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A woman with hyperkeratotic, verrucous plaques on her back
5441
4750
A woman with hyperkeratotic, verrucous plaques on her back Daniel P. Hertel, MD, Department of Dermatology, Henry Ford Health System; Angela J. Jiang, Stritch School of Medicine, Loyola University Chicago; Henry W. Lim, MD, Department of Dermatology, Henry Ford Health System Case Report: A 33-year-old woman with a history of Down syndrome presented for further evaluation and management of growths on her back and arms. The lesions developed over the preceding year and progressively enlarged. She has a history of similar lesions on her lower extremities and occiput that were previously treated with liquid nitrogen at an outside hospital with no improvement and subsequently surgical debridement with split thickness skin grafts. Physical examination revealed well-demarcated erythematous plaques with overlying scale on the bilateral forearms and right elbow in addition to hyperkeratotic, verrucous-appearing plaques over her mid and upper back. Biopsy of a lesion on her back was performed which revealed marked psoriasiform epidermal hyperplasia with papillomatosis, a diminished granular layer, parakeratosis and Munro’s microabscesses. Edema and vascular dilation in the papillary dermis were also noted. There was no viral cytopathic change and HPV immunostaining was negative. Discussion: Verrucous psoriasis (VP) is a rare variant of psoriasis that presents with a mix of psoriasiform and wart-like changes both clinically and histologically. Symmetric, hypertrophic, verrucous plaques on an erythematous base clinically characterize VP. Subtypes exist including dome-shaped or crater-like papules, annular and erythrodermic forms. There appears to be an association between VP and diabetes mellitus, pulmonary disease, and phlebitis. It is theorized that resulting local anoxia can lead to hyperkeratosis in these lesions. VP could also represent a response to repeated trauma and irritation in a patient with psoriasis. Histopathologically, classic psoriasiform changes are observed in addition to verrucoid features; however, they lack koilocytic changes and have negative HPV studies. Reported treatment options include both topical and systemic agents that are typically used to treat psoriasis, though an ideal regimen specifically for VP has not been established. Our patient had significant improvement using superpotent topical corticosteroids. Conclusion: Atypical presentations of psoriasis can lead to delayed diagnoses and unnecessary interventions. Knowledge of these variants combined with histopathological confirmation can help guide appropriate therapy.
Absolute and relative psoriasis area and severity indices over 1 year of treatment with ixekizumab: A descriptive analysis in patients with moderate-to-severe plaque psoriasis Ulrich Mrowietz, MD, University Medical Center Schlewsig-Holstein; Jose-Manuel Carrascosa, MD, Hospital Universitari Germans Trias i Pujol; Pablo Fernandez Pe~ nas, MD, University of Sydney; David Guede, Clinbay; Stefan Wilhelm, MD, Lilly Deutschland GmbH; Martin Dossenbach, MD, Eli Lilly Regional Operations GmbH Introduction: Treatment comparisons are usually based on the relative improvement from baseline on the Psoriasis Area and Severity Index (PASI). However, absolute PASI may be more relevant because it allows therapeutic decisions to be based on actual severity of disease. The purpose of this pooled analysis was to find an absolute PASI level that is a clinically meaningful alternative treatment goal.
Commercial support: None identified.
Methods: Data from a randomized, double-blind, placebo-controlled phase 3 clinical trial (UNCOVER-3) comparing etanercept (ETN) and ixekizumab (IXE) in patients with moderate-to-severe plaque psoriasis were used. Briefly, patients with PASI \12 were randomized to 12 weeks of treatment with IXE 80 mg (starting dose of 160 mg) either every 2 weeks (IXE Q2W) or every 4 weeks (IXE Q4W), ETN 50 mg twice weekly (ETN 50BIW), or placebo. After this 12-week induction dosing period, patients were allowed to switch to open-label treatment with IXE Q4W. Here, we report the results at 52 weeks. Missing values were imputed as nonresponders. Results: A total of 1274 patients participated in the open-label phase of the study (IXE Q2W/IXE Q4W, N ¼ 362; IXE Q4W/IXE Q4W, N ¼ 360; ETN 50BIW/IXE Q4W, N ¼ 369; and placebo/IXE Q4W, N ¼ 183). For IXE Q2W/IXE Q4W treatment (the approved dose), clinical outcomes were: PASI 100 ¼ 57.7%, PASI #1 ¼ 71.3%, PASI 90 ¼ 79.6%, PASI #2 ¼ 80.1%, PASI #3 ¼ 85.6%, PASI #5 ¼ 88.1%, and PASI 75 ¼ 89.2%. For all treatment groups combined, clinical outcomes were: PASI 100 ¼ 56.8%, PASI #1 ¼ 70.8%, PASI 90 ¼ 79.0%, PASI #2 ¼ 79.1%, PASI #3 ¼ 84.4%, PASI 75 ¼ 88.0%, and PASI #5 ¼ 88.4%. Considering only patients who reached PASI #1, the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 100%, 100%, and 80.3%, respectively; for PASI #2 the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 100%, 97.4%, and 71.8%, respectively; for PASI #3 the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 100%, 93.3%, and 67.3%, respectively; and for PASI #5 the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 98.6%, 89.4%, and 64.3%, respectively. Conclusions: For this 1-year study with an inclusion cut-off of PASI \12, similar proportions of responders are seen for PASI 75 versus PASI #5 and also for PASI 90 versus PASI #2. As PASI 90 is considered the new long-term treatment objective, an absolute PASI #2, as shown in this study, may be a clinically relevant treatment goal for patients with moderate-to-severe plaque psoriasis. Commercial support: This study was sponsored by Eli Lilly and Company.
