells which have been implicated in autoimmune myositis. As the use of UST increases in HS patients, it is important for clinicians to consider the potential risk of drug-induced myositis. Long-term clinical surveillance is needed to evaluate the significance and frequency of this occurrence

28522 The impact of the SARS-CoV-2 pandemic on phototherapy utilization

Phototherapy is a mainstay of treatment for several dermatologic conditions. Patients often require multiple treatments per week for several weeks to months to achieve treatment efficacy. The SARS-CoV-2 global pandemic caused many dermatology clinics to close completely or significantly reduce patient volumes, which may have limited patient access to this beneficial treatment. This retrospective study examines the pandemic’s impact on phototherapy treatment rates and reimbursement at one major tertiary care center and five locations of a private dermatology clinic in Southeast Michigan. Phototherapy CPT reimbursement data from March 1-June 30, 2020 was compared with the same timeframe in 2019. Units of phototherapy performed decreased by an average of 84%, and there was an average decrease of 43% in the number of unique patients receiving treatments. Reimbursement for phototherapy decreased by an average of 83%. The drastic decline in phototherapy reimbursement is a reflection of the pandemic’s financial impact and likely correlates to a larger scale of revenue loss in dermatology practices. Adequate phototherapy treatment was also likely delayed for many patients. As the pandemic continues, implementation of home phototherapy treatments may be necessary for patients to receive proper treatment and to minimize the impact of loss of revenue due to limited in-office phototherapy. Precautions will need to be taken to guarantee the safety of patients and the care team for patients to receive optimal in-office phototherapy treatment. The pandemic’s impact on medical dermatology finances could potentially destabilize access to patients who need this safe and effective treatment

26843 Carbon dioxide laser excision for hidradenitis suppurativa patients—Healing, complications, and recurrence in patients with diabetes mellitus and history of smoking

Introduction: Hidradenitis suppurativa (HS) is often refractory to medical and surgical interventions. Carbon dioxide (CO2) laser excision has demonstrated promising results for HS treatment. Objective: We characterized the efficacy and safety of CO2 laser excision for HS in smokers and diabetics. Methods: On initial data pull, 72 patients were identified. This number was reduced to 38 patients by including HS patients with all data points at Henry Ford Hospital who underwent CO2 laser excision between August 2014 to May 2017. Data were obtained from medical charts including healing and recurrence rates, complications, smoking status, and history of diabetes mellitus. Results: The average age of our cohort was 37.5 years and mean BMI was 34.9. In total, 3 patients had recurrence at a mean of 6 months following the procedure. Postoperative complications included: infection (n = 2), contracture (n = 2), dehiscence (n = 2), and paresthesia (n = 1). Patients with dehiscence were not smokers or diabetics. Twelve patients were smokers, and 26 patients were nonsmokers. The mean healing time in both smokers and nonsmokers was 6 months. Nine patients had a history of diabetes mellitus (DM), and 29 patients were not diabetic. The mean healing time was not significantly prolonged in diabetics compared to nondiabetics and was 7.3 months and 5.4 months, respectively. Conclusion: Both smokers and nonsmokers demonstrated similar healing time, recurrence rates, and postoperative complications. Patients with DM had prolonged healing times when compared to those without DM. Our study identifies important characteristics that clinicians should consider when assessing HS patients for CO2 laser excision

Visible Light and the Skin

Visible light (VL, 400-700 nm) was previously regarded as nonsignificant with minimal to no photobiologic effects on the skin. Recent studies have demonstrated that in dark-skinned individuals (skin phototypes IV-VI), VL can induce more intense and longer lasting pigmentation compared to ultraviolet A1 (UVA1, 340-400 nm). Additionally, long wavelength UVA1 (370-400 nm) has been shown to potentiate these effects of VL. The combination of VL and UVA1 (VL + UVA1, 370-700 nm) was also able to induce erythema in light-skinned individuals (skin phototypes I-III), which is a novel finding since the erythemogenic spectrum of sunlight has primarily been attributed to ultraviolet B (UVB, 290-320 nm) and short wavelength UVA2 (320-340 nm) only. Although biologic effects of VL + UVA1 have been established, there are no guidelines in any country to test for photoprotection against this waveband. This invited perspective aims to present the evolution of knowledge of photobiologic effects of VL, associated phototesting methodologies, and current position on VL photoprotection

26905 The effect of Polypodium leucotomos extract (Fernblock) on visible light and UV-induced photoaging

Traditional sunscreens containing organic ultraviolet (UV) filters have increasingly been scrutinized for their effects on the environment. As a result there has been an interest in environmentally safe polyphenol compounds as adjuvants which also provide systemic protection against different wavelengths of solar radiation. Fernblock the patented, standardized extract of Polypodium leucotomos, herein referred to as PLE, is an antioxidant widely available as oral supplement for photoprotection. We performed a comprehensive review of the available literature on the effect of PLE on UV and visible light (VL) induced photoaging. PLE increases TGF-β, type I and V collagen and elastin in UV-irradiated fibroblasts, as well as increased elastin and fibrillin 1 expression and decreased MMP-1 expression in VL-irradiated fibroblasts. PLE also decreases UVR-induced TNF-α, NO, iNOS, NF-kB and AP1 in keratinocytes. In murine models PLE increases catalase and glutathione peroxidase activity in the epidermis, inhibits dermal elastosis, decreases skin inflammatory cells and COX-2 levels, and reinforces dermal elastic fibers. In human skin, PLE prevents both VL and UV-induced COX-2 expression and VL-induced MMP-1 expression. Enhanced antioxidative protection of the skin was noted in human skin in vivo after consumption of an antioxidant supplement containing non-Fernblock extract of P leucotomos. PLE may protect against UV- and VL-induced photoaging through regulation of extracellular matrix (ECM) modeling, specifically via TGF-β signaling and MMP transcription factors, and downregulation of inflammation due to its anti-inflammatory and antioxidant properties. Future large-scale studies assessing the photoprotective effects of PLE in humans are warranted

The potential effect of Polypodium leucotomos extract on ultraviolet- and visible light-induced photoaging

Photoaging induced by both ultraviolet and visible light has been shown to lead to increased inflammation and dysregulation of the extracellular matrix. Standardized extract of the Polypodium leucotomos fern, PLE, possesses anti-inflammatory and antioxidant properties, and has been shown to potentially mitigate photoaging through various mechanisms. This comprehensive review presents the data available on the effects of P. leucotomos extract on UV and VL-induced photoaging in vitro as well as in vivo in murine and human models

Effects of visible light on mechanisms of skin photoaging

Human skin is not only affected by ultraviolet radiation but also by visible light wavelengths emitted by sunlight, electronic devices, and light emitting diodes. Similar to the ultraviolet radiation, visible light has been implicated in photoaging. In this review, the effects of blue light, yellow light, red light, and broad visible light are discussed in relation with photoaging. Different visible light wavelengths likely contribute beneficial and deleterious effects on photoaging by way of interaction with specific photoreceptors, ROS production, and other photon-mediated reactions. Further in vivo studies are needed to determine the mechanism and action spectrum of photoaging in humans, as well as optimal photoprotection with coverage against visible light wavelengths