Faculty Bibliography

BACKGROUND:The first-line treatment for patients with bullous pemphigoid (BP), the most common autoimmune blistering disease, is systemic glucocorticoids, which are associated with numerous side effects. Mycophenolate mofetil (MMF) may be beneficial in BP as a steroid-sparing alternative; however, evidence is limited. OBJECTIVES/OBJECTIVE:To evaluate the efficacy and safety of MMF in patients with BP. METHODS:In this retrospective chart review, records of patients with BP treated with MMF alone or in combination with prednisone, who presented between 2013 and 2017, were analyzed. RESULTS:Twenty-six patients were included. Twelve patients were treated with MMF alone (monotherapy) and fourteen were treated with MMF and prednisone concomitantly at some point during their treatment course (dual therapy). Improvement in BP was observed in 26 (100%) patients with MMF therapy. Mean time to improvement was 0.8 months. Twenty-five (96.2%) patients [11/12 (91.7%) on monotherapy and 14/14 (100%) on dual therapy] achieved complete control of their disease. Mean time to complete control amongst all patients was 5.6 months. Twelve (46.2%) patients [4/12 (33.3%) on monotherapy and 8/14 (57.1%) on dual therapy] experienced disease remission with no subsequent flares for up to 15 months after MMF was discontinued. Twelve mild adverse effects were reported with one individual discontinuing therapy due to gastrointestinal symptoms. No serious adverse effects were reported. CONCLUSION/CONCLUSIONS:MMF is a safe and effective therapy for BP and can yield improvement and complete response in most patients and remission in some. J Drugs Dermatol. 2022;21(2):151-155. doi:10.36849/JDD.6042.

Acquired ichthyosis is an uncommon disorder of cornification. It characteristically presents as symmetric scaling of the skin on the trunk and extensor surfaces of the extremities. It is clinically and histologically similar to ichthyosis vulgaris; however, acquired ichthyosis develops later in life and has been associated with various malignancies, infections, medications, autoimmune diseases, metabolic disorders, and malnutrition. We describe a case of a 35-year-old woman with active pulmonary tuberculosis and a history of breast cancer who presented with a several-month history of a widespread, scaly, pruritic skin eruption. Physical examination revealed fine, scaly patches on the extremities with relative sparing of the flexures and larger, scaly, ichthyosiform patches on the chest and back. Skin biopsy revealed orthokeratotic hyperkeratosis and a diminished granular layer, consistent with a diagnosis of acquired ichthyosis. Further evaluation, including positron-emission tomography/computed tomography scan, revealed hypermetabolic infiltrates and cavitation in the lungs, consistent with active pulmonary tuberculosis; there was no evidence of new or recurrent malignancy. The patient was treated with antituberculosis drugs and topical ammonium lactate cream. With incident cases rarely reported in the literature, this case of new-onset ichthyosis in the setting of active pulmonary tuberculosis highlights the distinctive clinical and histologic features of acquired ichthyosis and emphasizes the relationship of acquired ichthyosis with underlying systemic disease, particularly infection.

Importance/UNASSIGNED:The first-line treatment for patients with chronic spontaneous urticaria (CSU), which is divided into idiopathic and autoimmune subtypes, consists of H1-antihistamines. However, limited evidence guides the treatment of CSU after maximal therapy with antihistamines fails. Two randomized clinical trials suggest that dapsone may be a successful second-line therapy. Objective/UNASSIGNED:To evaluate the efficacy and safety of dapsone therapy in patients with CSU. Design, Setting, and Participants/UNASSIGNED:This retrospective medical record review included 79 patients with CSU treated with dapsone who presented to the tertiary care academic medical center at the New York University School of Medicine, New York, New York, from January 1, 2005, through April 15, 2017. Follow-up was completed on February 28, 2018. Data were analyzed from March 1 through May 31, 2018. Exposures/UNASSIGNED:Treatment with oral dapsone for CSU. Main Outcomes and Measures/UNASSIGNED:Efficacy of dapsone therapy for CSU was evaluated as improvement, complete response, and remission. Results/UNASSIGNED:Seventy-nine patients (65% women; mean [SD] age, 49.8 [16.1] years [range, 20-79 years]) were included in the analysis. Forty-five patients had chronic idiopathic urticaria and 34 had chronic autoimmune urticaria. Improvement in CSU was observed in 62 patients (78%) (36 [80%] with idiopathic and 26 [76%] with autoimmune disease) with dapsone. Mean (SD) time to improvement was 1.1 (1.0) months. A complete response was achieved in 29 (47%) of these 62 patients (16 [44%] with idiopathic and 13 [50%] with autoimmune disease). Mean (SD) time to complete response was 5.2 (5.2) months. Dapsone therapy was tapered in 21 patients after a mean (SD) of 2.4 (2.2) months and discontinued in 18. Ten patients experienced remission with no subsequent flares, even after dapsone therapy was discontinued with follow-up of 0.3 to 10.0 months. Sixteen patients experienced mild adverse effects. Two serious adverse effects were reported. Conclusions and Relevance/UNASSIGNED:Results of this study suggest that dapsone is a useful and well-tolerated second-line therapy for patients with CSU in whom antihistamines and other first-line agents have failed.

Psoriasis is a chronic systemic inflammatory skin disease, which has been associated with an increased risk of numerous medical and psychiatric comorbidities, including suicidality. Suicidality, which can be divided into the categories of suicidal ideation, suicide attempt, and completed suicide, is highly prevalent in the psoriasis population, and multiple studies have been published on the subject of psoriasis and suicidal ideation and behavior (SIB), including two recent meta-analyses. However, the available literature is limited and inconsistent, and the association between the two remains incompletely understood. The present review aims to cohesively synthesize and summarize the available evidence, while making a clinically relevant distinction between the sub-categories of suicidality, by examining not only the epidemiology of the association but also the plausible molecular mechanisms and the potential influence of biologic therapies. Additionally, this review aims to critically examine and understand the potential contribution of depression in the psoriasis and suicidality relationship. This will allow us to better understand the complex and multi-faceted relationship between psoriasis and suicidality, to identify those who may be most at risk for SIB, to make evidence-based clinical decisions regarding treatment and management, and to more completely address the needs of psoriasis patients.

Proximal subungual onychomycosis (PSO), which predominantly involves the nail plate from the proximal nail fold, is the rarest form of onychomycosis. Classically associated with an immunocompromised state, PSO is an uncommon diagnosis in individuals without immunodeficiency. We present a case of a healthy 51-year-old man, who presented with a three-month history of white discoloration of multiple toenails. Physical examination revealed white, opaque patches on the proximal third nail plates of multiple toenails. The affected digits also demonstrated proximal onycholysis, subungual debris, and mild paronychia. Laboratory examinations, including routine serologic studies as well as human immunodeficiency virus and antinuclear antibodies, were within normal limits. Proximal nail fragments of the left hallux showed sections of dystrophic nail plate with mounds of parakeratosis, collections of neutrophils, and hyphae that highlighted with periodic acid-Schiff staining. The patient was diagnosed with PSO and tinea pedis bilaterally and treated with oral fluconazole with gradual improvement. This case of PSO highlights the potential for its rare occurrence in a healthy host. However, the clinical presentation of PSO should trigger an evaluation for possible immunodeficiency. <p><em>J Drugs Dermatol. 2018;17(4):475-478.</em></p>.