5583 Abdominal actinomycetoma successfully treated with quadruple antibiotic therapy with trimethoprim - sulfamethoxazole, amikacin, imipenem and moxifloxacin Sandra Cecilia Garcia-Garcia, MD, Sandra Cecilia Garcia-Garcia; Ver onica Concepci on Camacho-Martınez, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL; Minerva G omez-Flores, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL; Lucio Vera-Cabrera, DDSc, Hospital Universitario Dr Jos e Eleuterio Gonzalez UANL; Jorge Ocampo-Candiani, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL; Oliverio Welsh, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL Mycetoma is a chronic granulomatous infection caused by aerobic bacteria (actinomycetoma) or fungi (eumycetoma). It commonly affects the skin and subcutaneous tissue and sometimes it can involve muscles, bones or underlying organs. In Mexico, 96% of mycetoma are caused by actinomycetes, most of them caused by Nocardia brasiliensis. The infection predominates in farm workers, it is acquired by inoculation through thorns. Mycetoma usually affects lower extremities and often posterior trunk. Sometimes treatment of actinomycetoma can be difficult and requires combined antibiotic therapy. Treatment of abdominal mycetoma with visceral involvement can become a therapeutic challenge. A 50-year-old farmer was seen in our dermatology department with a history of a 4-year mycetoma on his lower abdomen, characterized by multiple abscesses and fistulae that drained a serous-purulent exudate. He complained of dysuria, hematuria, abdominal pain, fever and weight loss. Microscopic examination of the draining material revealed Nocardia-like grains. Histopathology and cultures confirmed the diagnosis of actinomycetoma by N brasiliensis. High anti-N brasiliensis antibody serum titers were detected. Routine laboratory exams were reported within normal limits with the exception of microscopic hematuria. A CT scan revealed multiple fistulae in the abdominal wall affecting the sigmoid colon and bladder. After basal normal audiometry and creatinine clearance, his medical management included trimethoprim-sulfamethoxazole (T-S) 160/800 mg every 12 hours during 92 days, intravenous amikacin 500 mg every 12 hours (in cycles of 3 weeks, with a week of rest between cycles to assess for renal and otic function), and intravenous imipenem 1 g every 8 hours during 90 days. He was discharged with moxifloxacin 400 mg every 12 hours plus T-S. Two months later, healing of all lesions was achieved. Control skin biopsy and culture of the remaining scars were reported negative. Moxifloxacin was halted. Treatment of actinomycetoma is based on periods of T-S administration. In cases of abdominal actinomycetoma, treatment can become a challenge due to potential visceral involvement. This case illustrates the successful treatment outcome by the use of four active antibiotics against the Nocardia strain without the need of a surgical intervention. Commercial support: None identified.
