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American journal of clinical dermatology [journal]
- Topical Therapy for Toenail Onychomycosis: An Evidence-Based Review. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Sep 26.
Managing toenail onychomycosis with topical treatments is challenging. It is difficult for topical medication to penetrate the nail plate, and this is reflected in lower cure rates with topical treatment than with oral treatment. However, oral medications may not be suitable for some patients, because of drug interactions; therefore, topical treatments are critical in managing the disease in certain patient populations.This paper reviews the quality and content of the scientific literature on topical treatments for toenail onychomycosis.PubMed, Ovid (Medline and Embase), Scopus, Cochrane library, and clinicaltrials.gov databases were searched for original clinical reports of topical monotherapy for microscopy and/or culture-confirmed toenail onychomycosis in adults. Studies were evaluated using an onychomycosis study quality scale, which was based on the CONSORT guidelines.Twenty-five publications (28 studies) were identified and met the inclusion criteria. Thirteen studies scored high ratings on the quality scale. These were randomized controlled trials or randomized comparative trials. Low-quality studies were nonrandomized, open studies that prevented statistical analysis. Most studies reported clinical and mycological cure. The most variation was observed with reporting outcomes of clinical improvement. Amorolfine, ciclopirox, tavaborole, and efinaconazole produced clinical and mycological cure in patients with mild to moderate toenail onychomycosis (<50-65 % nail involvement), with efinaconazole showing the highest rates. Treatments were generally applied daily for 24-48 weeks, with longer treatment and follow-up showing better outcomes.Topical treatment with amorolfine, ciclopirox, tavaborole, or efinaconazole is appropriate for cases of mild to moderate toenail onychomycosis due to dermatophyte or mixed dermatophyte/Candida infection.
- Treatment of Pediculosis Capitis: A Critical Appraisal of the Current Literature. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Sep 16.
Pediculosis capitis is the most common ectoparasitic disease in children in industrialized countries and extremely common in resource-poor communities of the developing world. The extensive use of pediculicides with a neurotoxic mode of action has led to the development and spread of resistant head lice populations all over the world. This triggered the development of compounds with other modes of action. The current literature on treatment approaches of head lice infestation was searched, and published randomized controlled trials were critically analyzed. The following compounds/family of compounds were identified: spinosad, a novel compound with a new neurotoxic mode of action, isopropyl myristate, 1,2-octanediol, ivermectin, plant-based products, and dimeticones. The efficacy and safety of these compounds are reviewed and recommendations for the treatment of pediculosis capitis in individuals as well as the interruption of ongoing epidemics are provided.
- Disease Control for Patients with Psoriasis Receiving Continuous Versus Interrupted Therapy with Adalimumab or Etanercept: A Clinical Practice Study. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Sep 13.
Studies analyzing the efficacy and safety of interrupted psoriasis therapy with biologic drugs have not reported clear benefits in routine clinical practice.To identify differences in the disease control of psoriasis patients undergoing continuous or interrupted therapy with adalimumab or etanercept.This retrospective 3-year cohort study (interrupted vs. continuous therapy) involved 77 patients (47 adalimumab, 30 etanercept) who were managed under clinical practice conditions. The proportion of episodes with a Physician Global Assessment (PGA) ≥3 during the follow-up in each study cohort was the primary effectiveness endpoint. The relative risk of PGA ≥3 episodes in the interrupted therapy cohort was analyzed.Twenty-one patients receiving adalimumab were included in the interrupted therapy cohort (44.7 %), and 26 were included in the continuous therapy cohort (55.3 %). In the group of etanercept, 21 patients received continuous treatment (70.0 %), and nine patients started at least one interruption period (30.0 %). The proportion of PGA ≥3 episodes in continuous and interrupted groups were 19.2 % vs. 33.3 % for adalimumab patients (p = 0.27), and 42.9 % vs. 55.6 % in patients treated with etanercept (p = 0.52). The relative risk of PGA ≥3 episodes with interrupted therapy was 1.73 (95 % confidence interval 0.64-4.68; p = 0.27), and 1.30 (95 % confidence interval 0.60-2.79; p = 0.52) in the adalimumab and etanercept groups, respectively.In routine clinical practice, interrupted therapy with adalimumab or etanercept can provide adequate disease control for a subgroup of patients with excellent response to biologic drugs.
- Imiquimod in the Treatment of Cutaneous Warts: An Evidence-Based Review. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Sep 4.
