Treatment-resistant ulcerative necrobiosis lipoidica in a diabetic patient responsive to ustekinumab

Necrobiosis lipoidica is a chronic granulomatous disease of unknown etiopathogenesis, which is often difficult to treat. While data from randomized controlled trials for the treatment of necrobiosis lipoidica is lacking, several treatments of varying efficacy for necrobiosis lipoidica have been reported in the scientific literature. We present a case of a 29-year-old female with uncontrolled diabetes and treatment-resistant necrobiosis lipoidica which was responsive to ustekinumab

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

Treatment-resistant ulcerative necrobiosis lipoidica in a diabetic patient responsive to ustekinumab

Necrobiosis lipoidica is a chronic granulomatous disease of unknown etiopathogenesis, which is often difficult to treat. While data from randomized controlled trials for the treatment of necrobiosis lipoidica is lacking, several treatments of varying efficacy for necrobiosis lipoidica have been reported in the scientific literature. We present a case of a 29-year-old female with uncontrolled diabetes and treatment-resistant necrobiosis lipoidica which was responsive to ustekinumab

A review of next generation sequencing technologies used in the evaluation of the skin microbiome: what a time to be alive

The role of the microbiome in healthy and disease states of the human body is progressively being found to extend beyond the gastrointestinal tract and into other organ systems such as the skin. Researching the microbiome thus has become paramount to understanding additional physiological and pathophysiological mechanisms that may be at play between microbes and their hosts. Cell cultures have traditionally been used to study the microbiome, but in our current day and age, advanced metagenomic techniques - such as 16S rRNA amplicon sequencing and whole metagenomic shotgun sequencing - are better able to classify the microorganisms making up the microbiome. Utilizing metagenomics alone, however, does not allow for the study of the more complex effects of the microbiome, such as changes in gene expression and metabolic byproducts. Thus, incorporation of other modalities such as metatranscriptomics, metaproteomics, and metabolomics are needed to further elucidate the extensive intricacies of the skin microbiome

Recommendations for Reporting Methods in Phototesting Studies

The figure presented here illuminates the large number of variables that are necessary to adequately describe phototesting protocols. Each of these characteristics can be critical in understanding results presented in the photomedicine community as well as the broader photobiology and photochemistry communities. The inclusion of all of these variables within each phototesting publication will aid in discourse and further scientific discovery within our field

The effect of gluten on skin and hair: a systematic review

Non-celiac gluten sensitivity is often clinically indistinguishable from celiac disease, and patients show improvement or resolution of their symptoms with a gluten-free diet. In contrast to celiac disease, the effects of gluten on the skin and hair in the context of non-celiac gluten sensitivity are not as clear. This review aims to describe the impact of gluten on the skin and hair in patients with non-celiac gluten sensitivity and those without a definitive celiac disease diagnosis. A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines for systematic reviews. Forty-two publications met inclusion criteria with five studies describing the skin manifestations of non-celiac gluten sensitivity. Trials identifying the impact of a gluten-free diet on skin disease, as well as dermatologic conditions and their associations with antigliadin antibodies were also identified. Dermatologic manifestations in patients with non-celiac gluten sensitivity vary and may be non-specific. It may be appropriate for some of these patients with skin manifestations to trial a gluten-free diet. Dermatologic conditions that may respond positively to a gluten-free diet include psoriasis, atopic dermatitis, vitiligo, and palmoplantar pustulosis, while linear IgA disease does not appear to improve with this dietary change

Implementation of the vitiligo area scoring index in clinical studies of patients with vitiligo: a scoping review

The vitiligo area scoring index (VASI) is a validated, reliable clinician-reported outcome measure widely used to assess the extent of skin depigmentation seen in patients with vitiligo and to measure patient responses to therapies for vitiligo in clinical trials. However, its implementation in studies is inconsistent and makes comparing results across different studies difficult. The aim of this scoping review is to summarize interventional clinical studies that applied the VASI to measure vitiligo and identify variability in VASI implementation. A systematic search of Ovid Medline, Embase, Web of Science, Cochrane, and ClinicalTrials.gov was performed. Interventional studies published between January 1946 and October 2020 that used the VASI as an outcome measure for assessing vitiligo response were reviewed for methodological approach. Great heterogeneity was found within the 55 included interventional studies that used VASI as an outcome measure. A total of 9 VASI subtypes were described by the authors within 10 intervention categories. VASI determined study eligibility in one study. Body surface area was most frequently established using inconsistent methods. We found unclear or ambiguously scaled assessments of depigmentation. Most VASI outcomes were reported as mean absolute difference, percentage VASI improvement, and percentage of patients who achieved the VASI endpoint. The VASI score was over 100 in one study. Our scoping review revealed many VASI methodology variations in interventional clinical studies of vitiligo. While VASI is a standard method to measure vitiligo changes, substantial heterogeneity in methodology limits reliable comparison and interpretation of findings from different clinical trials. Our findings may be used as a foundation to standardize the VASI outcome measure methodology, allowing for improved clinician training and rigorous data analysis across vitiligo research groups worldwide