Cutis

The Diagnosis: Glochid Dermatitis

Biopsy of a nodule on the upper right arm showed chronic granulomatous inflammation and polarizable foreign material consistent with plant cellulose (Figure). A diagnosis of glochid dermatitis was made. The treatment plan included follow-up skin evaluation and punch excision of persistent papules 1 month after the initial presentation. The patient reported the rash began after he fell on a cactus plant while chasing his grandson. He was seen by various clinicians and was given hydrocortisone and clobetasol, which helped with pruritis but did not resolve the rash. His grandson developed a similar rash at the site of contact with the cactus plant. The patient and his grandson did not detect the presence of any cactus spines.

Injuries from cactus glochids most often occur due to accidental falls on cactus plants, but glochids also may be transferred from clothing to other individuals. The thin, hairlike glochids easily detach from the stem of the cactus and can become deeply embedded with virtually no pressure.¹

Glochid implantation from the prickly pear cactus commonly presents as a pruritic papular eruption known as glochid dermatitis. These penetrating injuries can lead to inoculation of Clostridium tetani and Staphylococcus aureus. Additionally, unrecognized and unremoved cactus spines may be highly inflammatory and may cause chronic granulomatous inflammation.²

Initially, acute glochid dermatitis occurs due to mechanical damage caused by the detatched cactus spine and may not resolve for up to 4 months. Granuloma formation has been reported several weeks after exposure and may persist for more than 8 months.³ Although an immune mechanism has been suggested, the literature has indicated that delayed hypersensitivity reactions are a more probable cause of the granulomatous inflammation after glochid exposure.³ Madkan et al⁴ reported that relatively few patients developed granulomas after implantation of glochids in the skin, thus suggesting that granuloma formation is an allergic response.

With regard to the pathogenesis of glochid dermatitis, the initial response to foreign plant matter in the dermis involves a neutrophilic infiltrate, which later is replaced by histiocytes; however, the foreign material remains undegraded in the macrophage cytoplasm.⁵ Activated macrophages secrete cytokines that intensify the inflammatory response, resulting in formation of a granuloma around the foreign body. The granuloma acts as a wall to isolate the foreign matter from the rest of the body.⁵

Regarding treatment of chronic granulomas, Madkan et al⁴ reported a case that showed some improvement with clobetasol ointment; however, clinical lesions resolved only after punch biopsies were performed to confirm the diagnosis of cactus spine granuloma. In a controlled study in rabbits, glochids were successfully removed by first detaching the larger clumps with tweezers then applying glue and gauze to the affected area.⁶ After the glue dried, the gauze was peeled off, resulting in the removal of 95% of the implanted glochids. Overall, removal of embedded spines is difficult because the glochids typically radiate in several directions.⁷ Treatment of foreign body granulomas caused by cactus spines can be achieved by expulsion of plant matter remnants and symptomatic treatment using midpotency topical steroids twice daily.⁴ Uncovering and performing punch biopsies of papules also can result in rapid healing of the lesions. Without manual removal of the glochid, lesions can persist for 2 to 8 months until gradual resolution with possible postinflammatory hyperpigmentation.⁴

The Diagnosis: Glochid Dermatitis

Biopsy of a nodule on the upper right arm showed chronic granulomatous inflammation and polarizable foreign material consistent with plant cellulose (Figure). A diagnosis of glochid dermatitis was made. The treatment plan included follow-up skin evaluation and punch excision of persistent papules 1 month after the initial presentation. The patient reported the rash began after he fell on a cactus plant while chasing his grandson. He was seen by various clinicians and was given hydrocortisone and clobetasol, which helped with pruritis but did not resolve the rash. His grandson developed a similar rash at the site of contact with the cactus plant. The patient and his grandson did not detect the presence of any cactus spines.

Injuries from cactus glochids most often occur due to accidental falls on cactus plants, but glochids also may be transferred from clothing to other individuals. The thin, hairlike glochids easily detach from the stem of the cactus and can become deeply embedded with virtually no pressure.¹

Glochid implantation from the prickly pear cactus commonly presents as a pruritic papular eruption known as glochid dermatitis. These penetrating injuries can lead to inoculation of Clostridium tetani and Staphylococcus aureus. Additionally, unrecognized and unremoved cactus spines may be highly inflammatory and may cause chronic granulomatous inflammation.²

Initially, acute glochid dermatitis occurs due to mechanical damage caused by the detatched cactus spine and may not resolve for up to 4 months. Granuloma formation has been reported several weeks after exposure and may persist for more than 8 months.³ Although an immune mechanism has been suggested, the literature has indicated that delayed hypersensitivity reactions are a more probable cause of the granulomatous inflammation after glochid exposure.³ Madkan et al⁴ reported that relatively few patients developed granulomas after implantation of glochids in the skin, thus suggesting that granuloma formation is an allergic response.

With regard to the pathogenesis of glochid dermatitis, the initial response to foreign plant matter in the dermis involves a neutrophilic infiltrate, which later is replaced by histiocytes; however, the foreign material remains undegraded in the macrophage cytoplasm.⁵ Activated macrophages secrete cytokines that intensify the inflammatory response, resulting in formation of a granuloma around the foreign body. The granuloma acts as a wall to isolate the foreign matter from the rest of the body.⁵

Regarding treatment of chronic granulomas, Madkan et al⁴ reported a case that showed some improvement with clobetasol ointment; however, clinical lesions resolved only after punch biopsies were performed to confirm the diagnosis of cactus spine granuloma. In a controlled study in rabbits, glochids were successfully removed by first detaching the larger clumps with tweezers then applying glue and gauze to the affected area.⁶ After the glue dried, the gauze was peeled off, resulting in the removal of 95% of the implanted glochids. Overall, removal of embedded spines is difficult because the glochids typically radiate in several directions.⁷ Treatment of foreign body granulomas caused by cactus spines can be achieved by expulsion of plant matter remnants and symptomatic treatment using midpotency topical steroids twice daily.⁴ Uncovering and performing punch biopsies of papules also can result in rapid healing of the lesions. Without manual removal of the glochid, lesions can persist for 2 to 8 months until gradual resolution with possible postinflammatory hyperpigmentation.⁴

The Diagnosis: Glochid Dermatitis

Biopsy of a nodule on the upper right arm showed chronic granulomatous inflammation and polarizable foreign material consistent with plant cellulose (Figure). A diagnosis of glochid dermatitis was made. The treatment plan included follow-up skin evaluation and punch excision of persistent papules 1 month after the initial presentation. The patient reported the rash began after he fell on a cactus plant while chasing his grandson. He was seen by various clinicians and was given hydrocortisone and clobetasol, which helped with pruritis but did not resolve the rash. His grandson developed a similar rash at the site of contact with the cactus plant. The patient and his grandson did not detect the presence of any cactus spines.

Injuries from cactus glochids most often occur due to accidental falls on cactus plants, but glochids also may be transferred from clothing to other individuals. The thin, hairlike glochids easily detach from the stem of the cactus and can become deeply embedded with virtually no pressure.¹

Glochid implantation from the prickly pear cactus commonly presents as a pruritic papular eruption known as glochid dermatitis. These penetrating injuries can lead to inoculation of Clostridium tetani and Staphylococcus aureus. Additionally, unrecognized and unremoved cactus spines may be highly inflammatory and may cause chronic granulomatous inflammation.²

Initially, acute glochid dermatitis occurs due to mechanical damage caused by the detatched cactus spine and may not resolve for up to 4 months. Granuloma formation has been reported several weeks after exposure and may persist for more than 8 months.³ Although an immune mechanism has been suggested, the literature has indicated that delayed hypersensitivity reactions are a more probable cause of the granulomatous inflammation after glochid exposure.³ Madkan et al⁴ reported that relatively few patients developed granulomas after implantation of glochids in the skin, thus suggesting that granuloma formation is an allergic response.

