Immunology

BARCELONA – Influenza vaccine has been shown to provide protection against cardiovascular events, but can the same be said for pneumococcal vaccine?

Yes, particularly in the elderly and in patients at high baseline cardiovascular risk, according to a meta-analysis presented by Dr. Dimitrios Terentes-Printzios at the annual congress of the European Society of Cardiology.

He analyzed 11 published studies comprising 332,267 subjects followed for a mean of 20 months. Because the studies focused on different populations and in some cases reached conflicting conclusions, he performed a series of subgroup analyses to gain a clearer picture.

One of these analyses found that the cardioprotective effects of pneumococcal vaccination wane over time. In studies with follow-up of less than 1 year, the relative risk of total cardiovascular events was 0.72, meaning that patients who received pneumococcal vaccine had a significant 28% relative risk reduction compared with those who did not. In studies with follow-up in excess of 1 year, however, there was no cardioprotective effect, according to Dr. Terentes-Printzios of Athens Medical School.

Significant protection against total cardiovascular events was seen in elderly vaccinated patients, with a 20% relative risk reduction, and in subjects at high baseline cardiovascular risk, who had an 8% risk reduction if they received pneumococcal vaccine.

Breaking down the specific endpoints, subjects who got pneumococcal vaccine had a statistically significant 8% reduction in the risk of cardiovascular mortality. However, vaccination provided no significant protective effect against acute MI or cerebrovascular events except in the elderly, where the relative risk reductions were 10% and 14%, respectively.

These cardio- and cerebrovascular protective benefits of the pneumococcal vaccine can be viewed as added value, given that the primary reason physicians prescribe the vaccine is its demonstrated ability to reduce the risk of invasive pneumococcal infection by up to 60%.

Dr. Terentes-Printzios reported having no financial conflicts.

[email protected]

BARCELONA – Influenza vaccine has been shown to provide protection against cardiovascular events, but can the same be said for pneumococcal vaccine?

Yes, particularly in the elderly and in patients at high baseline cardiovascular risk, according to a meta-analysis presented by Dr. Dimitrios Terentes-Printzios at the annual congress of the European Society of Cardiology.

He analyzed 11 published studies comprising 332,267 subjects followed for a mean of 20 months. Because the studies focused on different populations and in some cases reached conflicting conclusions, he performed a series of subgroup analyses to gain a clearer picture.

One of these analyses found that the cardioprotective effects of pneumococcal vaccination wane over time. In studies with follow-up of less than 1 year, the relative risk of total cardiovascular events was 0.72, meaning that patients who received pneumococcal vaccine had a significant 28% relative risk reduction compared with those who did not. In studies with follow-up in excess of 1 year, however, there was no cardioprotective effect, according to Dr. Terentes-Printzios of Athens Medical School.

Significant protection against total cardiovascular events was seen in elderly vaccinated patients, with a 20% relative risk reduction, and in subjects at high baseline cardiovascular risk, who had an 8% risk reduction if they received pneumococcal vaccine.

Breaking down the specific endpoints, subjects who got pneumococcal vaccine had a statistically significant 8% reduction in the risk of cardiovascular mortality. However, vaccination provided no significant protective effect against acute MI or cerebrovascular events except in the elderly, where the relative risk reductions were 10% and 14%, respectively.

These cardio- and cerebrovascular protective benefits of the pneumococcal vaccine can be viewed as added value, given that the primary reason physicians prescribe the vaccine is its demonstrated ability to reduce the risk of invasive pneumococcal infection by up to 60%.

Dr. Terentes-Printzios reported having no financial conflicts.

[email protected]

BARCELONA – Influenza vaccine has been shown to provide protection against cardiovascular events, but can the same be said for pneumococcal vaccine?

Yes, particularly in the elderly and in patients at high baseline cardiovascular risk, according to a meta-analysis presented by Dr. Dimitrios Terentes-Printzios at the annual congress of the European Society of Cardiology.

He analyzed 11 published studies comprising 332,267 subjects followed for a mean of 20 months. Because the studies focused on different populations and in some cases reached conflicting conclusions, he performed a series of subgroup analyses to gain a clearer picture.

One of these analyses found that the cardioprotective effects of pneumococcal vaccination wane over time. In studies with follow-up of less than 1 year, the relative risk of total cardiovascular events was 0.72, meaning that patients who received pneumococcal vaccine had a significant 28% relative risk reduction compared with those who did not. In studies with follow-up in excess of 1 year, however, there was no cardioprotective effect, according to Dr. Terentes-Printzios of Athens Medical School.

Significant protection against total cardiovascular events was seen in elderly vaccinated patients, with a 20% relative risk reduction, and in subjects at high baseline cardiovascular risk, who had an 8% risk reduction if they received pneumococcal vaccine.

Breaking down the specific endpoints, subjects who got pneumococcal vaccine had a statistically significant 8% reduction in the risk of cardiovascular mortality. However, vaccination provided no significant protective effect against acute MI or cerebrovascular events except in the elderly, where the relative risk reductions were 10% and 14%, respectively.

These cardio- and cerebrovascular protective benefits of the pneumococcal vaccine can be viewed as added value, given that the primary reason physicians prescribe the vaccine is its demonstrated ability to reduce the risk of invasive pneumococcal infection by up to 60%.

Dr. Terentes-Printzios reported having no financial conflicts.

[email protected]

A 67-year-old woman has had a very itchy rash on the dorsa of both feet for almost a year. In addition to consulting her primary care provider, she has presented to a number of medical venues, including urgent care clinics. Different products have been prescribed—including clotrimazole cream, nystatin powder, and OTC hydrocortisone 1% cream—none of which produced any beneficial effect. So the patient finally self-refers to dermatology. 

She reports that at one point, she was convinced her shoes were the source of the problem. But trying new shoes and even going entirely barefoot during a two-week vacation at the beach made no difference. 

The patient admits that it is “impossible” to leave the lesions alone, because they are so itchy. She knows that “scratching can’t be good,” so she tries to just rub them, often with a wet washcloth.

Aside from the foot rash, her health is excellent. Her only medications are NSAIDs for mild arthritis.

EXAMINATION
The lesions are confined to the forefeet. There are about five on the right foot and three on the left. The lesions are dark purplish round plaques with planar surfaces that are shiny but have a white frosting-like finish. On average, they measure 1.8 cm in diameter. No surrounding inflammation is appreciated. The patient has otherwise unremarkable type IV skin. 

What is the diagnosis?

DIAGNOSIS
Punch biopsy confirms the expected diagnosis of lichen planus. 

DISCUSSION
Lichen planus (LP) is a very common problem seen in dermatology offices worldwide. LP represents an immune response of unknown origin and may be found in association with other diseases of altered immunity (eg, dermatomyositis, alopecia areata, vitiligo, morphea, and myasthenia gravis). Some studies support the theory that LP is caused by hepatitis C. 

The most common forms of LP lend themselves to a useful mnemonic device that uses the letter “P” to describe common features of the disease: purple, papular or plaquish, planar (flat) surfaces, polygonal shapes, pruritic, penile (frequent location), and finally, “puzzling” to the clinician.

In contrast to this particular case, LP commonly affects flexural surfaces, such as the volar wrist. LP can also affect nails (with dystrophy or onycholysis), the scalp, and, most notoriously, the oral mucosae, where it can cause ulcerations and intense burning. Oral lesions often present with a lacy white look on the buccal mucosal surfaces. 

LP is only one of a number of skin diseases that “koebnerize” (ie, form along lines of trauma, such as a scratch). The resulting linear collection of planar purple papules—known as the Koebner phenomenon—is useful for diagnosis.

Biopsy is often needed to confirm the diagnosis. It will show hyperkeratotic epidermis with irregular acanthosis. In the upper dermis, there is often an infiltrating band of lymphocytic and histiocytic cells, along with many Langerhans cells, that effectively obliterates the dermo-epidermal junction (a pathognomic finding of LP).

Most cases of LP eventually resolve, usually within months, though some can persist for years. Treatment can be problematic, especially when the disease is widespread or manifests in difficult areas, such as the mouth or scalp. This particular patient’s problem was relatively simple to treat with topical clobetasol cream under occlusion (bid for three weeks). Had that not worked, we could have tried intralesional injection of triamcinolone (10 mg per cc).