Cutaneous warts are highly prevalent lesions caused by the infection of keratinocytes by different types of human papillomaviruses. Although cutaneous warts are capable of resolving spontaneously, these infections can persist for long periods of time by evading the host immune system, and, as a result, many patients choose to seek treatment. Imiquimod is an immune response modifier that is approved as a topical cream for the treatment of anogenital warts by the US Food and Drug Administration. However, the efficacy of imiquimod in the treatment of cutaneous warts has not been well established.The purpose of this article is to systematically review the published literature regarding the efficacy of imiquimod in the treatment of cutaneous warts, and to evaluate the quality and outcomes of these studies.A literature search was performed through clinical queries PubMed (National Library of Medicine) database and the Cochrane database. All completed studies written in English and published through May 2014 were considered. Studies evaluating the use of imiquimod for anogenital warts were excluded. There were no other restrictions based on patient age, sex, ethnicity, or skin type. The studies were evaluated and assessed based on study design, patient population, treatment regimen, clinical outcome, and adverse events.A total of 393 records were identified in the initial search; 23 full-text articles were assessed for eligibility and included in the review. Of these studies, six publications reported on immunocompromised individuals only. The highest quality study identified was a grade B, level 3 case-control cohort study in which patients with multiple warts had certain warts treated with imiquimod and others left untreated to serve as a control. The remaining studies identified were level 4 non-controlled case series (grade C) and level 5 case reports (grade D). In immunocompetent patients enrolled in non-controlled studies, the combined rate of patients achieving complete response to therapy was 44 %, ranging from 27 to 89 %. However, there was variation in the dose frequency and application among these studies. In immunosuppressed patients, two studies and four case reports were identified. Clinical improvement was seen in 33-50 % of patients, with no patients experiencing complete clinical clearance.There have been several studies demonstrating the successful use of imiquimod to treat recalcitrant cutaneous warts, either alone or as combination therapy. However, these studies are limited in number, include small populations, and are non-controlled. Further studies are needed to determine the efficacy of imiquimod, dose frequency and application, and optimal combination with other therapeutic measures such as paring, salicylic acid, or other destructive procedures.
- Neutrophilic Dermatoses: An Update. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Aug 26.
Neutrophilic dermatoses constitute a heterogeneous group of dermatologic diseases, which are unified by the predominance of neutrophils within the inflammatory infiltrate on histopathology. The aims of this review were to provide an update on the clinical and histologic presentation of the main neutrophilic dermatoses and to develop a guide for clinical practice. A structured literature search of PubMed, Medline, and Embase was performed, using the key words "neutrophilic disorders", "cutaneous small vessel vasculitis", "Sweet's syndrome", "bowel associated dermatosis arthritis syndrome", "Behcet's", "palisaded neutrophilic and granulomatous dermatosis", "rheumatoid neutrophilic dermatitis", and "pyoderma gangrenosum". Related articles were screened for key terms and were included if appropriate. This group contains a wide spectrum of unique disorders, each with its own histologic and clinical subtleties, making specific diagnosis of a given entity within the group diagnostically challenging. The fact that overlapping forms of neutrophilic dermatoses, which share features of multiple neutrophilic dermatoses, are not uncommon makes the diagnoses more challenging.
- Neonatal Junctional Epidermolysis Bullosa: Treatment Conundrums and Ethical Decision Making. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Aug 13.
Junctional epidermolysis bullosa (JEB), generalized severe (previously called JEB, Herlitz-type) has an extremely poor prognosis, with a mean age of death at 5 months old and most dead before age 3 years. We describe a typical case of a neonate with JEB who developed failure to thrive before his death from fungal septicemia at 4 months of age. This case highlights the ethical considerations of invasive treatments such as gastrostomy tube placements, intubations, and central line placements in neonates with JEB. We review the literature as well as discuss the ethical conundrums in the care of patients with JEB and other severe forms of epidermolysis bullosa.
- Dermatological toxicity associated with targeted therapies in cancer: optimal management. [Journal Article]
- Am J Clin Dermatol 2014 Oct; 15(5):425-44.