With regard to the pathogenesis of glochid dermatitis, the initial response to foreign plant matter in the dermis involves a neutrophilic infiltrate, which later is replaced by histiocytes; however, the foreign material remains undegraded in the macrophage cytoplasm.⁵ Activated macrophages secrete cytokines that intensify the inflammatory response, resulting in formation of a granuloma around the foreign body. The granuloma acts as a wall to isolate the foreign matter from the rest of the body.⁵

Regarding treatment of chronic granulomas, Madkan et al⁴ reported a case that showed some improvement with clobetasol ointment; however, clinical lesions resolved only after punch biopsies were performed to confirm the diagnosis of cactus spine granuloma. In a controlled study in rabbits, glochids were successfully removed by first detaching the larger clumps with tweezers then applying glue and gauze to the affected area.⁶ After the glue dried, the gauze was peeled off, resulting in the removal of 95% of the implanted glochids. Overall, removal of embedded spines is difficult because the glochids typically radiate in several directions.⁷ Treatment of foreign body granulomas caused by cactus spines can be achieved by expulsion of plant matter remnants and symptomatic treatment using midpotency topical steroids twice daily.⁴ Uncovering and performing punch biopsies of papules also can result in rapid healing of the lesions. Without manual removal of the glochid, lesions can persist for 2 to 8 months until gradual resolution with possible postinflammatory hyperpigmentation.⁴

Hidradenitis suppurativa (HS) is a chronic, non-contagious skin disease that causes acne-like boils to form in folds of skin, particularly in the axilla and groin areas.

Click here to visit the site

Hidradenitis suppurativa (HS) is a chronic, non-contagious skin disease that causes acne-like boils to form in folds of skin, particularly in the axilla and groin areas.

Click here to visit the site

Hidradenitis suppurativa (HS) is a chronic, non-contagious skin disease that causes acne-like boils to form in folds of skin, particularly in the axilla and groin areas.

Click here to visit the site

Myth: Eczema has a minimal impact on patients’ daily activities

Although eczema may be considered a relatively mild skin condition, the effects of the disease can be debilitating for many patients. Low quality of life (QoL) due to eczema flares and trigger avoidance can lead to decreased productivity in this population, and patients often report interference of the disease with participation in daily life, including activities at work and school.

In a series of patient satisfaction surveys administered by the National Eczema Foundation, 75% of adults with eczema said their disease interferes with their job and household chores. A study of 380 adult atopic dermatitis (AD) patients assessing the impact of the disease on QoL showed similar results, as 39.0% of participants said AD impacted shopping, home, and garden activities a lot or very much and 36.8% said it impacted these activities a little. Additionally, reports from caregivers of children with AD indicated that nearly 50% of children miss at least 1 day of the school year due to their disease, and 17% miss 5 or more days. Over time, these limitations can have a serious psychological impact in eczema patients of any age.

In the National Eczema Foundation survey, 71% of respondents said their disease also gets in the way of participating in sports or hobbies. Eczema patients may miss out on the physical and mental health benefits of activities associated with increased body temperature or prolonged contact with sports equipment, which can exacerbate symptoms. In general, outdoor activities in all seasons can be particularly troublesome in this population, as eczema flares can be triggered by cold or hot temperatures, humidity, wind, dry air, sun exposure, pollution, and contact with allergens like pollen or mold.

The impact of eczema treatments on patients’ daily activities also should be considered when evaluating QoL in this population, as it frequently takes considerable time out of a patient’s day to manage his/her disease. Control of symptoms often requires a multistep daily regimen involving medication, bathing, moisturizing, applying wet compresses, ridding the house of allergens, and/or cleaning sheets and clothing. According to the National Eczema Foundation survey, 1 in 3 respondents said it takes 1 or more hours per day to treat their disease. To encourage adherence and ensure optimal outcomes, physicians should work with patients to develop an eczema treatment plan that is both effective and manageable in terms of their daily routines.

Ultimately, the disease burden in eczema patients is multidimensional, extending beyond only cutaneous symptoms; therefore, it is important for clinicians to consider the impact on QoL when choosing treatments for patients with eczema and to initiate appropriate therapy at the onset of disease presentation to mitigate the effects of the condition on patients’ daily lives. Eczema management strategies should include QoL screening to ensure the disease has a minimal impact on patients' daily lives and preferred activities.

Myth: Eczema has a minimal impact on patients’ daily activities

Although eczema may be considered a relatively mild skin condition, the effects of the disease can be debilitating for many patients. Low quality of life (QoL) due to eczema flares and trigger avoidance can lead to decreased productivity in this population, and patients often report interference of the disease with participation in daily life, including activities at work and school.

In a series of patient satisfaction surveys administered by the National Eczema Foundation, 75% of adults with eczema said their disease interferes with their job and household chores. A study of 380 adult atopic dermatitis (AD) patients assessing the impact of the disease on QoL showed similar results, as 39.0% of participants said AD impacted shopping, home, and garden activities a lot or very much and 36.8% said it impacted these activities a little. Additionally, reports from caregivers of children with AD indicated that nearly 50% of children miss at least 1 day of the school year due to their disease, and 17% miss 5 or more days. Over time, these limitations can have a serious psychological impact in eczema patients of any age.

In the National Eczema Foundation survey, 71% of respondents said their disease also gets in the way of participating in sports or hobbies. Eczema patients may miss out on the physical and mental health benefits of activities associated with increased body temperature or prolonged contact with sports equipment, which can exacerbate symptoms. In general, outdoor activities in all seasons can be particularly troublesome in this population, as eczema flares can be triggered by cold or hot temperatures, humidity, wind, dry air, sun exposure, pollution, and contact with allergens like pollen or mold.

The impact of eczema treatments on patients’ daily activities also should be considered when evaluating QoL in this population, as it frequently takes considerable time out of a patient’s day to manage his/her disease. Control of symptoms often requires a multistep daily regimen involving medication, bathing, moisturizing, applying wet compresses, ridding the house of allergens, and/or cleaning sheets and clothing. According to the National Eczema Foundation survey, 1 in 3 respondents said it takes 1 or more hours per day to treat their disease. To encourage adherence and ensure optimal outcomes, physicians should work with patients to develop an eczema treatment plan that is both effective and manageable in terms of their daily routines.

Ultimately, the disease burden in eczema patients is multidimensional, extending beyond only cutaneous symptoms; therefore, it is important for clinicians to consider the impact on QoL when choosing treatments for patients with eczema and to initiate appropriate therapy at the onset of disease presentation to mitigate the effects of the condition on patients’ daily lives. Eczema management strategies should include QoL screening to ensure the disease has a minimal impact on patients' daily lives and preferred activities.

Myth: Eczema has a minimal impact on patients’ daily activities

Although eczema may be considered a relatively mild skin condition, the effects of the disease can be debilitating for many patients. Low quality of life (QoL) due to eczema flares and trigger avoidance can lead to decreased productivity in this population, and patients often report interference of the disease with participation in daily life, including activities at work and school.

In a series of patient satisfaction surveys administered by the National Eczema Foundation, 75% of adults with eczema said their disease interferes with their job and household chores. A study of 380 adult atopic dermatitis (AD) patients assessing the impact of the disease on QoL showed similar results, as 39.0% of participants said AD impacted shopping, home, and garden activities a lot or very much and 36.8% said it impacted these activities a little. Additionally, reports from caregivers of children with AD indicated that nearly 50% of children miss at least 1 day of the school year due to their disease, and 17% miss 5 or more days. Over time, these limitations can have a serious psychological impact in eczema patients of any age.

In the National Eczema Foundation survey, 71% of respondents said their disease also gets in the way of participating in sports or hobbies. Eczema patients may miss out on the physical and mental health benefits of activities associated with increased body temperature or prolonged contact with sports equipment, which can exacerbate symptoms. In general, outdoor activities in all seasons can be particularly troublesome in this population, as eczema flares can be triggered by cold or hot temperatures, humidity, wind, dry air, sun exposure, pollution, and contact with allergens like pollen or mold.

The impact of eczema treatments on patients’ daily activities also should be considered when evaluating QoL in this population, as it frequently takes considerable time out of a patient’s day to manage his/her disease. Control of symptoms often requires a multistep daily regimen involving medication, bathing, moisturizing, applying wet compresses, ridding the house of allergens, and/or cleaning sheets and clothing. According to the National Eczema Foundation survey, 1 in 3 respondents said it takes 1 or more hours per day to treat their disease. To encourage adherence and ensure optimal outcomes, physicians should work with patients to develop an eczema treatment plan that is both effective and manageable in terms of their daily routines.

Ultimately, the disease burden in eczema patients is multidimensional, extending beyond only cutaneous symptoms; therefore, it is important for clinicians to consider the impact on QoL when choosing treatments for patients with eczema and to initiate appropriate therapy at the onset of disease presentation to mitigate the effects of the condition on patients’ daily lives. Eczema management strategies should include QoL screening to ensure the disease has a minimal impact on patients' daily lives and preferred activities.

Click here to view the articles published in March 2018.

Click here to view the articles published in March 2018.

Click here to view the articles published in March 2018.