This case was typical of LP seen on the legs of older patients with darker skin. In these patients, the lesions tend to become hypertrophic and darker than the usual light pink to purple seen in those with fairer skin.

The differential for LP includes psoriasis, fixed-drug eruption, granuloma annulare, and nummular eczema.

TAKE-HOME LEARNING POINTS
• Lichen planus (LP) is a commonly encountered inflammatory condition that classically affects flexural skin, such as the volar wrist.

• LP lesions can often be seen in a linear configuration, following the line of a scratch or other trauma, a phenomenon known as the Koebner phenomenon (the isomorphic linear response), which can be helpful diagnostically.

• The “Ps” of LP include papular, purple, planar, plaquish, pruritic, penile, polygonal, and puzzling.

• LP can also affect hair follicles, nails, and oral mucosa.

• LP can present with hypertrophic plaques, especially on legs and feet.

A 67-year-old woman has had a very itchy rash on the dorsa of both feet for almost a year. In addition to consulting her primary care provider, she has presented to a number of medical venues, including urgent care clinics. Different products have been prescribed—including clotrimazole cream, nystatin powder, and OTC hydrocortisone 1% cream—none of which produced any beneficial effect. So the patient finally self-refers to dermatology. 

She reports that at one point, she was convinced her shoes were the source of the problem. But trying new shoes and even going entirely barefoot during a two-week vacation at the beach made no difference. 

The patient admits that it is “impossible” to leave the lesions alone, because they are so itchy. She knows that “scratching can’t be good,” so she tries to just rub them, often with a wet washcloth.

Aside from the foot rash, her health is excellent. Her only medications are NSAIDs for mild arthritis.

EXAMINATION
The lesions are confined to the forefeet. There are about five on the right foot and three on the left. The lesions are dark purplish round plaques with planar surfaces that are shiny but have a white frosting-like finish. On average, they measure 1.8 cm in diameter. No surrounding inflammation is appreciated. The patient has otherwise unremarkable type IV skin. 

What is the diagnosis?

DIAGNOSIS
Punch biopsy confirms the expected diagnosis of lichen planus. 

DISCUSSION
Lichen planus (LP) is a very common problem seen in dermatology offices worldwide. LP represents an immune response of unknown origin and may be found in association with other diseases of altered immunity (eg, dermatomyositis, alopecia areata, vitiligo, morphea, and myasthenia gravis). Some studies support the theory that LP is caused by hepatitis C. 

The most common forms of LP lend themselves to a useful mnemonic device that uses the letter “P” to describe common features of the disease: purple, papular or plaquish, planar (flat) surfaces, polygonal shapes, pruritic, penile (frequent location), and finally, “puzzling” to the clinician.

In contrast to this particular case, LP commonly affects flexural surfaces, such as the volar wrist. LP can also affect nails (with dystrophy or onycholysis), the scalp, and, most notoriously, the oral mucosae, where it can cause ulcerations and intense burning. Oral lesions often present with a lacy white look on the buccal mucosal surfaces. 

LP is only one of a number of skin diseases that “koebnerize” (ie, form along lines of trauma, such as a scratch). The resulting linear collection of planar purple papules—known as the Koebner phenomenon—is useful for diagnosis.

Biopsy is often needed to confirm the diagnosis. It will show hyperkeratotic epidermis with irregular acanthosis. In the upper dermis, there is often an infiltrating band of lymphocytic and histiocytic cells, along with many Langerhans cells, that effectively obliterates the dermo-epidermal junction (a pathognomic finding of LP).

Most cases of LP eventually resolve, usually within months, though some can persist for years. Treatment can be problematic, especially when the disease is widespread or manifests in difficult areas, such as the mouth or scalp. This particular patient’s problem was relatively simple to treat with topical clobetasol cream under occlusion (bid for three weeks). Had that not worked, we could have tried intralesional injection of triamcinolone (10 mg per cc).

This case was typical of LP seen on the legs of older patients with darker skin. In these patients, the lesions tend to become hypertrophic and darker than the usual light pink to purple seen in those with fairer skin.

The differential for LP includes psoriasis, fixed-drug eruption, granuloma annulare, and nummular eczema.

TAKE-HOME LEARNING POINTS
• Lichen planus (LP) is a commonly encountered inflammatory condition that classically affects flexural skin, such as the volar wrist.

• LP lesions can often be seen in a linear configuration, following the line of a scratch or other trauma, a phenomenon known as the Koebner phenomenon (the isomorphic linear response), which can be helpful diagnostically.

• The “Ps” of LP include papular, purple, planar, plaquish, pruritic, penile, polygonal, and puzzling.

• LP can also affect hair follicles, nails, and oral mucosa.

• LP can present with hypertrophic plaques, especially on legs and feet.

A 67-year-old woman has had a very itchy rash on the dorsa of both feet for almost a year. In addition to consulting her primary care provider, she has presented to a number of medical venues, including urgent care clinics. Different products have been prescribed—including clotrimazole cream, nystatin powder, and OTC hydrocortisone 1% cream—none of which produced any beneficial effect. So the patient finally self-refers to dermatology. 

She reports that at one point, she was convinced her shoes were the source of the problem. But trying new shoes and even going entirely barefoot during a two-week vacation at the beach made no difference. 

The patient admits that it is “impossible” to leave the lesions alone, because they are so itchy. She knows that “scratching can’t be good,” so she tries to just rub them, often with a wet washcloth.

Aside from the foot rash, her health is excellent. Her only medications are NSAIDs for mild arthritis.

EXAMINATION
The lesions are confined to the forefeet. There are about five on the right foot and three on the left. The lesions are dark purplish round plaques with planar surfaces that are shiny but have a white frosting-like finish. On average, they measure 1.8 cm in diameter. No surrounding inflammation is appreciated. The patient has otherwise unremarkable type IV skin. 

What is the diagnosis?

DIAGNOSIS
Punch biopsy confirms the expected diagnosis of lichen planus. 

DISCUSSION
Lichen planus (LP) is a very common problem seen in dermatology offices worldwide. LP represents an immune response of unknown origin and may be found in association with other diseases of altered immunity (eg, dermatomyositis, alopecia areata, vitiligo, morphea, and myasthenia gravis). Some studies support the theory that LP is caused by hepatitis C. 

The most common forms of LP lend themselves to a useful mnemonic device that uses the letter “P” to describe common features of the disease: purple, papular or plaquish, planar (flat) surfaces, polygonal shapes, pruritic, penile (frequent location), and finally, “puzzling” to the clinician.

In contrast to this particular case, LP commonly affects flexural surfaces, such as the volar wrist. LP can also affect nails (with dystrophy or onycholysis), the scalp, and, most notoriously, the oral mucosae, where it can cause ulcerations and intense burning. Oral lesions often present with a lacy white look on the buccal mucosal surfaces. 

LP is only one of a number of skin diseases that “koebnerize” (ie, form along lines of trauma, such as a scratch). The resulting linear collection of planar purple papules—known as the Koebner phenomenon—is useful for diagnosis.

Biopsy is often needed to confirm the diagnosis. It will show hyperkeratotic epidermis with irregular acanthosis. In the upper dermis, there is often an infiltrating band of lymphocytic and histiocytic cells, along with many Langerhans cells, that effectively obliterates the dermo-epidermal junction (a pathognomic finding of LP).

Most cases of LP eventually resolve, usually within months, though some can persist for years. Treatment can be problematic, especially when the disease is widespread or manifests in difficult areas, such as the mouth or scalp. This particular patient’s problem was relatively simple to treat with topical clobetasol cream under occlusion (bid for three weeks). Had that not worked, we could have tried intralesional injection of triamcinolone (10 mg per cc).

This case was typical of LP seen on the legs of older patients with darker skin. In these patients, the lesions tend to become hypertrophic and darker than the usual light pink to purple seen in those with fairer skin.

The differential for LP includes psoriasis, fixed-drug eruption, granuloma annulare, and nummular eczema.

TAKE-HOME LEARNING POINTS
• Lichen planus (LP) is a commonly encountered inflammatory condition that classically affects flexural skin, such as the volar wrist.

• LP lesions can often be seen in a linear configuration, following the line of a scratch or other trauma, a phenomenon known as the Koebner phenomenon (the isomorphic linear response), which can be helpful diagnostically.

