191 Increased risk of serious infection among patients with psoriasis: A population-based cohort study in the United Kingdom

191 Increased risk of serious infection among patients with psoriasis: A population-based cohort study in the United Kingdom

ABSTRACTS | Clinical Research I: Epidemiology and Patient Outcomes Research 190 191 A cross-sectional study evaluating skin, hair, nail and bone dis...

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ABSTRACTS | Clinical Research I: Epidemiology and Patient Outcomes Research 190

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A cross-sectional study evaluating skin, hair, nail and bone disease in patients with focal dermal hypoplasia N Gunasekera1, J Divito1, TS Kupper1, J Huang2 and S Divito1 1 Dermatology, Harvard Medical School, Boston, MA and 2 Boston Children’s Hospital, Boston, MA Focal Dermal Hypoplasia (FDH) is a rare X-linked dominant disease characterized by dermal thinning and fat herniation, with other ectodermal and mesodermal abnormalities. The literature is limited in regards to the natural history of skin, hair and nail involvement, and to the incidence of bone disease in FDH patients. This cross-sectional study aimed to address this gap in knowledge by investigating prevalence of and changes in skin, hair, nail and bone disease. A 30-item questionnaire was administered to patients/families attending the National Foundation for Ectodermal Dysplasias Conference, FDH Session. Seventeen patients/families participated. Study participants included 11 females and 5 males (1 omitted), with a median age of 9 years (range 1.6 e 57 years). Nine patients endorsed genetic mosaicism. Participants reported dermatologists as the most commonly seen provider, and saw an average of 5 different providers, including a variety of specialists. All 17 participants reported skin and nail involvement. Twelve of 17 participants reported scalp/hair involvement. All participants endorsed flares of their skin disease; common triggers included physical illness, heat/humidity, cold and/or dry air, emotional stress and exercise. Additionally, 11 patients noted progression of their skin disease, including nine patients who developed new papillomas. Three children experienced more than one bone fracture, including one child with confirmed osteoporosis. The data suggest that clinicians should consider (i) counseling patients/families regarding the possibility of disease flares and progression, particularly in regards to papilloma growth which can occur in the airway, and (ii) calcium and vitamin D supplementation and/ or bone density studies in FDH patients. Lastly, the data highlight the importance of dermatologists performing complete review of systems on FDH patients with referral to appropriate specialists as necessary.

Increased risk of serious infection among patients with psoriasis: A population-based cohort study in the United Kingdom J Takeshita, DB Shin, A Ogdie and JM Gelfand University of Pennsylvania, Philadelphia, PA Infection is the second leading cause of death among psoriasis patients on phototherapy or systemic medications. The types of infection risk associated with psoriasis remain poorly understood. The aim of our study was to determine the risk of serious infection (i.e., requiring hospitalization) among patients with psoriasis. We conducted a cohort study of patients with (N¼199,700) and without (N¼954,315) psoriasis in The Health Improvement Network electronic medical record database. Patients receiving phototherapy or systemic therapy were considered to have severe psoriasis (N¼12,442). The serious infection outcome was defined by a diagnostic code for a prespecified group of infections and documentation of hospitalization within 30 days of the infection date. The incidence rates of serious infection were 88.9, 85.7, and 145.7 per 10,000 person years for all patients with psoriasis and those with mild and severe disease, respectively, versus 78.5 per 10,000 person years for those without psoriasis. The most common types of serious infections among patients with psoriasis were lower respiratory, skin and soft tissue, and upper respiratory infections with incidence rates of 29.0, 16.4, and 16.3 per 10,000 person years, respectively. In multivariable analyses adjusting for age, gender, body mass index, smoking, systemic corticosteroids, flu or pneumonia vaccinations, prior infection or hospitalization, and comorbid disease including asthma/chronic obstructive pulmonary disease, diabetes, chronic kidney disease, and cardiovascular diseases, we found an increased risk of serious infection among patients with versus without psoriasis: hazard ratio 1.20 (95% confidence interval, 1.18-1.23). The risk was greater among those with severe psoriasis: mild, 1.19 (1.16-1.22); and severe psoriasis, 1.73 (1.61-1.86). Our results suggest serious infection, particularly respiratory and skin/soft tissue infections, to be an important and common cause of morbidity among patients with psoriasis, especially those with more severe disease.

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Diffuse dermal angiomatosis: A case report and review of the literature K Touloei1, E Tongdee2 and C Nousari1 1 Broward General Medical Center, Ft. Lauderdale, FL and 2 Florida International University Herbert Wertheim College of Medicine, Miami, FL This study provides a case report and review of the literature on diffuse dermal angiomatosis (DDA) - a rare acquired cutaneous, reactive vascular disorder with only 30 cases reported on PubMed. A case report is provided along with a review of the literature that discusses etiology, common comorbidities, and various treatment options previously used. The review of literature showed that DDA is associated with medical conditions predisposing an individual to ischemia. Strict control of comorbidities, especially smoking cessation, should be incorporated into the treatment plan. When DDA affects the breast, it appears that isotretinoin provides the best relief. Otherwise, treatment of the underlying cause, revascularization, or steroids seem to be the best treatment options at this time. These findings along with the case report provide further insight on a rare disorder along with treatment options to consider if a physician should ever come across DDA.