Avène TriXera

Pierre Fabre Dermo-Cosmetique launches the Avène TriXera line consisting of 3 products. The TriXera Nutrition Nutri-fluid Cleanser gently cleanses and nourishes dry to very dry, sensitive skin. TriXera Nutrition Nutri-fluid Lotion offers 48-hour hydration for dry, sensitive skin. These nourishing effects last up to 6 hours after application. TriXera Nutrition Nutri-fluid Balm has a fluidlike texture and also offers 48-hour hydration. All 3 products contain Avène Thermal Spring Water to soothe and soften as it restores the skin’s balance, as well as evening primrose oil and soy extract to rebuild the skin barrier and prevent moisture loss. For more information, visit www.aveneusa.com.

CoolSculpting

Allergan plc announces US Food and Drug Administration clearance for the CoolSculpting treatment, a nonsurgical fat reduction technology for improved appearance of lax tissue in conjunction with submental fat. CoolSculpting works by gently cooling targeted fat cells in the body to induce natural, controlled elimination of fat cells without affecting surrounding tissue. For more information, visit www.coolsculpting.com.

Discoloration Defense

SkinCeuticals introduces Discoloration Defense, a high-potency treatment serum that prevents and corrects multiple types of discoloration. This product contains tranexamic acid and niacinamide for pigmentation, hepes for hydration, and kojic acid to brighten skin and help to reduce the amount of melanin produced. These ingredients work together to help break up existing melanin clusters, inhibit the formation of melanocytes, and deactivate inflammatory mediators. The serum provides a reduction in visible and stubborn pigmentation for a revitalized and even complexion with refined texture and clarity. For more information, visit www.skinceuticals.com.

Eskata

Aclaris Therapeutics, Inc, announces US Food and Drug Administration approval of Eskata (hydrogen peroxide) topical solution 40% for the treatment of raised seborrheic keratoses. This product is a targeted, in-office treatment applied directly to raised seborrheic keratoses using a penlike applicator. Clinical studies showed clearing of seborrheic keratoses after 2 treatments. Eskata is expected to be commercially available in the spring of 2018. For more information, visit www.eskata.com.

Ixifi

Pfizer Inc announces US Food and Drug Administration approval of Ixifi (infliximab-qbtx), a chimeric human-murine monoclonal antibody against tumor necrosis factor, as a biosimilar to Remicade (infliximab) for all eligible indications of the reference product. Ixifi has been approved in the United States as a treatment for rheumatoid arthritis, Crohn disease, ulcerative colitis, psoriatic arthritis, and plaque psoriasis. For more information, visit www.pfizer.com.

Jemdel

Ortho Dermatologics announces US Food and Drug Administration acceptance of the New Drug Application for Jemdel (halobetasol propionate 0.01%), a high-potency topical steroid for the treatment of plaque psoriasis with dosing for as long as 8 weeks. Jemdel has a Prescription Drug User Fee Act action date of October 5, 2018. For more information, visit www.ortho-dermatologics.com.

Retin-A Micro

Ortho Dermatologics announces that Retin-A Micro (tretinoin) gel microsphere 0.06%, a topical treatment for acne vulgaris, will be available commercially to health care professionals. The US Food and Drug Administration previously approved the Supplemental New Drug Application for this product in October 2017. Retin-A Micro features a microsponge delivery system technology that helps control the release of tretinoin and improves photostability, even when used in conjunction with benzoyl peroxide. This product also features a pump delivery system for controlled dispensing and consistent dosing. Caution should be exercised when prescribing to eczema patients and nursing mothers. For more information, visit www.retinamicro.com.

If you would like your product included in Product News, please email a press release to the Editorial Office at [email protected].

Avène TriXera

Pierre Fabre Dermo-Cosmetique launches the Avène TriXera line consisting of 3 products. The TriXera Nutrition Nutri-fluid Cleanser gently cleanses and nourishes dry to very dry, sensitive skin. TriXera Nutrition Nutri-fluid Lotion offers 48-hour hydration for dry, sensitive skin. These nourishing effects last up to 6 hours after application. TriXera Nutrition Nutri-fluid Balm has a fluidlike texture and also offers 48-hour hydration. All 3 products contain Avène Thermal Spring Water to soothe and soften as it restores the skin’s balance, as well as evening primrose oil and soy extract to rebuild the skin barrier and prevent moisture loss. For more information, visit www.aveneusa.com.

CoolSculpting

Allergan plc announces US Food and Drug Administration clearance for the CoolSculpting treatment, a nonsurgical fat reduction technology for improved appearance of lax tissue in conjunction with submental fat. CoolSculpting works by gently cooling targeted fat cells in the body to induce natural, controlled elimination of fat cells without affecting surrounding tissue. For more information, visit www.coolsculpting.com.

Discoloration Defense

SkinCeuticals introduces Discoloration Defense, a high-potency treatment serum that prevents and corrects multiple types of discoloration. This product contains tranexamic acid and niacinamide for pigmentation, hepes for hydration, and kojic acid to brighten skin and help to reduce the amount of melanin produced. These ingredients work together to help break up existing melanin clusters, inhibit the formation of melanocytes, and deactivate inflammatory mediators. The serum provides a reduction in visible and stubborn pigmentation for a revitalized and even complexion with refined texture and clarity. For more information, visit www.skinceuticals.com.

Eskata

Aclaris Therapeutics, Inc, announces US Food and Drug Administration approval of Eskata (hydrogen peroxide) topical solution 40% for the treatment of raised seborrheic keratoses. This product is a targeted, in-office treatment applied directly to raised seborrheic keratoses using a penlike applicator. Clinical studies showed clearing of seborrheic keratoses after 2 treatments. Eskata is expected to be commercially available in the spring of 2018. For more information, visit www.eskata.com.

Ixifi

Pfizer Inc announces US Food and Drug Administration approval of Ixifi (infliximab-qbtx), a chimeric human-murine monoclonal antibody against tumor necrosis factor, as a biosimilar to Remicade (infliximab) for all eligible indications of the reference product. Ixifi has been approved in the United States as a treatment for rheumatoid arthritis, Crohn disease, ulcerative colitis, psoriatic arthritis, and plaque psoriasis. For more information, visit www.pfizer.com.

Jemdel

Ortho Dermatologics announces US Food and Drug Administration acceptance of the New Drug Application for Jemdel (halobetasol propionate 0.01%), a high-potency topical steroid for the treatment of plaque psoriasis with dosing for as long as 8 weeks. Jemdel has a Prescription Drug User Fee Act action date of October 5, 2018. For more information, visit www.ortho-dermatologics.com.

Retin-A Micro

Ortho Dermatologics announces that Retin-A Micro (tretinoin) gel microsphere 0.06%, a topical treatment for acne vulgaris, will be available commercially to health care professionals. The US Food and Drug Administration previously approved the Supplemental New Drug Application for this product in October 2017. Retin-A Micro features a microsponge delivery system technology that helps control the release of tretinoin and improves photostability, even when used in conjunction with benzoyl peroxide. This product also features a pump delivery system for controlled dispensing and consistent dosing. Caution should be exercised when prescribing to eczema patients and nursing mothers. For more information, visit www.retinamicro.com.

If you would like your product included in Product News, please email a press release to the Editorial Office at [email protected].

Avène TriXera

Pierre Fabre Dermo-Cosmetique launches the Avène TriXera line consisting of 3 products. The TriXera Nutrition Nutri-fluid Cleanser gently cleanses and nourishes dry to very dry, sensitive skin. TriXera Nutrition Nutri-fluid Lotion offers 48-hour hydration for dry, sensitive skin. These nourishing effects last up to 6 hours after application. TriXera Nutrition Nutri-fluid Balm has a fluidlike texture and also offers 48-hour hydration. All 3 products contain Avène Thermal Spring Water to soothe and soften as it restores the skin’s balance, as well as evening primrose oil and soy extract to rebuild the skin barrier and prevent moisture loss. For more information, visit www.aveneusa.com.

CoolSculpting

Allergan plc announces US Food and Drug Administration clearance for the CoolSculpting treatment, a nonsurgical fat reduction technology for improved appearance of lax tissue in conjunction with submental fat. CoolSculpting works by gently cooling targeted fat cells in the body to induce natural, controlled elimination of fat cells without affecting surrounding tissue. For more information, visit www.coolsculpting.com.