• The “Ps” of LP include papular, purple, planar, plaquish, pruritic, penile, polygonal, and puzzling.

• LP can also affect hair follicles, nails, and oral mucosa.

• LP can present with hypertrophic plaques, especially on legs and feet.

DALLAS – Vaccinations are beneficial for individuals with multiple sclerosis because they help avoid infections, which in turn lower the risk of relapse.

But while inactive vaccines are considered safe for MS patients, the use of live vaccines such as Varivax, Zostavax, or yellow fever vaccine is more nuanced, especially as more disease-modifying therapies (DMT) become available. There are limited data available about the effect of live vaccines on patients who are on DMTs, and the final decision comes down to the risk-benefit ratio, said, Dr. Patricia K. Coyle, professor of neurology and director of the MS Comprehensive Care Center at Stony Brook (N.Y.) University Medical Center.

In a video interview at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis, Dr. Coyle summarizes what’s known so far about vaccines and MS, and provides tips to clinicians.

[email protected]

On Twitter @naseemmiller

DALLAS – Vaccinations are beneficial for individuals with multiple sclerosis because they help avoid infections, which in turn lower the risk of relapse.

But while inactive vaccines are considered safe for MS patients, the use of live vaccines such as Varivax, Zostavax, or yellow fever vaccine is more nuanced, especially as more disease-modifying therapies (DMT) become available. There are limited data available about the effect of live vaccines on patients who are on DMTs, and the final decision comes down to the risk-benefit ratio, said, Dr. Patricia K. Coyle, professor of neurology and director of the MS Comprehensive Care Center at Stony Brook (N.Y.) University Medical Center.

In a video interview at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis, Dr. Coyle summarizes what’s known so far about vaccines and MS, and provides tips to clinicians.

[email protected]

On Twitter @naseemmiller

DALLAS – Vaccinations are beneficial for individuals with multiple sclerosis because they help avoid infections, which in turn lower the risk of relapse.

But while inactive vaccines are considered safe for MS patients, the use of live vaccines such as Varivax, Zostavax, or yellow fever vaccine is more nuanced, especially as more disease-modifying therapies (DMT) become available. There are limited data available about the effect of live vaccines on patients who are on DMTs, and the final decision comes down to the risk-benefit ratio, said, Dr. Patricia K. Coyle, professor of neurology and director of the MS Comprehensive Care Center at Stony Brook (N.Y.) University Medical Center.

In a video interview at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis, Dr. Coyle summarizes what’s known so far about vaccines and MS, and provides tips to clinicians.

[email protected]

On Twitter @naseemmiller

It’s somewhat unusual to see a patient with an eight-year history of the same problem, but this is what happens when a 51-year-old man presents to dermatology. Specifically, the problem is a very itchy foot rash, for which the patient has tried many OTC products without success. He has also used halobetasol cream, prescribed by a dermatologist he saw several years ago.

The patient denies having a rash anywhere else. He does, however, have a markedly atopic history, significant for seasonal allergies, asthma, and very sensitive skin.

For the past several years, when the rash has been particularly unbearable, he admits to pouring rubbing alcohol on his feet. This burned terribly, but his feet felt better afterward.

Asked what else happened eight years ago, the patient recalls starting his current job as a lineman for a power company—an occupation that requires him to wear steel-toed leather boots for hours at a time.

EXAMINATION
A dense, red, papulovesicular rash covers both feet in a stocking pattern. The rash stops abruptly at the same place on both lower legs, completely sparing the soles and interdigital skin. Focal areas of scaling and broken skin are seen on the tops and sides of both feet.

Continue for Joe Monroe's diagnosis and discussion >>

DISCUSSION
In the ’90s, a commercial for sneakers utilized the catchphrase, "It's the shoes!" And so it is occasionally with rashes on the feet. In this case, the patient was allergic to the leather on the inside of his work boots.

A true allergy such as this would be expected to itch and to manifest as a papulovesicular rash limited to areas touched by the leather on the upper portions of his shoes. And it would persist, despite the quantity of topical medications tried, because the patient wore the shoes for eight to 12 hours a day, five or six days per week, continually re-exposing his skin to the offending material. He had never taken any significant time off work and therefore hadn’t refrained from wearing the shoes long enough to allow the rash to abate.

Often, frustrated and uncomfortable patients take matters into their own hands, which can ultimately compound the problem. This patient didn't do his skin any favors with the rubbing alcohol and other products he'd tried (the most common offender being triple-antibiotic ointment, although this patient used it only on rare occasions). Another strategy these patients often employ is to soak their feet in watered-down bleach. Fortunately, this patient had considered this option but thought better of it. A more benign, but just as ineffective, attempt at self-treatment had been to change laundry detergents, which of course did nothing to resolve the rash. (His first clue should have been that laundry detergent would not affect the tops of his feet while sparing the rest of his body.)

The insides of leather shoes are usually tanned with potassium dichromate, a chemical known to provoke this kind of reaction. Even after the source of the rash was identified, however, getting some distance between the patient and his shoes wasn’t easy. I had to write him a note for work, requesting that he be allowed to refrain from wearing his boots for about two weeks.

During that time, he started a week-long course of cephalexin 500 mg tid and applied clobetasol foam twice a day. In dermatology, we assume that any longstanding wet rash on the feet will become secondarily infected or at least colonized with gram-positive bacteria. Of course, giving him the steroid foam meant we were utilizing a class 1 corticosteroid in a very drying vehicle.

Within a week, he was a new man, with almost totally clear foot skin. This still left him with the problem of the work boots and the job—but one problem at a time.

TAKE-HOME LEARNING POINTS
• The areas spared by a rash are often just as important as those that are affected.

• Laundry detergents, often blamed for rashes, are seldom the culprit.

• Fungal infections rarely affect the dorsum of the foot while sparing interdigital and plantar surfaces.

• The patient’s atopic state will likely render him/her more susceptible to allergens.

• The vehicle (cream, gel, ointment, solution, foam) and strength of topical steroids both matter.

• Patients can become sensitized to the preservatives or other chemicals in OTC or prescription corticosteroid creams.

It’s somewhat unusual to see a patient with an eight-year history of the same problem, but this is what happens when a 51-year-old man presents to dermatology. Specifically, the problem is a very itchy foot rash, for which the patient has tried many OTC products without success. He has also used halobetasol cream, prescribed by a dermatologist he saw several years ago.

The patient denies having a rash anywhere else. He does, however, have a markedly atopic history, significant for seasonal allergies, asthma, and very sensitive skin.

For the past several years, when the rash has been particularly unbearable, he admits to pouring rubbing alcohol on his feet. This burned terribly, but his feet felt better afterward.

Asked what else happened eight years ago, the patient recalls starting his current job as a lineman for a power company—an occupation that requires him to wear steel-toed leather boots for hours at a time.

EXAMINATION
A dense, red, papulovesicular rash covers both feet in a stocking pattern. The rash stops abruptly at the same place on both lower legs, completely sparing the soles and interdigital skin. Focal areas of scaling and broken skin are seen on the tops and sides of both feet.

Continue for Joe Monroe's diagnosis and discussion >>

DISCUSSION
In the ’90s, a commercial for sneakers utilized the catchphrase, "It's the shoes!" And so it is occasionally with rashes on the feet. In this case, the patient was allergic to the leather on the inside of his work boots.

A true allergy such as this would be expected to itch and to manifest as a papulovesicular rash limited to areas touched by the leather on the upper portions of his shoes. And it would persist, despite the quantity of topical medications tried, because the patient wore the shoes for eight to 12 hours a day, five or six days per week, continually re-exposing his skin to the offending material. He had never taken any significant time off work and therefore hadn’t refrained from wearing the shoes long enough to allow the rash to abate.

Often, frustrated and uncomfortable patients take matters into their own hands, which can ultimately compound the problem. This patient didn't do his skin any favors with the rubbing alcohol and other products he'd tried (the most common offender being triple-antibiotic ointment, although this patient used it only on rare occasions). Another strategy these patients often employ is to soak their feet in watered-down bleach. Fortunately, this patient had considered this option but thought better of it. A more benign, but just as ineffective, attempt at self-treatment had been to change laundry detergents, which of course did nothing to resolve the rash. (His first clue should have been that laundry detergent would not affect the tops of his feet while sparing the rest of his body.)