Risk of venous thromboembolism is increased among patients with psoriasis MH Noe1, A Ogdie2, DB Shin1, J Takeshita1, ZC Chiesa Fuxench1 and JM Gelfand1 1 Dermatology, University of Pennsylvania, Philadelphia, PA and 2 Medicine, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA The risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) & pulmonary embolism (PE) has been shown to be increased in patients with chronic inflammatory disorders like systemic lupus erythematosus and rheumatoid arthritis. A longitudinal cohort study was conducted in The Health Improvement Network (THIN), a primary care medical record database in the United Kingdom, to determine the risk of DVT and PE in adults with psoriasis, compared to matched controls sampled from the same practices. Cox proportional hazards models were used to calculate the hazard ratios (HR) for each outcome. Multivariable models were constructed to account for confounders such as previous hospitalization, cancer, hypertension, hyperlipidemia, liver disease, oral glucocorticoid use, non-steroidal anti-inflammatory drug use, body mass index, smoking, and alcohol use. Patients on systemic treatment (oral agents & biologics) or phototherapy were considered to have “severe” psoriasis. Among 188,506 patients with mild psoriasis, 6133 patients with severe psoriasis and 1,247,342 controls, the incidence of VTE was 34.98/10,000 person years in patients with mild psoriasis, 35.99/10,000 person years in patients with severe psoriasis, and 29.43/10,000 person years in controls. In the fully adjusted model, patients with mild psoriasis had an increased risk of DVT(aHR: 1.21, 95%CI: 1.16-1.26) and a marginally, non-statistically significant, increased risk of PE(aHR: 1.05, 95%CI: 0.96-1.15). Patients with severe psoriasis had an increased, albeit non-statistically significant, risk for VTE(aHR: 1.16, 95%CI: 0.93-1.44), DVT(aHR: 1.10, 95%CI: 0.86-1.40) and PE(aHR 1.51, 95%CI: 0.98-2.32). While the risk of VTE is increased in all patients with psoriasis, larger studies may be necessary to more precisely describe this risk. Given the mortality risk associated with VTE, it is important to recognize this significant medical comorbidity associated with chronic inflammatory diseases like psoriasis.

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Cigarette smoking and risk of incident rosacea in women: A prospective study S Li1,2, E Cho2,3,4, AA Qureshi2,3,4 and W Li2,3 1 Department of Epidemiology, School of Public Health, Shandong University, Jinan, China, 2 Department of Dermatology, Warren Alpert Medical School, Brown University, Providence, RI, 3 School of Public Health, Brown University, Providence, RI and 4 Department of Medicine, Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA Rosacea is a chronic inflammatory disorder. Smoking may influence the risk of rosacea through affecting the immune system. Previous data on smoking and rosacea has been limited, with case-control studies reporting distinct associations among current and former smokers. No prospective data are available on the association between smoking and incident risk of rosacea. We examined the association based on a large prospective cohort of women. A total of 95,809 women were included from the Nurses’ Health Study II (NHS II) (19912005). Information on smoking was collected biennially during follow-up. Information on lifetime history of clinician-diagnosed rosacea and diagnosis year was collected in 2005. We used Cox proportional hazard models to estimate age and multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for the association between different measures of smoking and risk of rosacea. Over 14 years in NHS II, we identified 5462 incident cases of rosacea. Compared with never smokers, the multivariate-adjusted HR of rosacea was 0.64 (95% CI: 0.57e0.72) for current smokers and 1.10 (95% CI: 1.04e1.17) for former smokers. When examining pack-years, we also found that increasing pack-years was associated with an elevated risk of rosacea among past smokers (Ptrend¼0.0002), but was associated with a decreased risk of rosacea among current smokers (Ptrend<0.0001). Increasing years since smoking cessation appeared to enhance the risk of rosacea (Ptrend<0.0001), and the association persisted over two decades after smoking cessation. Our study suggests that current smoking is associated with a decreased risk of rosacea among women, while former smoking is associated with an increased risk of rosacea.

S34 Journal of Investigative Dermatology (2016), Volume 136

The association of gastrointestinal disorders and worry with rosacea supports the concept of a gut-brain-skin interaction in rosacea BM Rainer, AH Fischer, D Luz Felipe da Silva, S Kang and AL Chien Dermatology, Johns Hopkins School of Medicine, Baltimore, MD We previously reported that rosacea is associated with gastroesophageal reflux disease (GERD) and other gastrointestinal (GI) ailments. In addition, psychogenic factors may precipitate the manifestation of rosacea. To test our hypothesis of a gut-brain-skin interaction in rosacea, we enrolled rosacea patients in a matched case-control manner to examine if rosacea is associated with worry and if this association is modified by GI diseases. Standardized questionnaires were administered to participants and a dermatologist completed clinical evaluations of rosacea. We evaluated level of worry using a composite score of 8 questions from the Penn State Worry Questionnaire and defined worriers as subjects in the highest tertile of worry scores. Odds ratios (ORs) were computed using conditional logistic regression. We enrolled 65 rosacea cases (95% Caucasian, 34% male, mean age¼50.6 years) and 65 controls matched on race, sex, and age5 years. Increasing worry was associated with increasing odds of rosacea (ORs of 1.0, 3.6, and 4.4 for the lowest, middle, and highest tertiles of worry, respectively; P-trend¼0.003). Worriers with GERD were more likely to have rosacea (OR¼8.2; 95% CI¼1.8-37.8) beyond what would be expected with either having GERD (OR¼2.9; 1.0-8.5) or being a worrier (OR¼1.3; 0.5-3.7) alone, compared to nonworriers without GERD (1.0; reference). Similarly, worriers with other GI disease were more likely to have rosacea (OR¼7.7; 1.6-37.7) beyond what would be expected with either having GI disease (OR¼2.0; 0.7-6.1) or being a worrier (OR¼1.7; 0.7-4.2) alone, compared to nonworriers without GI disease (1.0; reference). Our data demonstrate that the combined presence of worry and GI disorders significantly increases the association that each condition has with rosacea. This supports the presence of a gut-brain-skin interaction in rosacea, and emphasizes the need to consider nondermatologic factors in the disease expression.