Targeted therapies have developed rapidly over the last few years in the field of oncology thanks to a better understanding of carcinogenesis. They target pathways involved in signal transduction (EGFR, HER2, HER3, HER4, FLT3, RAS, RAF, MEK, KIT, RET, mTOR, SRC, EPH, SCF), tumor angiogenesis (VEGFR, TIE2), and tumor microenvironment (PDGFR, FGFR). They rarely cause the systemic adverse reactions generally associated with chemotherapy, but frequently cause disabling and specific skin toxicity. The impact on patient quality of life can be important both in terms of symptoms caused and of potentially aesthetic consequences. Inappropriate management can increase the risk of dose reduction or discontinuation of the cancer treatment. In this review, we will discuss skin toxicity associated with the main drug classes-EGFR, BRAF, MEK, mTOR, c-KIT, CTLA4, and SMO inhibitors, and anti-angiogenic agents. Targeted therapy-induced skin toxicities will be detailed in terms of symptoms, frequency, evolution, complications, and topical and oral treatments in order to improve their diagnosis and management.
- Biologic Therapy with or Without Topical Treatment in Psoriasis: What Does the Current Evidence Say? [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Jul 16.
Biologic therapy represents a relatively new class of drugs which have revolutionized the treatment of psoriasis and are used with increasing frequency in order to control this chronic, systemic inflammatory disease. However, it is unclear what role there is for combination therapy of biologics with traditional topical agents. The purpose of this article is to assess the literature on the role of topical agents as adjuvants to biological treatments in the treatment of psoriasis and identify areas for further research. A MEDLINE search was performed in order to identify English-language publications from 1996 to 2014 examining combination biologic therapy with topical medications in the treatment of psoriasis. Data from these clinical studies are summarized and the outcomes are discussed. In general, the addition of adjuvant topical therapy to systemic biologic therapy allowed for a reduction in dosage and side effects of both agents, maintenance of initial response to biologics, treatment of recalcitrant lesions in partial responders, and potential acceleration of response to biologic therapies. The current data, though limited, suggest that using topical therapies as adjunct treatment to biologics is a well tolerated and effective means of controlling psoriasis and improving quality of life for patients. However, the treating physician should remain attentive to signs of adverse events and seek opportunities to reduce the dose or treatment frequency during chronic use.
- Isotretinoin Use and Celiac Disease: A Population-Based Cross-Sectional Study. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Jul 15.
Isotretinoin, a vitamin A analogue, can promote a pro-inflammatory milieu in the small intestine in response to dietary antigens. We hypothesized that oral isotretinoin exposure would increase the risk of celiac disease (CD).We contacted all 28 pathology departments in Sweden, and through biopsy reports identified 26,739 individuals with CD. We then compared the prevalence of ever using oral isotretinoin to the prevalence in 134,277 matched controls through conditional logistic regression. Data on isotretinoin exposure were obtained from the national Swedish Prescribed Drug Registry. As the only indication for isotretinoin use in Sweden is acne, we also examined its relationship to CD. Data on acne were obtained from the Swedish Patient Registry.Ninety-three individuals with CD (0.35 %) and 378 matched controls (0.28 %) had a prescription of isotretinoin. This corresponded to an odds ratio (OR) of 1.22 [95 % confidence interval (CI) 0.97-1.54]. Risk estimates were similar in men and women, and when we restricted our data to individuals diagnosed after the start of the Prescribed Drug Registry. Restricting our analyses to individuals diagnosed aged 12-45 years did not influence the risk estimates (OR 1.38, 95 % CI 0.97-1.97). Meanwhile, having a diagnosis of acne was positively associated with CD (OR 1.34, 95 % CI 1.20-1.51).This study found no association between isotretinoin use and CD, but a small excess risk of CD in patients with a diagnosis of acne.
- Optimal Management of Skin Cancer in Immunosuppressed Patients. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Jul 12.
Skin cancer is the most common malignancy in humans with basal cell carcinoma representing the majority of cases in the general population. The prevalence of skin cancer is increased amongst immunosuppressed patients such as those with lymphoproliferative disorders including non-Hodgkin lymphoma and chronic lymphocytic leukemia or those with iatrogenic immunosuppression following organ transplantation. In addition, these patients experience greater morbidity and mortality associated with skin cancers. The most common skin cancer in immunosuppressed patients is squamous cell carcinoma, which often presents with more aggressive features and has a greater rate of metastasis. This article reviews the risk factors, etiology, clinical presentation, and prevalence of skin cancer amongst immunosuppressed patients, including organ transplant, lymphoproliferative disorders, autoimmune disorders, and human immunodeficiency virus. We also provide a comprehensive review of treatment guidelines for immunosuppressed patients with cutaneous malignancy. Surgical therapy is the cornerstone of treatment; however, we also discuss pharmacologic treatment options, lifestyle modifications, and revision of immunosuppressive regimens.