The insides of leather shoes are usually tanned with potassium dichromate, a chemical known to provoke this kind of reaction. Even after the source of the rash was identified, however, getting some distance between the patient and his shoes wasn’t easy. I had to write him a note for work, requesting that he be allowed to refrain from wearing his boots for about two weeks.

During that time, he started a week-long course of cephalexin 500 mg tid and applied clobetasol foam twice a day. In dermatology, we assume that any longstanding wet rash on the feet will become secondarily infected or at least colonized with gram-positive bacteria. Of course, giving him the steroid foam meant we were utilizing a class 1 corticosteroid in a very drying vehicle.

Within a week, he was a new man, with almost totally clear foot skin. This still left him with the problem of the work boots and the job—but one problem at a time.

TAKE-HOME LEARNING POINTS
• The areas spared by a rash are often just as important as those that are affected.

• Laundry detergents, often blamed for rashes, are seldom the culprit.

• Fungal infections rarely affect the dorsum of the foot while sparing interdigital and plantar surfaces.

• The patient’s atopic state will likely render him/her more susceptible to allergens.

• The vehicle (cream, gel, ointment, solution, foam) and strength of topical steroids both matter.

• Patients can become sensitized to the preservatives or other chemicals in OTC or prescription corticosteroid creams.

It’s somewhat unusual to see a patient with an eight-year history of the same problem, but this is what happens when a 51-year-old man presents to dermatology. Specifically, the problem is a very itchy foot rash, for which the patient has tried many OTC products without success. He has also used halobetasol cream, prescribed by a dermatologist he saw several years ago.

The patient denies having a rash anywhere else. He does, however, have a markedly atopic history, significant for seasonal allergies, asthma, and very sensitive skin.

For the past several years, when the rash has been particularly unbearable, he admits to pouring rubbing alcohol on his feet. This burned terribly, but his feet felt better afterward.

Asked what else happened eight years ago, the patient recalls starting his current job as a lineman for a power company—an occupation that requires him to wear steel-toed leather boots for hours at a time.

EXAMINATION
A dense, red, papulovesicular rash covers both feet in a stocking pattern. The rash stops abruptly at the same place on both lower legs, completely sparing the soles and interdigital skin. Focal areas of scaling and broken skin are seen on the tops and sides of both feet.

Continue for Joe Monroe's diagnosis and discussion >>

DISCUSSION
In the ’90s, a commercial for sneakers utilized the catchphrase, "It's the shoes!" And so it is occasionally with rashes on the feet. In this case, the patient was allergic to the leather on the inside of his work boots.

A true allergy such as this would be expected to itch and to manifest as a papulovesicular rash limited to areas touched by the leather on the upper portions of his shoes. And it would persist, despite the quantity of topical medications tried, because the patient wore the shoes for eight to 12 hours a day, five or six days per week, continually re-exposing his skin to the offending material. He had never taken any significant time off work and therefore hadn’t refrained from wearing the shoes long enough to allow the rash to abate.

Often, frustrated and uncomfortable patients take matters into their own hands, which can ultimately compound the problem. This patient didn't do his skin any favors with the rubbing alcohol and other products he'd tried (the most common offender being triple-antibiotic ointment, although this patient used it only on rare occasions). Another strategy these patients often employ is to soak their feet in watered-down bleach. Fortunately, this patient had considered this option but thought better of it. A more benign, but just as ineffective, attempt at self-treatment had been to change laundry detergents, which of course did nothing to resolve the rash. (His first clue should have been that laundry detergent would not affect the tops of his feet while sparing the rest of his body.)

The insides of leather shoes are usually tanned with potassium dichromate, a chemical known to provoke this kind of reaction. Even after the source of the rash was identified, however, getting some distance between the patient and his shoes wasn’t easy. I had to write him a note for work, requesting that he be allowed to refrain from wearing his boots for about two weeks.

During that time, he started a week-long course of cephalexin 500 mg tid and applied clobetasol foam twice a day. In dermatology, we assume that any longstanding wet rash on the feet will become secondarily infected or at least colonized with gram-positive bacteria. Of course, giving him the steroid foam meant we were utilizing a class 1 corticosteroid in a very drying vehicle.

Within a week, he was a new man, with almost totally clear foot skin. This still left him with the problem of the work boots and the job—but one problem at a time.

TAKE-HOME LEARNING POINTS
• The areas spared by a rash are often just as important as those that are affected.

• Laundry detergents, often blamed for rashes, are seldom the culprit.

• Fungal infections rarely affect the dorsum of the foot while sparing interdigital and plantar surfaces.

• The patient’s atopic state will likely render him/her more susceptible to allergens.

• The vehicle (cream, gel, ointment, solution, foam) and strength of topical steroids both matter.

• Patients can become sensitized to the preservatives or other chemicals in OTC or prescription corticosteroid creams.

SAN DIEGO – Using chronic sinusitis patients’ response to Pneumovax to screen them for specific antibody deficiency may lead to overtreatment with intravenous immunoglobulin, a study showed.

In addition to its traditional use to prevent pneumonia and other infections, Pneumovax (pneumococcal vaccine polyvalent) has found a new role recently: as a screening tool in chronic rhinosinusitis (CRS) patients for specific antibody deficiency (SAD), a type of immune deficiency. If patients have a poor antibody response to the Pneumovax shot, they are thought to have SAD and are placed on intravenous immunoglobulin (IVIG) – sometimes without much regard for their clinical history. The practice has been fueled by the growing suspicion that chronic rhinosinusitis might be driven by a faulty immune system.

Frontline Medical News

However, the severity of SAD does not correlate neatly with the response to Pneumovax, Northwestern University investigators found in a study of 595 adult CRS patients. So, treating patients with IVIG based primarily on how they respond to the vaccine might be overkill. To prevent overuse of IVIG, it’s probably best to limit Pneumovax screening to patients with clinically worse disease, according to lead investigator Dr. Anjeni Keswani, formerly of Northwestern University in Chicago but now an allergist/immunologist at Duke University in Durham, N.C.

Overall, the proper role of Pneumovax screening still needs to be worked out. At least for now, SAD "just can’t be a laboratory diagnosis. It should include clinical history before you make a decision on IVIG therapy," Dr. Keswani said.

In the Lund-MacKay staging system for CRS, higher scores mean worse disease. The 95 patients in the study who had mild SAD (defined as 7-9 protective Streptococcus pneumoniae antibody titers after vaccination, out of 14 serotypes measured) and the 120 patients with moderate SAD (3-6 protective titers after vaccination) had significantly higher Lund-MacKay scores than the 24 patients with severe SAD. Severe SAD was defined as 2 or fewer protective titers following the vaccine.

Mild and moderate SAD patients also had significantly higher rates of asthma and higher, although not significantly higher, rates of allergic rhinitis and nasal polyps, Dr. Keswani said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Meanwhile, patients with more severe SAD were significantly more likely than mild SAD patients to have pneumonia histories and, when present, more severe asthma. And they used significantly more antibiotics in the 2 years following vaccination.

Asthma severity, antibiotic use, and pneumonia history in mild SAD patients were, in fact, similar to rates in CRS patients without immune deficiency. That raises the possibility that what’s now considered mild SAD might not even be an immunodeficiency, hence the notion of limiting Pneumovax screening to patients who are worse off.

As it all gets sorted out, "we don’t want patients diagnosed with SAD to automatically be placed on immunoglobulin replacement," Dr. Keswani said. "I don’t think that’s useful for the majority of patients. There is a proportion who mount a good response to infection; they may have an impaired response to the vaccine, but we can manage them with antibiotic prophylaxis and early assessment.

"We are trying to come up with guidelines to better help determine who should be screened," she added. "If they don’t have evidence of infection, I don’t think we can actually call them SAD."

Dr. Keswani said she had no relevant disclosures, and there was no outside funding involved in the project.

[email protected]

SAN DIEGO – Using chronic sinusitis patients’ response to Pneumovax to screen them for specific antibody deficiency may lead to overtreatment with intravenous immunoglobulin, a study showed.