AB30
J AM ACAD DERMATOL
5213 Absolute PASI and its correlation with DLQI: An ex post analysis of the CLEAR study Max Reinhardt, MD, Novartis Pharma; Diamant Thaci, MD, Comprehensive Center for Inflammation Medicine, University Hospital Schleswig-Holstein; Kristian Reich, MD, Dermatologikum Hamburg and GeorgAugust-University G€ ottingen; Andreas Pinter, MD, Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main; Nima Melzer, PhD, Novartis Pharma Background: Relative improvement of psoriasis area and severity index (PASI 50/75/90 and 100) during an antipsoriatic treatment compared to baseline PASI is a basis in assessing treatment response and in defining psoriasis treatment goals. Assessments of treatment response as PASI are clinically relevant only if they correlate with healthrelated quality of life (HRQoL), which is usually measured by the Dermatology Life Quality Index (DLQI). This analysis was performed in order to evaluate absolute PASI treatment goals, asking whether predefined absolute PASI ranges correlate with the time spent in a DLQI score #1in the CLEAR study population. Methods: The analysis included the full study population of the CLEAR study, which was a randomized, double-blind, multicenter, head-to-head comparison between secukinumab (300 mg s.c., every 4 weeks), an anti-IL-17A antibody, and ustekinumab (45 mg s.c., every 12 weeks), an anti-IL-12/IL-23 antibody. The timespan analyzed was week 16-52. Patients with a constant PASI value were grouped by the range of their absolute PASI: PASI 0-1, PASI [1-3, PASI [3-5 and PASI [5. Patients who exceeded PASI 5 on no more than two occasions but otherwise did not achieve constant PASI values, were included in the group ‘‘PASI #5, not constant.’’ Patients were excluded from these groups if they exceeded or fell below the defined limits on more than two occasions. Patients with less than 4 visits were excluded from the analysis. DLQI was operationalized as number of weeks with a DLQI-score #1. Results: 338 patients fulfilled criteria of PASI 0-1 group, 44 of PASI [1-3 group, 8 of PASI[3-5 group and 42 patients fulfilled criteria of PASI[5 group. 165 patients were included in the group ‘‘PASI # 5, not constant.’’ PASI 0-1 responders spent a mean of 28.0 weeks with a DLQI #1, PASI [1-3 responders a mean of 20.9 weeks, PASI [3-5 responders a mean of 8.9 weeks and PASI [5 responders a mean of 4.0 weeks. PASI #5, not constant responders spent a mean of 17.8 weeks with a DLQI #1. Conclusions: The provided analysis indicates that the used absolute PASI ranges achieve good discriminatory value as regards time spent in a DLQI score #1. Patients with a lower constant PASI, eg, 0-1 or [1-3 spent more time with a DLQI #1 than patients with higher constant PASI values or patients whose PASI values were not constant. This post hoc analysis was 100% financed by Novartis. Commercial support: This post hoc analysis was 100% financed by Novartis.
JUNE 2017
4750
A woman with hyperkeratotic, verrucous plaques on her back Daniel P. Hertel, MD, Department of Dermatology, Henry Ford Health System; Angela J. Jiang, Stritch School of Medicine, Loyola University Chicago; Henry W. Lim, MD, Department of Dermatology, Henry Ford Health System Case Report: A 33-year-old woman with a history of Down syndrome presented for further evaluation and management of growths on her back and arms. The lesions developed over the preceding year and progressively enlarged. She has a history of similar lesions on her lower extremities and occiput that were previously treated with liquid nitrogen at an outside hospital with no improvement and subsequently surgical debridement with split thickness skin grafts. Physical examination revealed well-demarcated erythematous plaques with overlying scale on the bilateral forearms and right elbow in addition to hyperkeratotic, verrucous-appearing plaques over her mid and upper back. Biopsy of a lesion on her back was performed which revealed marked psoriasiform epidermal hyperplasia with papillomatosis, a diminished granular layer, parakeratosis and Munro’s microabscesses. Edema and vascular dilation in the papillary dermis were also noted. There was no viral cytopathic change and HPV immunostaining was negative. Discussion: Verrucous psoriasis (VP) is a rare variant of psoriasis that presents with a mix of psoriasiform and wart-like changes both clinically and histologically. Symmetric, hypertrophic, verrucous plaques on an erythematous base clinically characterize VP. Subtypes exist including dome-shaped or crater-like papules, annular and erythrodermic forms. There appears to be an association between VP and diabetes mellitus, pulmonary disease, and phlebitis. It is theorized that resulting local anoxia can lead to hyperkeratosis in these lesions. VP could also represent a response to repeated trauma and irritation in a patient with psoriasis. Histopathologically, classic psoriasiform changes are observed in addition to verrucoid features; however, they lack koilocytic changes and have negative HPV studies. Reported treatment options include both topical and systemic agents that are typically used to treat psoriasis, though an ideal regimen specifically for VP has not been established. Our patient had significant improvement using superpotent topical corticosteroids. Conclusion: Atypical presentations of psoriasis can lead to delayed diagnoses and unnecessary interventions. Knowledge of these variants combined with histopathological confirmation can help guide appropriate therapy.