Discoloration Defense

SkinCeuticals introduces Discoloration Defense, a high-potency treatment serum that prevents and corrects multiple types of discoloration. This product contains tranexamic acid and niacinamide for pigmentation, hepes for hydration, and kojic acid to brighten skin and help to reduce the amount of melanin produced. These ingredients work together to help break up existing melanin clusters, inhibit the formation of melanocytes, and deactivate inflammatory mediators. The serum provides a reduction in visible and stubborn pigmentation for a revitalized and even complexion with refined texture and clarity. For more information, visit www.skinceuticals.com.

Eskata

Aclaris Therapeutics, Inc, announces US Food and Drug Administration approval of Eskata (hydrogen peroxide) topical solution 40% for the treatment of raised seborrheic keratoses. This product is a targeted, in-office treatment applied directly to raised seborrheic keratoses using a penlike applicator. Clinical studies showed clearing of seborrheic keratoses after 2 treatments. Eskata is expected to be commercially available in the spring of 2018. For more information, visit www.eskata.com.

Ixifi

Pfizer Inc announces US Food and Drug Administration approval of Ixifi (infliximab-qbtx), a chimeric human-murine monoclonal antibody against tumor necrosis factor, as a biosimilar to Remicade (infliximab) for all eligible indications of the reference product. Ixifi has been approved in the United States as a treatment for rheumatoid arthritis, Crohn disease, ulcerative colitis, psoriatic arthritis, and plaque psoriasis. For more information, visit www.pfizer.com.

Jemdel

Ortho Dermatologics announces US Food and Drug Administration acceptance of the New Drug Application for Jemdel (halobetasol propionate 0.01%), a high-potency topical steroid for the treatment of plaque psoriasis with dosing for as long as 8 weeks. Jemdel has a Prescription Drug User Fee Act action date of October 5, 2018. For more information, visit www.ortho-dermatologics.com.

Retin-A Micro

Ortho Dermatologics announces that Retin-A Micro (tretinoin) gel microsphere 0.06%, a topical treatment for acne vulgaris, will be available commercially to health care professionals. The US Food and Drug Administration previously approved the Supplemental New Drug Application for this product in October 2017. Retin-A Micro features a microsponge delivery system technology that helps control the release of tretinoin and improves photostability, even when used in conjunction with benzoyl peroxide. This product also features a pump delivery system for controlled dispensing and consistent dosing. Caution should be exercised when prescribing to eczema patients and nursing mothers. For more information, visit www.retinamicro.com.

If you would like your product included in Product News, please email a press release to the Editorial Office at [email protected].

What causes psoriasis in children?

Psoriasis is a chronic immune-mediated inflammatory skin disease with a genetic predisposition (Eichenfield et al). Similar to many inflammatory skin diseases, school-aged children have a greater predisposition before or in early adolescence. As with adult disease, pediatric psoriasis has a complex pathogenesis largely related to aberrant immune response to triggers such as infections (eg, streptococcal pharyngitis, perianal streptococcal dermatitis, upper respiratory viral infections), trauma (ie, Koebner phenomenon), stress, and obesity.

What are the emerging data and recommendations on screening for comorbidities in children with psoriasis?

Similar to psoriasis in adults, obesity and the metabolic syndrome are a true association with pediatric psoriasis that has been discussed in the literature (Eichenfield et al). Although many children with psoriasis have obesity as a potential comorbidity, the risk of cardiovascular comorbidities independent of obesity is high in pediatric psoriasis including elevated lipids, hypertension, polycystic ovaries, nonalcoholic liver disease, and elevated liver enzymes (Tollefson et al). Children with psoriasis have greater central obesity and adiposity, often accompanied by a family history of obesity. Interventions in this direction may be needed for long-term disease control and general health (Mercy and Paller). One target population is hospitalized children with psoriasis, particularly black and Hispanic children aged 0 to 9 years. This population has been identified to have a greater risk for obesity, diabetes mellitus, hypertension, arrhythmia, and valvular heart disease (Kwa et al). Therefore, it can be said that dermatologists can help to improve the overall health and lifestyle long-term in children with psoriasis.

Early-onset disease also is associated with greater risk for lifetime quality-of-life impairments including poor lifetime dermatology life quality index scores, depression and psoriasis-induced depression, social discrimination, sleep problems, and recreational drug usage (Kim et al).

How does psoriasis in children differ from adults?

Children have a variety of features that differ from adult disease. First, they are more likely to have an infectious trigger and therefore may have an identifiable treatable source. Second, they are more likely to have a family history of disease, with one-third having a relative with psoriasis, therefore, identifying the child at risk for long-standing disease. Third, children have far more visible head and neck disease, especially facial involvement including eyelids (Raychaudhuri and Gross), which increases the risk of bullying, social stigma, and negative effects on self-image. Of course, site is affected by age, and in infancy diaper dermatitis and inverse disease with maceration and overlying candidal diaper dermatitis can occur. Although children have less joint disease, it can be dramatic and crippling to the developing child.

What treatments are available for children?

In childhood, identification of precipitating infections such as streptococcal infection is ideal with appropriate intervention thereafter. Topical therapies are appropriate for limited disease with minimal disability; however, phototherapy and systemic agents can be used in pediatric psoriasis in extensive cases. Topical therapies can include corticosteroids, calcineurin inhibitors often used in sensitive skin such as the face and intertriginous areas, and calcipotriene (Eichenfield et al). Additional agents such as tar and salicylic acid can be used, with limitations on the latter due to risk for absorption in smaller children. Systemic interventions often are introduced after years of disease. A recent study identified practitioners with special interest in pediatric psoriasis and determined that systemic interventions were on average introduced 3 years after psoriasis was diagnosed and most commonly included methotrexate followed by etanercept, the latter having fewer gastrointestinal tract side effects. The panel found that usage of folic acid 6 days weekly minimized gastrointestinal tract side effects with methotrexate. Acitretin and cyclosporine were alternatives (Bronckers et al; Psoriasis Investigator Group [PsIG] of the Pediatric Dermatology Research Alliance and the European Working Group on Pediatric Psoriasis [EWGPP]).

Recently, dermatologists have become aware of the dramatic benefits of immune response modifiers and some biologics on pediatric psoriasis. In the setting of joint and skin involvement, I allow the rheumatologist to make the choice of agents for the child's best outcome. However, for pediatric and adolescent psoriasis, we now have 2 US Food and Drug Administration-approved agents and more rapid and thorough testing of adult-approved agents in children, with a hope of greater ability to modify disease course at a younger age, both now and in the future.

Which biologics are approved for the pediatric patient population?

Currently, in the United States 2 biologics have been approved: (1) etanercept, a fusion protein of tumor necrosis factor receptor extracellular domain linked to the Fc portion of human IgG, for moderate to severe plaque psoriasis in patients 4 years and older, and (2) ustekinumab, a human IgG1κ monoclonal antibody against the shared p40 subunit of the IL-12 and IL-23 cytokines, for moderate to severe plaque psoriasis in patients 12 years and older based on the encouraging data of the CADMUS trial (Kellen et al; Landells et al). In Europe, adalimumab has been approved as a first-line therapy in pediatric psoriasis (age ≥4 years), and etanercept (age ≥6 years) and ustekinumab (age ≥12 years) have been approved as second-line agents, all with grade A evidence, according to a recent Italian panel (Fortina et al). (A thorough review of the guidelines on screening, administration, and vaccination is available from Eichenfield et al.)

What treatments are in the pipeline?

In the United States we have clinical trials ongoing of adult-approved topical and immune response-modifying agents such as apremilast. These agents, as they become available and the data are gathered, will be added to what I refer to as our "pharmamentarium" of agents we can use to combat a difficult and disabling illness. 

What gaps are there in the pediatric psoriasis research?

Currently, there is poor awareness that there is research for pediatric psoriasis, and there is a need for pediatric groups and the National Psoriasis Foundation to allow children, adolescents, and their families to know that clinical trials are available looking into newer, more targeted, and less immunosuppressive agents. There is new hope on the horizon!

Suggested Readings

Bronckers IMGJ, Seyger MMB, West DP, et al; Psoriasis Investigator Group (PsIG) of the Pediatric Dermatology Research Alliance and the European Working Group on Pediatric Psoriasis (EWGPP). Safety of systemic agents for the treatment of pediatric psoriasis. JAMA Dermatol. 2017;153:1147-1157.

Eichenfield LF, Paller AS, Tom WL, et al. Pediatric psoriasis: evolving perspectives [published online January 4, 2018]. Pediatr Dermatol. doi:10.1111/pde.13382.