In addition to its traditional use to prevent pneumonia and other infections, Pneumovax (pneumococcal vaccine polyvalent) has found a new role recently: as a screening tool in chronic rhinosinusitis (CRS) patients for specific antibody deficiency (SAD), a type of immune deficiency. If patients have a poor antibody response to the Pneumovax shot, they are thought to have SAD and are placed on intravenous immunoglobulin (IVIG) – sometimes without much regard for their clinical history. The practice has been fueled by the growing suspicion that chronic rhinosinusitis might be driven by a faulty immune system.

Frontline Medical News

However, the severity of SAD does not correlate neatly with the response to Pneumovax, Northwestern University investigators found in a study of 595 adult CRS patients. So, treating patients with IVIG based primarily on how they respond to the vaccine might be overkill. To prevent overuse of IVIG, it’s probably best to limit Pneumovax screening to patients with clinically worse disease, according to lead investigator Dr. Anjeni Keswani, formerly of Northwestern University in Chicago but now an allergist/immunologist at Duke University in Durham, N.C.

Overall, the proper role of Pneumovax screening still needs to be worked out. At least for now, SAD "just can’t be a laboratory diagnosis. It should include clinical history before you make a decision on IVIG therapy," Dr. Keswani said.

In the Lund-MacKay staging system for CRS, higher scores mean worse disease. The 95 patients in the study who had mild SAD (defined as 7-9 protective Streptococcus pneumoniae antibody titers after vaccination, out of 14 serotypes measured) and the 120 patients with moderate SAD (3-6 protective titers after vaccination) had significantly higher Lund-MacKay scores than the 24 patients with severe SAD. Severe SAD was defined as 2 or fewer protective titers following the vaccine.

Mild and moderate SAD patients also had significantly higher rates of asthma and higher, although not significantly higher, rates of allergic rhinitis and nasal polyps, Dr. Keswani said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Meanwhile, patients with more severe SAD were significantly more likely than mild SAD patients to have pneumonia histories and, when present, more severe asthma. And they used significantly more antibiotics in the 2 years following vaccination.

Asthma severity, antibiotic use, and pneumonia history in mild SAD patients were, in fact, similar to rates in CRS patients without immune deficiency. That raises the possibility that what’s now considered mild SAD might not even be an immunodeficiency, hence the notion of limiting Pneumovax screening to patients who are worse off.

As it all gets sorted out, "we don’t want patients diagnosed with SAD to automatically be placed on immunoglobulin replacement," Dr. Keswani said. "I don’t think that’s useful for the majority of patients. There is a proportion who mount a good response to infection; they may have an impaired response to the vaccine, but we can manage them with antibiotic prophylaxis and early assessment.

"We are trying to come up with guidelines to better help determine who should be screened," she added. "If they don’t have evidence of infection, I don’t think we can actually call them SAD."

Dr. Keswani said she had no relevant disclosures, and there was no outside funding involved in the project.

[email protected]

SAN DIEGO – Using chronic sinusitis patients’ response to Pneumovax to screen them for specific antibody deficiency may lead to overtreatment with intravenous immunoglobulin, a study showed.

In addition to its traditional use to prevent pneumonia and other infections, Pneumovax (pneumococcal vaccine polyvalent) has found a new role recently: as a screening tool in chronic rhinosinusitis (CRS) patients for specific antibody deficiency (SAD), a type of immune deficiency. If patients have a poor antibody response to the Pneumovax shot, they are thought to have SAD and are placed on intravenous immunoglobulin (IVIG) – sometimes without much regard for their clinical history. The practice has been fueled by the growing suspicion that chronic rhinosinusitis might be driven by a faulty immune system.

Frontline Medical News

However, the severity of SAD does not correlate neatly with the response to Pneumovax, Northwestern University investigators found in a study of 595 adult CRS patients. So, treating patients with IVIG based primarily on how they respond to the vaccine might be overkill. To prevent overuse of IVIG, it’s probably best to limit Pneumovax screening to patients with clinically worse disease, according to lead investigator Dr. Anjeni Keswani, formerly of Northwestern University in Chicago but now an allergist/immunologist at Duke University in Durham, N.C.

Overall, the proper role of Pneumovax screening still needs to be worked out. At least for now, SAD "just can’t be a laboratory diagnosis. It should include clinical history before you make a decision on IVIG therapy," Dr. Keswani said.

In the Lund-MacKay staging system for CRS, higher scores mean worse disease. The 95 patients in the study who had mild SAD (defined as 7-9 protective Streptococcus pneumoniae antibody titers after vaccination, out of 14 serotypes measured) and the 120 patients with moderate SAD (3-6 protective titers after vaccination) had significantly higher Lund-MacKay scores than the 24 patients with severe SAD. Severe SAD was defined as 2 or fewer protective titers following the vaccine.

Mild and moderate SAD patients also had significantly higher rates of asthma and higher, although not significantly higher, rates of allergic rhinitis and nasal polyps, Dr. Keswani said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Meanwhile, patients with more severe SAD were significantly more likely than mild SAD patients to have pneumonia histories and, when present, more severe asthma. And they used significantly more antibiotics in the 2 years following vaccination.

Asthma severity, antibiotic use, and pneumonia history in mild SAD patients were, in fact, similar to rates in CRS patients without immune deficiency. That raises the possibility that what’s now considered mild SAD might not even be an immunodeficiency, hence the notion of limiting Pneumovax screening to patients who are worse off.

As it all gets sorted out, "we don’t want patients diagnosed with SAD to automatically be placed on immunoglobulin replacement," Dr. Keswani said. "I don’t think that’s useful for the majority of patients. There is a proportion who mount a good response to infection; they may have an impaired response to the vaccine, but we can manage them with antibiotic prophylaxis and early assessment.

"We are trying to come up with guidelines to better help determine who should be screened," she added. "If they don’t have evidence of infection, I don’t think we can actually call them SAD."

Dr. Keswani said she had no relevant disclosures, and there was no outside funding involved in the project.

[email protected]

SAN DIEGO – Waiting 3 months after successful oral immunotherapy for peanut allergy before exposure to peanuts significantly increased the odds of reactivity returning in a prospective study of 20 children.

All 20 patients became desensitized to peanuts while on daily oral immunotherapy and successfully passed double-blind, placebo-controlled food challenges at the end of immunotherapy. All 16 patients who then avoided peanuts for 1 month passed a second food challenge, but only 1 of 4 patients who avoided peanuts for 3 months after immunotherapy passed a second one.

© mates/Fotolia.com

"If you wait long enough, the desensitization effect may well wear off," Dr. Brian P. Vickery said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

He and his associates looked at levels of basophil activation and conducted skin prick tests to peanut to get a better sense of why this was happening. Basophil activation to peanut antigen and anti-IgE stimulation increased significantly between the times of the first and second food challenges in the patients who avoided peanuts for 3 months but not in those who avoided the nuts for only 1 month.

The basophil activation levels had been similar between groups at the end of immunotherapy, suggesting that desensitization succeeded in all patients, but the length of peanut avoidance affected basophil responses, leading to revival of clinical reactivity.

Skin prick test results returned to baseline levels in three of the four patients who avoided peanuts for 3 months after the end of immunotherapy.

The amount of time on oral immunotherapy did not seem to be a key factor in the likelihood of sustained suppression of allergic disease, reported Dr. Vickery of the department of pediatrics at the University of North Carolina at Chapel Hill. Patients who waited 1 month before exposure to peanut had been on approximately 20-50 months of oral immunotherapy, and patients who waited 3 months before exposure had been on approximately 60 months of immunotherapy.

The lead author of the study was Michael D. Kulis Jr., Ph.D., also of the university.

Prolonged avoidance of peanut after peanut oral immunotherapy appears to be detrimental and may reverse the effects of the treatment, Dr. A. Wesley Burks said at a press briefing.

The findings may be applicable to other food allergies, but "we don’t know that because there have not been enough studies that long with other foods," said Dr. Burks, a coinvestigator in the study and chairman of the department of pediatrics at the university. "I wouldn’t anticipate that it would be different."

The average age of children in the study was 6 years.

This exploratory study was not controlled and was limited by its small size. The Peanut Oral Immunotherapy in Children (IMPACT) study is underway and should answer the question of how long the clinical effects of oral immunotherapy last, Dr. Vickery said. The study is being sponsored by the Immune Tolerance Network and the National Institute of Allergy and Infectious Diseases.

Dr. Vickery, Dr. Kulis, and Dr. Burks reported having no financial disclosures. The National Institutes of Health funded the study.