Absolute and relative psoriasis area and severity indices over 1 year of treatment with ixekizumab: A descriptive analysis in patients with moderate-to-severe plaque psoriasis Ulrich Mrowietz, MD, University Medical Center Schlewsig-Holstein; Jose-Manuel Carrascosa, MD, Hospital Universitari Germans Trias i Pujol; Pablo Fernandez Pe~ nas, MD, University of Sydney; David Guede, Clinbay; Stefan Wilhelm, MD, Lilly Deutschland GmbH; Martin Dossenbach, MD, Eli Lilly Regional Operations GmbH Introduction: Treatment comparisons are usually based on the relative improvement from baseline on the Psoriasis Area and Severity Index (PASI). However, absolute PASI may be more relevant because it allows therapeutic decisions to be based on actual severity of disease. The purpose of this pooled analysis was to find an absolute PASI level that is a clinically meaningful alternative treatment goal.
Commercial support: None identified.
Methods: Data from a randomized, double-blind, placebo-controlled phase 3 clinical trial (UNCOVER-3) comparing etanercept (ETN) and ixekizumab (IXE) in patients with moderate-to-severe plaque psoriasis were used. Briefly, patients with PASI \12 were randomized to 12 weeks of treatment with IXE 80 mg (starting dose of 160 mg) either every 2 weeks (IXE Q2W) or every 4 weeks (IXE Q4W), ETN 50 mg twice weekly (ETN 50BIW), or placebo. After this 12-week induction dosing period, patients were allowed to switch to open-label treatment with IXE Q4W. Here, we report the results at 52 weeks. Missing values were imputed as nonresponders. Results: A total of 1274 patients participated in the open-label phase of the study (IXE Q2W/IXE Q4W, N ¼ 362; IXE Q4W/IXE Q4W, N ¼ 360; ETN 50BIW/IXE Q4W, N ¼ 369; and placebo/IXE Q4W, N ¼ 183). For IXE Q2W/IXE Q4W treatment (the approved dose), clinical outcomes were: PASI 100 ¼ 57.7%, PASI #1 ¼ 71.3%, PASI 90 ¼ 79.6%, PASI #2 ¼ 80.1%, PASI #3 ¼ 85.6%, PASI #5 ¼ 88.1%, and PASI 75 ¼ 89.2%. For all treatment groups combined, clinical outcomes were: PASI 100 ¼ 56.8%, PASI #1 ¼ 70.8%, PASI 90 ¼ 79.0%, PASI #2 ¼ 79.1%, PASI #3 ¼ 84.4%, PASI 75 ¼ 88.0%, and PASI #5 ¼ 88.4%. Considering only patients who reached PASI #1, the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 100%, 100%, and 80.3%, respectively; for PASI #2 the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 100%, 97.4%, and 71.8%, respectively; for PASI #3 the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 100%, 93.3%, and 67.3%, respectively; and for PASI #5 the percentages of patients reaching PASI 75, PASI 90, and PASI 100 were 98.6%, 89.4%, and 64.3%, respectively. Conclusions: For this 1-year study with an inclusion cut-off of PASI \12, similar proportions of responders are seen for PASI 75 versus PASI #5 and also for PASI 90 versus PASI #2. As PASI 90 is considered the new long-term treatment objective, an absolute PASI #2, as shown in this study, may be a clinically relevant treatment goal for patients with moderate-to-severe plaque psoriasis. Commercial support: This study was sponsored by Eli Lilly and Company.