Fortina AB, Bardazzi F, Berti S, et al. Treatment of severe psoriasis in children: recommendations of an Italian expert group [published online August 23, 2017]. Eur J Pediatr. 2017;176:1339-1354.

Kellen R, Silverberg NB, Lebwohl M. Efficacy and safety of ustekinumab in adolescents. Pediatric Health Med Ther. 2016;7:109-120.

Kim GE, Seidler E, Kimball AB. Effect of age at diagnosis on chronic quality of life and long-term outcomes of individuals with psoriasis [published online December 29, 2014]. Pediatr Dermatol. 2015;32:656-662.

Kwa L, Kwa MC, Silverberg JI. Cardiovascular comorbidities of pediatric psoriasis among hospitalized children in the United States. J Am Acad Dermatol. 2017;77:1023-1029.

Landells I, Marano C, Hsu MC, et al. Ustekinumab in adolescent patients age 12 to 17 years with moderate-to-severe plaque psoriasis: results of the randomized phase 3 CADMUS study [published online August 7, 2015]. J Am Acad Dermatol. 2015;73:594-603.

Mercy KM, Paller AS. The relationship between obesity and psoriasis in the pediatric population: implications and future directions. Cutis. 2013;92:107-109.

Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17:174-178.

Tollefson MM, Van Houten HK, Asante D, et al. Association of psoriasis with comorbidity development in children with psoriasis [published online January 10, 2018]. JAMA Dermatol. doi:10.1001/jamadermatol.2017.5417. 

What causes psoriasis in children?

Psoriasis is a chronic immune-mediated inflammatory skin disease with a genetic predisposition (Eichenfield et al). Similar to many inflammatory skin diseases, school-aged children have a greater predisposition before or in early adolescence. As with adult disease, pediatric psoriasis has a complex pathogenesis largely related to aberrant immune response to triggers such as infections (eg, streptococcal pharyngitis, perianal streptococcal dermatitis, upper respiratory viral infections), trauma (ie, Koebner phenomenon), stress, and obesity.

What are the emerging data and recommendations on screening for comorbidities in children with psoriasis?

Similar to psoriasis in adults, obesity and the metabolic syndrome are a true association with pediatric psoriasis that has been discussed in the literature (Eichenfield et al). Although many children with psoriasis have obesity as a potential comorbidity, the risk of cardiovascular comorbidities independent of obesity is high in pediatric psoriasis including elevated lipids, hypertension, polycystic ovaries, nonalcoholic liver disease, and elevated liver enzymes (Tollefson et al). Children with psoriasis have greater central obesity and adiposity, often accompanied by a family history of obesity. Interventions in this direction may be needed for long-term disease control and general health (Mercy and Paller). One target population is hospitalized children with psoriasis, particularly black and Hispanic children aged 0 to 9 years. This population has been identified to have a greater risk for obesity, diabetes mellitus, hypertension, arrhythmia, and valvular heart disease (Kwa et al). Therefore, it can be said that dermatologists can help to improve the overall health and lifestyle long-term in children with psoriasis.

Early-onset disease also is associated with greater risk for lifetime quality-of-life impairments including poor lifetime dermatology life quality index scores, depression and psoriasis-induced depression, social discrimination, sleep problems, and recreational drug usage (Kim et al).

How does psoriasis in children differ from adults?

Children have a variety of features that differ from adult disease. First, they are more likely to have an infectious trigger and therefore may have an identifiable treatable source. Second, they are more likely to have a family history of disease, with one-third having a relative with psoriasis, therefore, identifying the child at risk for long-standing disease. Third, children have far more visible head and neck disease, especially facial involvement including eyelids (Raychaudhuri and Gross), which increases the risk of bullying, social stigma, and negative effects on self-image. Of course, site is affected by age, and in infancy diaper dermatitis and inverse disease with maceration and overlying candidal diaper dermatitis can occur. Although children have less joint disease, it can be dramatic and crippling to the developing child.

What treatments are available for children?

In childhood, identification of precipitating infections such as streptococcal infection is ideal with appropriate intervention thereafter. Topical therapies are appropriate for limited disease with minimal disability; however, phototherapy and systemic agents can be used in pediatric psoriasis in extensive cases. Topical therapies can include corticosteroids, calcineurin inhibitors often used in sensitive skin such as the face and intertriginous areas, and calcipotriene (Eichenfield et al). Additional agents such as tar and salicylic acid can be used, with limitations on the latter due to risk for absorption in smaller children. Systemic interventions often are introduced after years of disease. A recent study identified practitioners with special interest in pediatric psoriasis and determined that systemic interventions were on average introduced 3 years after psoriasis was diagnosed and most commonly included methotrexate followed by etanercept, the latter having fewer gastrointestinal tract side effects. The panel found that usage of folic acid 6 days weekly minimized gastrointestinal tract side effects with methotrexate. Acitretin and cyclosporine were alternatives (Bronckers et al; Psoriasis Investigator Group [PsIG] of the Pediatric Dermatology Research Alliance and the European Working Group on Pediatric Psoriasis [EWGPP]).

Recently, dermatologists have become aware of the dramatic benefits of immune response modifiers and some biologics on pediatric psoriasis. In the setting of joint and skin involvement, I allow the rheumatologist to make the choice of agents for the child's best outcome. However, for pediatric and adolescent psoriasis, we now have 2 US Food and Drug Administration-approved agents and more rapid and thorough testing of adult-approved agents in children, with a hope of greater ability to modify disease course at a younger age, both now and in the future.

Which biologics are approved for the pediatric patient population?

Currently, in the United States 2 biologics have been approved: (1) etanercept, a fusion protein of tumor necrosis factor receptor extracellular domain linked to the Fc portion of human IgG, for moderate to severe plaque psoriasis in patients 4 years and older, and (2) ustekinumab, a human IgG1κ monoclonal antibody against the shared p40 subunit of the IL-12 and IL-23 cytokines, for moderate to severe plaque psoriasis in patients 12 years and older based on the encouraging data of the CADMUS trial (Kellen et al; Landells et al). In Europe, adalimumab has been approved as a first-line therapy in pediatric psoriasis (age ≥4 years), and etanercept (age ≥6 years) and ustekinumab (age ≥12 years) have been approved as second-line agents, all with grade A evidence, according to a recent Italian panel (Fortina et al). (A thorough review of the guidelines on screening, administration, and vaccination is available from Eichenfield et al.)

What treatments are in the pipeline?

In the United States we have clinical trials ongoing of adult-approved topical and immune response-modifying agents such as apremilast. These agents, as they become available and the data are gathered, will be added to what I refer to as our "pharmamentarium" of agents we can use to combat a difficult and disabling illness. 

What gaps are there in the pediatric psoriasis research?

Currently, there is poor awareness that there is research for pediatric psoriasis, and there is a need for pediatric groups and the National Psoriasis Foundation to allow children, adolescents, and their families to know that clinical trials are available looking into newer, more targeted, and less immunosuppressive agents. There is new hope on the horizon!

Suggested Readings

Bronckers IMGJ, Seyger MMB, West DP, et al; Psoriasis Investigator Group (PsIG) of the Pediatric Dermatology Research Alliance and the European Working Group on Pediatric Psoriasis (EWGPP). Safety of systemic agents for the treatment of pediatric psoriasis. JAMA Dermatol. 2017;153:1147-1157.

Eichenfield LF, Paller AS, Tom WL, et al. Pediatric psoriasis: evolving perspectives [published online January 4, 2018]. Pediatr Dermatol. doi:10.1111/pde.13382.

Fortina AB, Bardazzi F, Berti S, et al. Treatment of severe psoriasis in children: recommendations of an Italian expert group [published online August 23, 2017]. Eur J Pediatr. 2017;176:1339-1354.

Kellen R, Silverberg NB, Lebwohl M. Efficacy and safety of ustekinumab in adolescents. Pediatric Health Med Ther. 2016;7:109-120.

Kim GE, Seidler E, Kimball AB. Effect of age at diagnosis on chronic quality of life and long-term outcomes of individuals with psoriasis [published online December 29, 2014]. Pediatr Dermatol. 2015;32:656-662.

Kwa L, Kwa MC, Silverberg JI. Cardiovascular comorbidities of pediatric psoriasis among hospitalized children in the United States. J Am Acad Dermatol. 2017;77:1023-1029.

Landells I, Marano C, Hsu MC, et al. Ustekinumab in adolescent patients age 12 to 17 years with moderate-to-severe plaque psoriasis: results of the randomized phase 3 CADMUS study [published online August 7, 2015]. J Am Acad Dermatol. 2015;73:594-603.