[email protected]

On Twitter @sherryboschert

SAN DIEGO – Waiting 3 months after successful oral immunotherapy for peanut allergy before exposure to peanuts significantly increased the odds of reactivity returning in a prospective study of 20 children.

All 20 patients became desensitized to peanuts while on daily oral immunotherapy and successfully passed double-blind, placebo-controlled food challenges at the end of immunotherapy. All 16 patients who then avoided peanuts for 1 month passed a second food challenge, but only 1 of 4 patients who avoided peanuts for 3 months after immunotherapy passed a second one.

© mates/Fotolia.com

"If you wait long enough, the desensitization effect may well wear off," Dr. Brian P. Vickery said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

He and his associates looked at levels of basophil activation and conducted skin prick tests to peanut to get a better sense of why this was happening. Basophil activation to peanut antigen and anti-IgE stimulation increased significantly between the times of the first and second food challenges in the patients who avoided peanuts for 3 months but not in those who avoided the nuts for only 1 month.

The basophil activation levels had been similar between groups at the end of immunotherapy, suggesting that desensitization succeeded in all patients, but the length of peanut avoidance affected basophil responses, leading to revival of clinical reactivity.

Skin prick test results returned to baseline levels in three of the four patients who avoided peanuts for 3 months after the end of immunotherapy.

The amount of time on oral immunotherapy did not seem to be a key factor in the likelihood of sustained suppression of allergic disease, reported Dr. Vickery of the department of pediatrics at the University of North Carolina at Chapel Hill. Patients who waited 1 month before exposure to peanut had been on approximately 20-50 months of oral immunotherapy, and patients who waited 3 months before exposure had been on approximately 60 months of immunotherapy.

The lead author of the study was Michael D. Kulis Jr., Ph.D., also of the university.

Prolonged avoidance of peanut after peanut oral immunotherapy appears to be detrimental and may reverse the effects of the treatment, Dr. A. Wesley Burks said at a press briefing.

The findings may be applicable to other food allergies, but "we don’t know that because there have not been enough studies that long with other foods," said Dr. Burks, a coinvestigator in the study and chairman of the department of pediatrics at the university. "I wouldn’t anticipate that it would be different."

The average age of children in the study was 6 years.

This exploratory study was not controlled and was limited by its small size. The Peanut Oral Immunotherapy in Children (IMPACT) study is underway and should answer the question of how long the clinical effects of oral immunotherapy last, Dr. Vickery said. The study is being sponsored by the Immune Tolerance Network and the National Institute of Allergy and Infectious Diseases.

Dr. Vickery, Dr. Kulis, and Dr. Burks reported having no financial disclosures. The National Institutes of Health funded the study.

[email protected]

On Twitter @sherryboschert

SAN DIEGO – Waiting 3 months after successful oral immunotherapy for peanut allergy before exposure to peanuts significantly increased the odds of reactivity returning in a prospective study of 20 children.

All 20 patients became desensitized to peanuts while on daily oral immunotherapy and successfully passed double-blind, placebo-controlled food challenges at the end of immunotherapy. All 16 patients who then avoided peanuts for 1 month passed a second food challenge, but only 1 of 4 patients who avoided peanuts for 3 months after immunotherapy passed a second one.

© mates/Fotolia.com

"If you wait long enough, the desensitization effect may well wear off," Dr. Brian P. Vickery said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

He and his associates looked at levels of basophil activation and conducted skin prick tests to peanut to get a better sense of why this was happening. Basophil activation to peanut antigen and anti-IgE stimulation increased significantly between the times of the first and second food challenges in the patients who avoided peanuts for 3 months but not in those who avoided the nuts for only 1 month.

The basophil activation levels had been similar between groups at the end of immunotherapy, suggesting that desensitization succeeded in all patients, but the length of peanut avoidance affected basophil responses, leading to revival of clinical reactivity.

Skin prick test results returned to baseline levels in three of the four patients who avoided peanuts for 3 months after the end of immunotherapy.

The amount of time on oral immunotherapy did not seem to be a key factor in the likelihood of sustained suppression of allergic disease, reported Dr. Vickery of the department of pediatrics at the University of North Carolina at Chapel Hill. Patients who waited 1 month before exposure to peanut had been on approximately 20-50 months of oral immunotherapy, and patients who waited 3 months before exposure had been on approximately 60 months of immunotherapy.

The lead author of the study was Michael D. Kulis Jr., Ph.D., also of the university.

Prolonged avoidance of peanut after peanut oral immunotherapy appears to be detrimental and may reverse the effects of the treatment, Dr. A. Wesley Burks said at a press briefing.

The findings may be applicable to other food allergies, but "we don’t know that because there have not been enough studies that long with other foods," said Dr. Burks, a coinvestigator in the study and chairman of the department of pediatrics at the university. "I wouldn’t anticipate that it would be different."

The average age of children in the study was 6 years.

This exploratory study was not controlled and was limited by its small size. The Peanut Oral Immunotherapy in Children (IMPACT) study is underway and should answer the question of how long the clinical effects of oral immunotherapy last, Dr. Vickery said. The study is being sponsored by the Immune Tolerance Network and the National Institute of Allergy and Infectious Diseases.

Dr. Vickery, Dr. Kulis, and Dr. Burks reported having no financial disclosures. The National Institutes of Health funded the study.

[email protected]

On Twitter @sherryboschert

The Food and Drug Administration has approved Ragwitek, a sublingual treatment for short ragweed pollen–related allergic rhinitis in people aged 18-65 years.

This is the first FDA-approved oral therapy for hay fever, with or without conjunctivitis, and the third oral allergy medication approved by the FDA in less than a month. On April 1, the agency green-lighted Oralair for the treatment of gross pollen-related allergies in persons aged 10-65 years. On April 15, Grastek earned approval as an oral treatment for grass pollen allergy in people aged 5-65 years.

The approval offers "millions of adults living with ragweed-pollen allergies in the United States an alternative to allergy shots to help manage their disease," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement. Other treatments include avoiding the allergen and medications to treat symptoms.

Ragwitek contains traces of pollen from the short ragweed (Ambrosia artemisiifolia) plant, and is administered as a quick-dissolving tablet placed once daily under the tongue. Treatment begins 12 weeks before the ragweed pollen season begins in late summer/early fall, and continues throughout the season. The first dose of the therapy is taken under observation by a health care provider. If no adverse reaction is noted after 30 minutes, the patient self-administers the medication thereafter.

Ragwitek’s safety was assessed in approximately 1,700 adults. The most common adverse reactions included itching in the mouth and ears and some throat irritation. Among those patients, 760 were evaluated to determine the therapy’s efficacy. Those assigned to Ragwitek reported about a 26% reduction in symptoms, compared with those who took placebo.

A black box warning accompanies the treatment, cautioning that life-threatening, severe allergic reactions are possible. A self-injected dose of epinephrine is recommended if needed.

Catalent Pharma Solutions manufactures Ragwitek for Merck, Sharp & Dohme.

[email protected]

On Twitter @whitneymcknight 

The Food and Drug Administration has approved Ragwitek, a sublingual treatment for short ragweed pollen–related allergic rhinitis in people aged 18-65 years.

This is the first FDA-approved oral therapy for hay fever, with or without conjunctivitis, and the third oral allergy medication approved by the FDA in less than a month. On April 1, the agency green-lighted Oralair for the treatment of gross pollen-related allergies in persons aged 10-65 years. On April 15, Grastek earned approval as an oral treatment for grass pollen allergy in people aged 5-65 years.

The approval offers "millions of adults living with ragweed-pollen allergies in the United States an alternative to allergy shots to help manage their disease," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement. Other treatments include avoiding the allergen and medications to treat symptoms.

Ragwitek contains traces of pollen from the short ragweed (Ambrosia artemisiifolia) plant, and is administered as a quick-dissolving tablet placed once daily under the tongue. Treatment begins 12 weeks before the ragweed pollen season begins in late summer/early fall, and continues throughout the season. The first dose of the therapy is taken under observation by a health care provider. If no adverse reaction is noted after 30 minutes, the patient self-administers the medication thereafter.

Ragwitek’s safety was assessed in approximately 1,700 adults. The most common adverse reactions included itching in the mouth and ears and some throat irritation. Among those patients, 760 were evaluated to determine the therapy’s efficacy. Those assigned to Ragwitek reported about a 26% reduction in symptoms, compared with those who took placebo.