5583 Abdominal actinomycetoma successfully treated with quadruple antibiotic therapy with trimethoprim - sulfamethoxazole, amikacin, imipenem and moxifloxacin Sandra Cecilia Garcia-Garcia, MD, Sandra Cecilia Garcia-Garcia; Ver onica Concepci on Camacho-Martınez, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL; Minerva G omez-Flores, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL; Lucio Vera-Cabrera, DDSc, Hospital Universitario Dr Jos e Eleuterio Gonzalez UANL; Jorge Ocampo-Candiani, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL; Oliverio Welsh, MD, Hospital Universitario Dr Jose Eleuterio Gonzalez UANL Mycetoma is a chronic granulomatous infection caused by aerobic bacteria (actinomycetoma) or fungi (eumycetoma). It commonly affects the skin and subcutaneous tissue and sometimes it can involve muscles, bones or underlying organs. In Mexico, 96% of mycetoma are caused by actinomycetes, most of them caused by Nocardia brasiliensis. The infection predominates in farm workers, it is acquired by inoculation through thorns. Mycetoma usually affects lower extremities and often posterior trunk. Sometimes treatment of actinomycetoma can be difficult and requires combined antibiotic therapy. Treatment of abdominal mycetoma with visceral involvement can become a therapeutic challenge. A 50-year-old farmer was seen in our dermatology department with a history of a 4-year mycetoma on his lower abdomen, characterized by multiple abscesses and fistulae that drained a serous-purulent exudate. He complained of dysuria, hematuria, abdominal pain, fever and weight loss. Microscopic examination of the draining material revealed Nocardia-like grains. Histopathology and cultures confirmed the diagnosis of actinomycetoma by N brasiliensis. High anti-N brasiliensis antibody serum titers were detected. Routine laboratory exams were reported within normal limits with the exception of microscopic hematuria. A CT scan revealed multiple fistulae in the abdominal wall affecting the sigmoid colon and bladder. After basal normal audiometry and creatinine clearance, his medical management included trimethoprim-sulfamethoxazole (T-S) 160/800 mg every 12 hours during 92 days, intravenous amikacin 500 mg every 12 hours (in cycles of 3 weeks, with a week of rest between cycles to assess for renal and otic function), and intravenous imipenem 1 g every 8 hours during 90 days. He was discharged with moxifloxacin 400 mg every 12 hours plus T-S. Two months later, healing of all lesions was achieved. Control skin biopsy and culture of the remaining scars were reported negative. Moxifloxacin was halted. Treatment of actinomycetoma is based on periods of T-S administration. In cases of abdominal actinomycetoma, treatment can become a challenge due to potential visceral involvement. This case illustrates the successful treatment outcome by the use of four active antibiotics against the Nocardia strain without the need of a surgical intervention. Commercial support: None identified.
AB30
J AM ACAD DERMATOL
5213 Absolute PASI and its correlation with DLQI: An ex post analysis of the CLEAR study Max Reinhardt, MD, Novartis Pharma; Diamant Thaci, MD, Comprehensive Center for Inflammation Medicine, University Hospital Schleswig-Holstein; Kristian Reich, MD, Dermatologikum Hamburg and GeorgAugust-University G€ ottingen; Andreas Pinter, MD, Department of Dermatology, Venerology and Allergology, University Hospital Frankfurt am Main; Nima Melzer, PhD, Novartis Pharma Background: Relative improvement of psoriasis area and severity index (PASI 50/75/90 and 100) during an antipsoriatic treatment compared to baseline PASI is a basis in assessing treatment response and in defining psoriasis treatment goals. Assessments of treatment response as PASI are clinically relevant only if they correlate with healthrelated quality of life (HRQoL), which is usually measured by the Dermatology Life Quality Index (DLQI). This analysis was performed in order to evaluate absolute PASI treatment goals, asking whether predefined absolute PASI ranges correlate with the time spent in a DLQI score #1in the CLEAR study population. Methods: The analysis included the full study population of the CLEAR study, which was a randomized, double-blind, multicenter, head-to-head comparison between secukinumab (300 mg s.c., every 4 weeks), an anti-IL-17A antibody, and ustekinumab (45 mg s.c., every 12 weeks), an anti-IL-12/IL-23 antibody. The timespan analyzed was week 16-52. Patients with a constant PASI value were grouped by the range of their absolute PASI: PASI 0-1, PASI [1-3, PASI [3-5 and PASI [5. Patients who exceeded PASI 5 on no more than two occasions but otherwise did not achieve constant PASI values, were included in the group ‘‘PASI #5, not constant.’’ Patients were excluded from these groups if they exceeded or fell below the defined limits on more than two occasions. Patients with less than 4 visits were excluded from the analysis. DLQI was operationalized as number of weeks with a DLQI-score #1. Results: 338 patients fulfilled criteria of PASI 0-1 group, 44 of PASI [1-3 group, 8 of PASI[3-5 group and 42 patients fulfilled criteria of PASI[5 group. 165 patients were included in the group ‘‘PASI # 5, not constant.’’ PASI 0-1 responders spent a mean of 28.0 weeks with a DLQI #1, PASI [1-3 responders a mean of 20.9 weeks, PASI [3-5 responders a mean of 8.9 weeks and PASI [5 responders a mean of 4.0 weeks. PASI #5, not constant responders spent a mean of 17.8 weeks with a DLQI #1. Conclusions: The provided analysis indicates that the used absolute PASI ranges achieve good discriminatory value as regards time spent in a DLQI score #1. Patients with a lower constant PASI, eg, 0-1 or [1-3 spent more time with a DLQI #1 than patients with higher constant PASI values or patients whose PASI values were not constant. This post hoc analysis was 100% financed by Novartis. Commercial support: This post hoc analysis was 100% financed by Novartis.
JUNE 2017