Mercy KM, Paller AS. The relationship between obesity and psoriasis in the pediatric population: implications and future directions. Cutis. 2013;92:107-109.

Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17:174-178.

Tollefson MM, Van Houten HK, Asante D, et al. Association of psoriasis with comorbidity development in children with psoriasis [published online January 10, 2018]. JAMA Dermatol. doi:10.1001/jamadermatol.2017.5417. 

What causes psoriasis in children?

Psoriasis is a chronic immune-mediated inflammatory skin disease with a genetic predisposition (Eichenfield et al). Similar to many inflammatory skin diseases, school-aged children have a greater predisposition before or in early adolescence. As with adult disease, pediatric psoriasis has a complex pathogenesis largely related to aberrant immune response to triggers such as infections (eg, streptococcal pharyngitis, perianal streptococcal dermatitis, upper respiratory viral infections), trauma (ie, Koebner phenomenon), stress, and obesity.

What are the emerging data and recommendations on screening for comorbidities in children with psoriasis?

Similar to psoriasis in adults, obesity and the metabolic syndrome are a true association with pediatric psoriasis that has been discussed in the literature (Eichenfield et al). Although many children with psoriasis have obesity as a potential comorbidity, the risk of cardiovascular comorbidities independent of obesity is high in pediatric psoriasis including elevated lipids, hypertension, polycystic ovaries, nonalcoholic liver disease, and elevated liver enzymes (Tollefson et al). Children with psoriasis have greater central obesity and adiposity, often accompanied by a family history of obesity. Interventions in this direction may be needed for long-term disease control and general health (Mercy and Paller). One target population is hospitalized children with psoriasis, particularly black and Hispanic children aged 0 to 9 years. This population has been identified to have a greater risk for obesity, diabetes mellitus, hypertension, arrhythmia, and valvular heart disease (Kwa et al). Therefore, it can be said that dermatologists can help to improve the overall health and lifestyle long-term in children with psoriasis.

Early-onset disease also is associated with greater risk for lifetime quality-of-life impairments including poor lifetime dermatology life quality index scores, depression and psoriasis-induced depression, social discrimination, sleep problems, and recreational drug usage (Kim et al).

How does psoriasis in children differ from adults?

Children have a variety of features that differ from adult disease. First, they are more likely to have an infectious trigger and therefore may have an identifiable treatable source. Second, they are more likely to have a family history of disease, with one-third having a relative with psoriasis, therefore, identifying the child at risk for long-standing disease. Third, children have far more visible head and neck disease, especially facial involvement including eyelids (Raychaudhuri and Gross), which increases the risk of bullying, social stigma, and negative effects on self-image. Of course, site is affected by age, and in infancy diaper dermatitis and inverse disease with maceration and overlying candidal diaper dermatitis can occur. Although children have less joint disease, it can be dramatic and crippling to the developing child.

What treatments are available for children?

In childhood, identification of precipitating infections such as streptococcal infection is ideal with appropriate intervention thereafter. Topical therapies are appropriate for limited disease with minimal disability; however, phototherapy and systemic agents can be used in pediatric psoriasis in extensive cases. Topical therapies can include corticosteroids, calcineurin inhibitors often used in sensitive skin such as the face and intertriginous areas, and calcipotriene (Eichenfield et al). Additional agents such as tar and salicylic acid can be used, with limitations on the latter due to risk for absorption in smaller children. Systemic interventions often are introduced after years of disease. A recent study identified practitioners with special interest in pediatric psoriasis and determined that systemic interventions were on average introduced 3 years after psoriasis was diagnosed and most commonly included methotrexate followed by etanercept, the latter having fewer gastrointestinal tract side effects. The panel found that usage of folic acid 6 days weekly minimized gastrointestinal tract side effects with methotrexate. Acitretin and cyclosporine were alternatives (Bronckers et al; Psoriasis Investigator Group [PsIG] of the Pediatric Dermatology Research Alliance and the European Working Group on Pediatric Psoriasis [EWGPP]).

Recently, dermatologists have become aware of the dramatic benefits of immune response modifiers and some biologics on pediatric psoriasis. In the setting of joint and skin involvement, I allow the rheumatologist to make the choice of agents for the child's best outcome. However, for pediatric and adolescent psoriasis, we now have 2 US Food and Drug Administration-approved agents and more rapid and thorough testing of adult-approved agents in children, with a hope of greater ability to modify disease course at a younger age, both now and in the future.

Which biologics are approved for the pediatric patient population?

Currently, in the United States 2 biologics have been approved: (1) etanercept, a fusion protein of tumor necrosis factor receptor extracellular domain linked to the Fc portion of human IgG, for moderate to severe plaque psoriasis in patients 4 years and older, and (2) ustekinumab, a human IgG1κ monoclonal antibody against the shared p40 subunit of the IL-12 and IL-23 cytokines, for moderate to severe plaque psoriasis in patients 12 years and older based on the encouraging data of the CADMUS trial (Kellen et al; Landells et al). In Europe, adalimumab has been approved as a first-line therapy in pediatric psoriasis (age ≥4 years), and etanercept (age ≥6 years) and ustekinumab (age ≥12 years) have been approved as second-line agents, all with grade A evidence, according to a recent Italian panel (Fortina et al). (A thorough review of the guidelines on screening, administration, and vaccination is available from Eichenfield et al.)

What treatments are in the pipeline?

In the United States we have clinical trials ongoing of adult-approved topical and immune response-modifying agents such as apremilast. These agents, as they become available and the data are gathered, will be added to what I refer to as our "pharmamentarium" of agents we can use to combat a difficult and disabling illness. 

What gaps are there in the pediatric psoriasis research?

Currently, there is poor awareness that there is research for pediatric psoriasis, and there is a need for pediatric groups and the National Psoriasis Foundation to allow children, adolescents, and their families to know that clinical trials are available looking into newer, more targeted, and less immunosuppressive agents. There is new hope on the horizon!

Suggested Readings

Bronckers IMGJ, Seyger MMB, West DP, et al; Psoriasis Investigator Group (PsIG) of the Pediatric Dermatology Research Alliance and the European Working Group on Pediatric Psoriasis (EWGPP). Safety of systemic agents for the treatment of pediatric psoriasis. JAMA Dermatol. 2017;153:1147-1157.

Eichenfield LF, Paller AS, Tom WL, et al. Pediatric psoriasis: evolving perspectives [published online January 4, 2018]. Pediatr Dermatol. doi:10.1111/pde.13382.

Fortina AB, Bardazzi F, Berti S, et al. Treatment of severe psoriasis in children: recommendations of an Italian expert group [published online August 23, 2017]. Eur J Pediatr. 2017;176:1339-1354.

Kellen R, Silverberg NB, Lebwohl M. Efficacy and safety of ustekinumab in adolescents. Pediatric Health Med Ther. 2016;7:109-120.

Kim GE, Seidler E, Kimball AB. Effect of age at diagnosis on chronic quality of life and long-term outcomes of individuals with psoriasis [published online December 29, 2014]. Pediatr Dermatol. 2015;32:656-662.

Kwa L, Kwa MC, Silverberg JI. Cardiovascular comorbidities of pediatric psoriasis among hospitalized children in the United States. J Am Acad Dermatol. 2017;77:1023-1029.

Landells I, Marano C, Hsu MC, et al. Ustekinumab in adolescent patients age 12 to 17 years with moderate-to-severe plaque psoriasis: results of the randomized phase 3 CADMUS study [published online August 7, 2015]. J Am Acad Dermatol. 2015;73:594-603.

Mercy KM, Paller AS. The relationship between obesity and psoriasis in the pediatric population: implications and future directions. Cutis. 2013;92:107-109.

Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17:174-178.

Tollefson MM, Van Houten HK, Asante D, et al. Association of psoriasis with comorbidity development in children with psoriasis [published online January 10, 2018]. JAMA Dermatol. doi:10.1001/jamadermatol.2017.5417. 

What do patients need to know initially about psoriasis treatment?