A black box warning accompanies the treatment, cautioning that life-threatening, severe allergic reactions are possible. A self-injected dose of epinephrine is recommended if needed.

Catalent Pharma Solutions manufactures Ragwitek for Merck, Sharp & Dohme.

[email protected]

On Twitter @whitneymcknight 

The Food and Drug Administration has approved Ragwitek, a sublingual treatment for short ragweed pollen–related allergic rhinitis in people aged 18-65 years.

This is the first FDA-approved oral therapy for hay fever, with or without conjunctivitis, and the third oral allergy medication approved by the FDA in less than a month. On April 1, the agency green-lighted Oralair for the treatment of gross pollen-related allergies in persons aged 10-65 years. On April 15, Grastek earned approval as an oral treatment for grass pollen allergy in people aged 5-65 years.

The approval offers "millions of adults living with ragweed-pollen allergies in the United States an alternative to allergy shots to help manage their disease," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement. Other treatments include avoiding the allergen and medications to treat symptoms.

Ragwitek contains traces of pollen from the short ragweed (Ambrosia artemisiifolia) plant, and is administered as a quick-dissolving tablet placed once daily under the tongue. Treatment begins 12 weeks before the ragweed pollen season begins in late summer/early fall, and continues throughout the season. The first dose of the therapy is taken under observation by a health care provider. If no adverse reaction is noted after 30 minutes, the patient self-administers the medication thereafter.

Ragwitek’s safety was assessed in approximately 1,700 adults. The most common adverse reactions included itching in the mouth and ears and some throat irritation. Among those patients, 760 were evaluated to determine the therapy’s efficacy. Those assigned to Ragwitek reported about a 26% reduction in symptoms, compared with those who took placebo.

A black box warning accompanies the treatment, cautioning that life-threatening, severe allergic reactions are possible. A self-injected dose of epinephrine is recommended if needed.

Catalent Pharma Solutions manufactures Ragwitek for Merck, Sharp & Dohme.

[email protected]

On Twitter @whitneymcknight 

MADRID – Aspirin sensitivity was strongly associated with asthma severity and the presence of chronic rhinosinusitis with nasal polyps in a prospective, multicenter study.

"Aspirin sensitivity may be considered a clinical marker for severe asthma and for the presence of chronic rhinosinusitis with nasal polyps, and a potential marker for united airway disease," Dr. José Antonio Castillo reported at the world congress of the American College of Chest Physicians.

Aspirin-exacerbated respiratory disease is commonly associated with chronic rhinosinusitis (CRS) with nasal polyps, but little information is available on the correlation between aspirin sensitivity and severe asthma.

To evaluate the presence of aspirin sensitivity and CRS with nasal polyps in a cohort of asthmatic patients, pulmonologists and ear, nose, and throat specialists at 23 hospitals in Spain and Latin America recruited 492 patients, aged 18-70 years, attending outpatient clinics with the diagnosis of asthma for at least 1 year. Aspirin sensitivity was assessed by clinical history and/or aspirin challenge, and CRS with nasal polyps was assessed by nasal symptoms, nasal endoscopy, and sinus computed tomography (CT) scan.

Among 473 evaluable patients, 72 (15%) were aspirin sensitive, 14.6% had no nasosinal disease, 12.6% nonallergic rhinitis, 36.8% allergic rhinitis, 16.6% CRS without nasal polyps, and 19.4% CRS with nasal polyps.

*Aspirin-intolerant asthma was strongly related to asthma severity. In all, 3 of the 72 (4.2%) aspirin-intolerant patients were classified as having intermittent asthma (odds ratio, 1); 17 (23.6%) as mild persistent (OR, 4.3); 21 (29.2%) as moderate persistent (OR, 4.3); and 31 (43%) as severe persistent asthma, which was statistically significant (OR, 7.8; P less than .05), reported Dr. Castillo, with the pneumology service at Chiron Dexeus University Hospital, Barcelona.

The presence of CRS with nasal polyps was also significantly associated (38.9%; 28/72 patients) with aspirin sensitivity (OR, 9.05; P less than .001).

Aspirin sensitivity was present in 4.5% of patients with no nasosinal disease, 18.6% of those with nonallergic rhinitis, 9.2% with allergic rhinitis, 17.5% with CRS with no nasal polyps, and 29.8% with CRS and nasal polyps.

Further, patients with aspirin-intolerant asthma showed significantly higher Lund & McKay CT scores than aspirin-tolerant asthmatic patients, according to the poster presentation.

The current results perhaps could be validated by matching aspirin sensitivity with a biomarker of severe asthma, that is, periostin, but are such that they already use aspirin sensitivity as a clinical marker of severe asthma, Dr. Castillo said in an interview.

Patients in the study had a mean age of 45 years and a mean body mass index of 26.9 kg/m² (range, 16.8-49.8 kg/m²); 70.5% were female, and 9.6% were smokers.

Asthma was intermittent in 85 patients, mild persistent in 122, moderate persistent in 154, and severe persistent in 131, according to Global Initiative for Asthma (GINA) severity criteria.

Dr. Castillo and his coauthors reported no financial disclosures.

[email protected]

*This article was updated 4/7/14

MADRID – Aspirin sensitivity was strongly associated with asthma severity and the presence of chronic rhinosinusitis with nasal polyps in a prospective, multicenter study.

"Aspirin sensitivity may be considered a clinical marker for severe asthma and for the presence of chronic rhinosinusitis with nasal polyps, and a potential marker for united airway disease," Dr. José Antonio Castillo reported at the world congress of the American College of Chest Physicians.

Aspirin-exacerbated respiratory disease is commonly associated with chronic rhinosinusitis (CRS) with nasal polyps, but little information is available on the correlation between aspirin sensitivity and severe asthma.

To evaluate the presence of aspirin sensitivity and CRS with nasal polyps in a cohort of asthmatic patients, pulmonologists and ear, nose, and throat specialists at 23 hospitals in Spain and Latin America recruited 492 patients, aged 18-70 years, attending outpatient clinics with the diagnosis of asthma for at least 1 year. Aspirin sensitivity was assessed by clinical history and/or aspirin challenge, and CRS with nasal polyps was assessed by nasal symptoms, nasal endoscopy, and sinus computed tomography (CT) scan.

Among 473 evaluable patients, 72 (15%) were aspirin sensitive, 14.6% had no nasosinal disease, 12.6% nonallergic rhinitis, 36.8% allergic rhinitis, 16.6% CRS without nasal polyps, and 19.4% CRS with nasal polyps.

*Aspirin-intolerant asthma was strongly related to asthma severity. In all, 3 of the 72 (4.2%) aspirin-intolerant patients were classified as having intermittent asthma (odds ratio, 1); 17 (23.6%) as mild persistent (OR, 4.3); 21 (29.2%) as moderate persistent (OR, 4.3); and 31 (43%) as severe persistent asthma, which was statistically significant (OR, 7.8; P less than .05), reported Dr. Castillo, with the pneumology service at Chiron Dexeus University Hospital, Barcelona.

The presence of CRS with nasal polyps was also significantly associated (38.9%; 28/72 patients) with aspirin sensitivity (OR, 9.05; P less than .001).

Aspirin sensitivity was present in 4.5% of patients with no nasosinal disease, 18.6% of those with nonallergic rhinitis, 9.2% with allergic rhinitis, 17.5% with CRS with no nasal polyps, and 29.8% with CRS and nasal polyps.

Further, patients with aspirin-intolerant asthma showed significantly higher Lund & McKay CT scores than aspirin-tolerant asthmatic patients, according to the poster presentation.

The current results perhaps could be validated by matching aspirin sensitivity with a biomarker of severe asthma, that is, periostin, but are such that they already use aspirin sensitivity as a clinical marker of severe asthma, Dr. Castillo said in an interview.

Patients in the study had a mean age of 45 years and a mean body mass index of 26.9 kg/m² (range, 16.8-49.8 kg/m²); 70.5% were female, and 9.6% were smokers.

Asthma was intermittent in 85 patients, mild persistent in 122, moderate persistent in 154, and severe persistent in 131, according to Global Initiative for Asthma (GINA) severity criteria.