It is important to set expectations with the patient based on the treatment selected, not only for patient satisfaction but to forge an enduring bond with the patient so he/she will trust you to guide the treatment plan if the first therapy does not work as well as anticipated. Because psoriasis is a longitudinal disease process, the patient-physician relationship should be, too. Certainly, these principles generally apply among all patient groups and demographics; however, one may take into account a few special circumstances when dealing with psoriasis. In a pediatric patient, I may try to see if topical therapy including calcipotriene can adequately treat the skin disease before pursuing systemic treatment. The rationale is 2-fold: (1) this patient would be committed to an extended period on immunomodulatory therapy if he/she truly requires it, and (2) some of the forms of psoriasis in children, such as guttate psoriasis, may be self-limited, so it is reasonable to see if it will persist before forging ahead with a long-term systemic medication. In patients with a recent history of cancer, I would likely choose an oral medication such as apremilast before a biologic; even though there are no real data to suggest biologics are associated with higher rates of solid-organ malignancy, most practitioners would err on the side of being more conservative. For patients with human immunodeficiency virus, the tendency is to use the agents with more data (eg, tumor necrosis factor α inhibitors) due to safety concerns with an immunomodulatory medication.

What are your go-to treatments?

I tend to be as aggressive as the patient wants to be with therapy. I regularly see patients in whom multiple systemic treatments have failed and a more creative regimen is needed, such as combining a biologic medication with an oral antipsoriatic treatment (eg, apremilast, acitretin). However, I do have patients with moderate to severe psoriasis who have not seen a dermatologist before. I do not find it necessary to have topical treatments fail before starting a biologic; after all, the sequelae of long-term topical steroid use are notable.

With the newer biologics on the market, such as the IL-17 and IL-23 inhibitors, the sky's the limit for psoriasis area and severity index clearance, but the true benefit is that these medications are much more targeted toward the pathogenesis of psoriasis. Unfortunately, we have to be mindful of insurance and formulary restrictions, but when faced with choosing a broad-acting immunomodulatory agent or a more specific/targeted immunomodulatory agent for an inflammatory disease, most dermatologists would choose the more targeted medication. The data support that the newer agents have better psoriasis area and severity index responses and a much greater proportion of clearance, but there is something to be said about biologics such as etanercept, adalimumab, and ustekinumab, which have been on the market for much longer and have shown durable response with a longer track record of safety and efficacy. Recent head-to-head comparisons can help guide treatment. For instance, patients who achieved suboptimal clearance on ustekinumab can safely and reasonably be switched to guselkumab based on the findings of the NAVIGATE study, which looked at this exact situation. More of these studies looking at specific prior treatment failures and improvement upon switching to a newer agent are needed to underscore the efficacy of these drugs and also to help argue for their placement on insurance formularies.

For a new patient with psoriasis, I will screen for psoriatic arthritis, look at involvement (eg, body surface area, individual plaque severity/thickness, locations such as scalp and extremities), and assess patient attitudes toward different treatments. Two patients with the exact same clinical appearance might have completely different strategies, one wanting to be as aggressive as possible to get rid of the psoriasis and the other not believing in systemic treatments and wanting to be as "natural" as possible.

For patients with only cutaneous involvement, the dosing frequency and efficacy of the newer IL-17 and IL-23 classes of medications are hard to beat. If a patient has notable psoriatic arthritis, I still tend to reach for a tumor necrosis factor α inhibitor first. For patients with limited involvement, especially those with scalp and/or palmoplantar psoriasis, I have found that apremilast works quite well. Apremilast, in general, would be a good first-step medication for patients wary of systemic therapy, and with its relatively benign side-effect profile, it has almost completely supplanted methotrexate in my practice. We also have a few newer topical medicines such as a calcipotriene 0.005%-betamethasone dipropionate 0.064% foam and a betamethasone dipropionate spray 0.05% that have proven useful, with more products in the pipeline.

How do you keep patients compliant with treatment?

Setting expectations is most important, and letting patients know what to expect from their first visit really helps to keep them satisfied with the plan and progress. Giving the patient a say in guiding the treatment and perhaps coming up with a rough treatment plan with a defined timeline also helps, such as starting with a topical regimen but moving on to an oral medicine if the topical does not work within 2 to 3 months, and then a biologic if oral therapy does not work well within 3 to 6 months. It is important not to push the patient to pursue a more aggressive therapy unless he/she wants to, otherwise the patient might not be compliant or may stop altogether.

What do you do if they refuse treatment?

If the patient is in your office, clearly he/she does want some help. Try to figure out what is at the root of the treatment refusal. Is the patient refusing topical steroids because he/she is afraid of them? Is the patient unable to stomach having to inject himself/herself? Finding the basis of their reticence may take more time, but we usually can find a mutually agreeable plan of action. Even if the first step is to watch and wait, you want the patient leaving your office knowing that if things do not progress as expected or get worse, they can have faith in you to come back and get more help.

What resources do you recommend to patients for more information?

The National Psoriasis Foundation is a great resource for patients. They have numerous outreach programs and a wealth of patient information. Also, the American Academy of Dermatology is a good resource, not just for patients but for providers; for example, the academy offers appeals letters that can be sent to insurance companies to try to advocate for a specific medication for patients.

Suggested Readings

Help patients appeal denial of psoriasis drugs. American Academy of Dermatology website. https://www.aad.org/members/publications/member-to-member/2017/jan-27-2017/help-patients-appeal-denial-of-psoriasis-drugs. Accessed February 9, 2018.

Langley RG, Tsai TF, Flavin S, et al. Efficacy and safety of guselkumab in patients with psoriasis who have an inadequate response to ustekinumab: results of the randomized, double-blind, phase III NAVIGATE trial [published online October 10, 2017]. Br J Dermatol. 2018;178:114-123.

What do patients need to know initially about psoriasis treatment?

It is important to set expectations with the patient based on the treatment selected, not only for patient satisfaction but to forge an enduring bond with the patient so he/she will trust you to guide the treatment plan if the first therapy does not work as well as anticipated. Because psoriasis is a longitudinal disease process, the patient-physician relationship should be, too. Certainly, these principles generally apply among all patient groups and demographics; however, one may take into account a few special circumstances when dealing with psoriasis. In a pediatric patient, I may try to see if topical therapy including calcipotriene can adequately treat the skin disease before pursuing systemic treatment. The rationale is 2-fold: (1) this patient would be committed to an extended period on immunomodulatory therapy if he/she truly requires it, and (2) some of the forms of psoriasis in children, such as guttate psoriasis, may be self-limited, so it is reasonable to see if it will persist before forging ahead with a long-term systemic medication. In patients with a recent history of cancer, I would likely choose an oral medication such as apremilast before a biologic; even though there are no real data to suggest biologics are associated with higher rates of solid-organ malignancy, most practitioners would err on the side of being more conservative. For patients with human immunodeficiency virus, the tendency is to use the agents with more data (eg, tumor necrosis factor α inhibitors) due to safety concerns with an immunomodulatory medication.

What are your go-to treatments?

I tend to be as aggressive as the patient wants to be with therapy. I regularly see patients in whom multiple systemic treatments have failed and a more creative regimen is needed, such as combining a biologic medication with an oral antipsoriatic treatment (eg, apremilast, acitretin). However, I do have patients with moderate to severe psoriasis who have not seen a dermatologist before. I do not find it necessary to have topical treatments fail before starting a biologic; after all, the sequelae of long-term topical steroid use are notable.

With the newer biologics on the market, such as the IL-17 and IL-23 inhibitors, the sky's the limit for psoriasis area and severity index clearance, but the true benefit is that these medications are much more targeted toward the pathogenesis of psoriasis. Unfortunately, we have to be mindful of insurance and formulary restrictions, but when faced with choosing a broad-acting immunomodulatory agent or a more specific/targeted immunomodulatory agent for an inflammatory disease, most dermatologists would choose the more targeted medication. The data support that the newer agents have better psoriasis area and severity index responses and a much greater proportion of clearance, but there is something to be said about biologics such as etanercept, adalimumab, and ustekinumab, which have been on the market for much longer and have shown durable response with a longer track record of safety and efficacy. Recent head-to-head comparisons can help guide treatment. For instance, patients who achieved suboptimal clearance on ustekinumab can safely and reasonably be switched to guselkumab based on the findings of the NAVIGATE study, which looked at this exact situation. More of these studies looking at specific prior treatment failures and improvement upon switching to a newer agent are needed to underscore the efficacy of these drugs and also to help argue for their placement on insurance formularies.

For a new patient with psoriasis, I will screen for psoriatic arthritis, look at involvement (eg, body surface area, individual plaque severity/thickness, locations such as scalp and extremities), and assess patient attitudes toward different treatments. Two patients with the exact same clinical appearance might have completely different strategies, one wanting to be as aggressive as possible to get rid of the psoriasis and the other not believing in systemic treatments and wanting to be as "natural" as possible.

For patients with only cutaneous involvement, the dosing frequency and efficacy of the newer IL-17 and IL-23 classes of medications are hard to beat. If a patient has notable psoriatic arthritis, I still tend to reach for a tumor necrosis factor α inhibitor first. For patients with limited involvement, especially those with scalp and/or palmoplantar psoriasis, I have found that apremilast works quite well. Apremilast, in general, would be a good first-step medication for patients wary of systemic therapy, and with its relatively benign side-effect profile, it has almost completely supplanted methotrexate in my practice. We also have a few newer topical medicines such as a calcipotriene 0.005%-betamethasone dipropionate 0.064% foam and a betamethasone dipropionate spray 0.05% that have proven useful, with more products in the pipeline.

How do you keep patients compliant with treatment?

Setting expectations is most important, and letting patients know what to expect from their first visit really helps to keep them satisfied with the plan and progress. Giving the patient a say in guiding the treatment and perhaps coming up with a rough treatment plan with a defined timeline also helps, such as starting with a topical regimen but moving on to an oral medicine if the topical does not work within 2 to 3 months, and then a biologic if oral therapy does not work well within 3 to 6 months. It is important not to push the patient to pursue a more aggressive therapy unless he/she wants to, otherwise the patient might not be compliant or may stop altogether.

What do you do if they refuse treatment?

If the patient is in your office, clearly he/she does want some help. Try to figure out what is at the root of the treatment refusal. Is the patient refusing topical steroids because he/she is afraid of them? Is the patient unable to stomach having to inject himself/herself? Finding the basis of their reticence may take more time, but we usually can find a mutually agreeable plan of action. Even if the first step is to watch and wait, you want the patient leaving your office knowing that if things do not progress as expected or get worse, they can have faith in you to come back and get more help.

What resources do you recommend to patients for more information?

The National Psoriasis Foundation is a great resource for patients. They have numerous outreach programs and a wealth of patient information. Also, the American Academy of Dermatology is a good resource, not just for patients but for providers; for example, the academy offers appeals letters that can be sent to insurance companies to try to advocate for a specific medication for patients.

Suggested Readings

Help patients appeal denial of psoriasis drugs. American Academy of Dermatology website. https://www.aad.org/members/publications/member-to-member/2017/jan-27-2017/help-patients-appeal-denial-of-psoriasis-drugs. Accessed February 9, 2018.

Langley RG, Tsai TF, Flavin S, et al. Efficacy and safety of guselkumab in patients with psoriasis who have an inadequate response to ustekinumab: results of the randomized, double-blind, phase III NAVIGATE trial [published online October 10, 2017]. Br J Dermatol. 2018;178:114-123.

What do patients need to know initially about psoriasis treatment?

It is important to set expectations with the patient based on the treatment selected, not only for patient satisfaction but to forge an enduring bond with the patient so he/she will trust you to guide the treatment plan if the first therapy does not work as well as anticipated. Because psoriasis is a longitudinal disease process, the patient-physician relationship should be, too. Certainly, these principles generally apply among all patient groups and demographics; however, one may take into account a few special circumstances when dealing with psoriasis. In a pediatric patient, I may try to see if topical therapy including calcipotriene can adequately treat the skin disease before pursuing systemic treatment. The rationale is 2-fold: (1) this patient would be committed to an extended period on immunomodulatory therapy if he/she truly requires it, and (2) some of the forms of psoriasis in children, such as guttate psoriasis, may be self-limited, so it is reasonable to see if it will persist before forging ahead with a long-term systemic medication. In patients with a recent history of cancer, I would likely choose an oral medication such as apremilast before a biologic; even though there are no real data to suggest biologics are associated with higher rates of solid-organ malignancy, most practitioners would err on the side of being more conservative. For patients with human immunodeficiency virus, the tendency is to use the agents with more data (eg, tumor necrosis factor α inhibitors) due to safety concerns with an immunomodulatory medication.

What are your go-to treatments?

I tend to be as aggressive as the patient wants to be with therapy. I regularly see patients in whom multiple systemic treatments have failed and a more creative regimen is needed, such as combining a biologic medication with an oral antipsoriatic treatment (eg, apremilast, acitretin). However, I do have patients with moderate to severe psoriasis who have not seen a dermatologist before. I do not find it necessary to have topical treatments fail before starting a biologic; after all, the sequelae of long-term topical steroid use are notable.

With the newer biologics on the market, such as the IL-17 and IL-23 inhibitors, the sky's the limit for psoriasis area and severity index clearance, but the true benefit is that these medications are much more targeted toward the pathogenesis of psoriasis. Unfortunately, we have to be mindful of insurance and formulary restrictions, but when faced with choosing a broad-acting immunomodulatory agent or a more specific/targeted immunomodulatory agent for an inflammatory disease, most dermatologists would choose the more targeted medication. The data support that the newer agents have better psoriasis area and severity index responses and a much greater proportion of clearance, but there is something to be said about biologics such as etanercept, adalimumab, and ustekinumab, which have been on the market for much longer and have shown durable response with a longer track record of safety and efficacy. Recent head-to-head comparisons can help guide treatment. For instance, patients who achieved suboptimal clearance on ustekinumab can safely and reasonably be switched to guselkumab based on the findings of the NAVIGATE study, which looked at this exact situation. More of these studies looking at specific prior treatment failures and improvement upon switching to a newer agent are needed to underscore the efficacy of these drugs and also to help argue for their placement on insurance formularies.

For a new patient with psoriasis, I will screen for psoriatic arthritis, look at involvement (eg, body surface area, individual plaque severity/thickness, locations such as scalp and extremities), and assess patient attitudes toward different treatments. Two patients with the exact same clinical appearance might have completely different strategies, one wanting to be as aggressive as possible to get rid of the psoriasis and the other not believing in systemic treatments and wanting to be as "natural" as possible.

For patients with only cutaneous involvement, the dosing frequency and efficacy of the newer IL-17 and IL-23 classes of medications are hard to beat. If a patient has notable psoriatic arthritis, I still tend to reach for a tumor necrosis factor α inhibitor first. For patients with limited involvement, especially those with scalp and/or palmoplantar psoriasis, I have found that apremilast works quite well. Apremilast, in general, would be a good first-step medication for patients wary of systemic therapy, and with its relatively benign side-effect profile, it has almost completely supplanted methotrexate in my practice. We also have a few newer topical medicines such as a calcipotriene 0.005%-betamethasone dipropionate 0.064% foam and a betamethasone dipropionate spray 0.05% that have proven useful, with more products in the pipeline.

How do you keep patients compliant with treatment?

Setting expectations is most important, and letting patients know what to expect from their first visit really helps to keep them satisfied with the plan and progress. Giving the patient a say in guiding the treatment and perhaps coming up with a rough treatment plan with a defined timeline also helps, such as starting with a topical regimen but moving on to an oral medicine if the topical does not work within 2 to 3 months, and then a biologic if oral therapy does not work well within 3 to 6 months. It is important not to push the patient to pursue a more aggressive therapy unless he/she wants to, otherwise the patient might not be compliant or may stop altogether.

What do you do if they refuse treatment?

If the patient is in your office, clearly he/she does want some help. Try to figure out what is at the root of the treatment refusal. Is the patient refusing topical steroids because he/she is afraid of them? Is the patient unable to stomach having to inject himself/herself? Finding the basis of their reticence may take more time, but we usually can find a mutually agreeable plan of action. Even if the first step is to watch and wait, you want the patient leaving your office knowing that if things do not progress as expected or get worse, they can have faith in you to come back and get more help.

What resources do you recommend to patients for more information?

The National Psoriasis Foundation is a great resource for patients. They have numerous outreach programs and a wealth of patient information. Also, the American Academy of Dermatology is a good resource, not just for patients but for providers; for example, the academy offers appeals letters that can be sent to insurance companies to try to advocate for a specific medication for patients.

Suggested Readings

Help patients appeal denial of psoriasis drugs. American Academy of Dermatology website. https://www.aad.org/members/publications/member-to-member/2017/jan-27-2017/help-patients-appeal-denial-of-psoriasis-drugs. Accessed February 9, 2018.

Langley RG, Tsai TF, Flavin S, et al. Efficacy and safety of guselkumab in patients with psoriasis who have an inadequate response to ustekinumab: results of the randomized, double-blind, phase III NAVIGATE trial [published online October 10, 2017]. Br J Dermatol. 2018;178:114-123.