Dr. Castillo and his coauthors reported no financial disclosures.

[email protected]

*This article was updated 4/7/14

MADRID – Aspirin sensitivity was strongly associated with asthma severity and the presence of chronic rhinosinusitis with nasal polyps in a prospective, multicenter study.

"Aspirin sensitivity may be considered a clinical marker for severe asthma and for the presence of chronic rhinosinusitis with nasal polyps, and a potential marker for united airway disease," Dr. José Antonio Castillo reported at the world congress of the American College of Chest Physicians.

Aspirin-exacerbated respiratory disease is commonly associated with chronic rhinosinusitis (CRS) with nasal polyps, but little information is available on the correlation between aspirin sensitivity and severe asthma.

To evaluate the presence of aspirin sensitivity and CRS with nasal polyps in a cohort of asthmatic patients, pulmonologists and ear, nose, and throat specialists at 23 hospitals in Spain and Latin America recruited 492 patients, aged 18-70 years, attending outpatient clinics with the diagnosis of asthma for at least 1 year. Aspirin sensitivity was assessed by clinical history and/or aspirin challenge, and CRS with nasal polyps was assessed by nasal symptoms, nasal endoscopy, and sinus computed tomography (CT) scan.

Among 473 evaluable patients, 72 (15%) were aspirin sensitive, 14.6% had no nasosinal disease, 12.6% nonallergic rhinitis, 36.8% allergic rhinitis, 16.6% CRS without nasal polyps, and 19.4% CRS with nasal polyps.

*Aspirin-intolerant asthma was strongly related to asthma severity. In all, 3 of the 72 (4.2%) aspirin-intolerant patients were classified as having intermittent asthma (odds ratio, 1); 17 (23.6%) as mild persistent (OR, 4.3); 21 (29.2%) as moderate persistent (OR, 4.3); and 31 (43%) as severe persistent asthma, which was statistically significant (OR, 7.8; P less than .05), reported Dr. Castillo, with the pneumology service at Chiron Dexeus University Hospital, Barcelona.

The presence of CRS with nasal polyps was also significantly associated (38.9%; 28/72 patients) with aspirin sensitivity (OR, 9.05; P less than .001).

Aspirin sensitivity was present in 4.5% of patients with no nasosinal disease, 18.6% of those with nonallergic rhinitis, 9.2% with allergic rhinitis, 17.5% with CRS with no nasal polyps, and 29.8% with CRS and nasal polyps.

Further, patients with aspirin-intolerant asthma showed significantly higher Lund & McKay CT scores than aspirin-tolerant asthmatic patients, according to the poster presentation.

The current results perhaps could be validated by matching aspirin sensitivity with a biomarker of severe asthma, that is, periostin, but are such that they already use aspirin sensitivity as a clinical marker of severe asthma, Dr. Castillo said in an interview.

Patients in the study had a mean age of 45 years and a mean body mass index of 26.9 kg/m² (range, 16.8-49.8 kg/m²); 70.5% were female, and 9.6% were smokers.

Asthma was intermittent in 85 patients, mild persistent in 122, moderate persistent in 154, and severe persistent in 131, according to Global Initiative for Asthma (GINA) severity criteria.

Dr. Castillo and his coauthors reported no financial disclosures.

[email protected]

*This article was updated 4/7/14

The Food and Drug Administration has approved Ragwitek, a sublingual treatment for short ragweed pollen–related allergic rhinitis in people aged 18-65 years.

This is the first FDA-approved oral therapy for hay fever, with or without conjunctivitis, and the third oral allergy medication approved by the FDA in less than a month. On April 1, the agency green-lighted Oralair for the treatment of gross pollen-related allergies in persons aged 10-65 years. On April 15, Grastek earned approval as an oral treatment for grass pollen allergy in people aged 5-65 years.

The approval offers "millions of adults living with ragweed-pollen allergies in the United States an alternative to allergy shots to help manage their disease," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement. Other treatments include avoiding the allergen and medications to treat symptoms.

Ragwitek contains traces of pollen from the short ragweed (Ambrosia artemisiifolia) plant, and is administered as a quick-dissolving tablet placed once daily under the tongue. Treatment begins 12 weeks before the ragweed pollen season begins in late summer/early fall, and continues throughout the season. The first dose of the therapy is taken under observation by a health care provider. If no adverse reaction is noted after 30 minutes, the patient self-administers the medication thereafter.

Ragwitek’s safety was assessed in approximately 1,700 adults. The most common adverse reactions included itching in the mouth and ears and some throat irritation. Among those patients, 760 were evaluated to determine the therapy’s efficacy. Those assigned to Ragwitek reported about a 26% reduction in symptoms, compared with those who took placebo.

A black box warning accompanies the treatment, cautioning that life-threatening, severe allergic reactions are possible. A self-injected dose of epinephrine is recommended if needed.

Catalent Pharma Solutions manufactures Ragwitek for Merck, Sharp & Dohme.

[email protected]

On Twitter @whitneymcknight

The Food and Drug Administration has approved Ragwitek, a sublingual treatment for short ragweed pollen–related allergic rhinitis in people aged 18-65 years.

This is the first FDA-approved oral therapy for hay fever, with or without conjunctivitis, and the third oral allergy medication approved by the FDA in less than a month. On April 1, the agency green-lighted Oralair for the treatment of gross pollen-related allergies in persons aged 10-65 years. On April 15, Grastek earned approval as an oral treatment for grass pollen allergy in people aged 5-65 years.

The approval offers "millions of adults living with ragweed-pollen allergies in the United States an alternative to allergy shots to help manage their disease," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement. Other treatments include avoiding the allergen and medications to treat symptoms.

Ragwitek contains traces of pollen from the short ragweed (Ambrosia artemisiifolia) plant, and is administered as a quick-dissolving tablet placed once daily under the tongue. Treatment begins 12 weeks before the ragweed pollen season begins in late summer/early fall, and continues throughout the season. The first dose of the therapy is taken under observation by a health care provider. If no adverse reaction is noted after 30 minutes, the patient self-administers the medication thereafter.

Ragwitek’s safety was assessed in approximately 1,700 adults. The most common adverse reactions included itching in the mouth and ears and some throat irritation. Among those patients, 760 were evaluated to determine the therapy’s efficacy. Those assigned to Ragwitek reported about a 26% reduction in symptoms, compared with those who took placebo.

A black box warning accompanies the treatment, cautioning that life-threatening, severe allergic reactions are possible. A self-injected dose of epinephrine is recommended if needed.

Catalent Pharma Solutions manufactures Ragwitek for Merck, Sharp & Dohme.

[email protected]

On Twitter @whitneymcknight

The Food and Drug Administration has approved Ragwitek, a sublingual treatment for short ragweed pollen–related allergic rhinitis in people aged 18-65 years.

This is the first FDA-approved oral therapy for hay fever, with or without conjunctivitis, and the third oral allergy medication approved by the FDA in less than a month. On April 1, the agency green-lighted Oralair for the treatment of gross pollen-related allergies in persons aged 10-65 years. On April 15, Grastek earned approval as an oral treatment for grass pollen allergy in people aged 5-65 years.

The approval offers "millions of adults living with ragweed-pollen allergies in the United States an alternative to allergy shots to help manage their disease," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement. Other treatments include avoiding the allergen and medications to treat symptoms.

Ragwitek contains traces of pollen from the short ragweed (Ambrosia artemisiifolia) plant, and is administered as a quick-dissolving tablet placed once daily under the tongue. Treatment begins 12 weeks before the ragweed pollen season begins in late summer/early fall, and continues throughout the season. The first dose of the therapy is taken under observation by a health care provider. If no adverse reaction is noted after 30 minutes, the patient self-administers the medication thereafter.

Ragwitek’s safety was assessed in approximately 1,700 adults. The most common adverse reactions included itching in the mouth and ears and some throat irritation. Among those patients, 760 were evaluated to determine the therapy’s efficacy. Those assigned to Ragwitek reported about a 26% reduction in symptoms, compared with those who took placebo.

A black box warning accompanies the treatment, cautioning that life-threatening, severe allergic reactions are possible. A self-injected dose of epinephrine is recommended if needed.

Catalent Pharma Solutions manufactures Ragwitek for Merck, Sharp & Dohme.

[email protected]

On Twitter @whitneymcknight