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Prurigo nodularis in a patient with pustular psoriasis, treated with tumor necrosis factor inhibitors
2023
1448
Prurigo nodularis in a patient with pustular psoriasis, treated with tumor necrosis factor inhibitors ngel Cardona Hernandez, MD, PhD, Ana Paula Orozco Anahuati, MD, Miguel A Gisela Navarrete Franco, MD, PhD, Maribet Gonzalez Gonzalez, MD, PhD, Cesar Alfonso Maldonado Garcıa, MD, PhD
Psoriasis in elderly and adult population: Clinical features and management Maddalena Napolitano, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Fabio Ayala, MD, PhD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Lucia Gallo, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Maria Schiattarella, PhD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Matteo Megna, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Nicola Balato, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy
Prurigo nodularis is a low prevalence pruriginous chronic inflammatory disease that requires clinicopathologic correlation to diagnose. We present the case of a 23-yearold woman with a previous diagnosis of atopic dermatitis and pustular psoriasis, treated with anti-tumor necrosis factor therapy with partial response, developing prurigo nodularis. She presented at ‘‘Centro Dermatol ogico Dr Ladislao de la Pascua’’ in March 2014, referring new lesions in lower extremities. On examination we found a disseminated symmetrical dermatosis with inferior limb predominance without plantar involvement. It was characterized by multiple erythematous-violaceous nodular aspect lesions, about 1.5 cm in diameter, with scale and excoriations in the surface, firm consistency and infiltrate aspect with well-defined borders. Few isolated pustules were seen in some lesions. She was diagnosed on 2010 with atopic dermatitis, plaque and palmar psoriasis. Required topical treatment with moisturizers, steroids, calcineurin inhibitors and vitamin D analogs. In 2011, she presented dissemination of dermatosis, multiples pustules, arthralgia and malaise that required hospitalization. Histopathologic features consistent with pustular psoriasis. Laboratory tests showed increased IgE levels (3145 IU/mL). Therapy was begun with adalimumab for a year and since there was partial improvement the decision was taken to change to etanercept for a year. At the time of presentation to our center on March 2014 she was still on treatment with etanercept. Mantoux test showed an area of induration of 18 mm and normal chest radiograph. A biopsy revealed hyperkeratosis parakeratosis, fibrin deposits, zones with lack of granulosum stratum, and psuedoepitheliomatous hyperplasia. In superficial dermis fibrosis, and dilated congestive vessels surrounded by moderate lymphohistiocytic infiltrate that extends to middle dermis. This psoriasiform pattern required clinicopathologic correlation and a diagnosis of prurigo nodularis was made. She required a new evaluation by a hematologist, finding increased levels of IgG 3162 (552-1631 mg/dL) and IgE 6540 (\100 mg/dL), immunologic tests and skull radiograph normal, a stool cultured revealed Blastocystis hominis cysts that required treatment with nitazoxanide. She is still on follow up by a hematologist. The pustular psoriasis presented a good response to isotretinoin and the prurigo nodularis to high potency topical steroids, antihistamines and moisturizers.
Psoriasis may affect people of any age, being common among elderly. However, their management may be difficult mainly due to comorbidities and concomitant medications. Nevertheless, only very few studies have been conducted on psoriasis treatment long-term effects and/or safety in the elderly, especially regarding biologic drugs as well as on investigating clinical features of elderly ([65 years) compared with adult psoriasis subjects. A prospective observational study on 502 psoriatic patients (173 elderly subjects, 115 male and 58 female, mean age 69.1 and 329 adult patients, 207 male and 122 female, mean age 39.2) attending the outpatient Clinic of the University of Naples Federico II from 2009 to 2012 was performed. Demographic and clinical features, highlighting eventual differences in comorbidities and treatment adverse events, were analyzed through a follow-up period of at least 6 months. The two groups of patients differed especially for comorbidities and treatment profile. Particularly, adults were treated more frequently with biologic drugs compared to elderly. Among biologics, etanercept seemed to be well tolerated in elderly group as reported in literature, possibly because of its lower immunosuppressive characteristics. Moreover, our data suggested that ustekinumab presented a high efficacy and safety profile in this particular population. However, elderly did not develop more metabolic abnormalities than younger patients after systemic therapy, as well as, nearly all the registered serious adverse events occurred in subjects \65 years of age. Our study did not show substantial clinical differences between elderly and adults. Older patients might be treated with biologic drugs when required since their safety and tolerability profiles are favorable in this population. Commercial support: None identified.
Commercial support: None identified.
504 Psoriasis and wound healing: A population study of incident wound complications between patients with and without psoriasis Kory Parsi, DO, University of California, Davis, Sacramento, CA, United States; April Armstrong, MD, MPH, University of Colorado, Denver, Aurora, CO, United States; Clayton Schupp, PhD, UC Davis, Sacramento, CA, United States Introduction: Previous psoriasis wound healing outcomes research is limited to postsurgical outcomes, which report conflicting results and recommendations. The main objective of this study is to determine differences in incident wound complications between patients with and without psoriasis. Methods: We performed a retrospective cohort study in patients with cutaneous wounds to examine differences in wound complications between patients with and without psoriasis. Patients with wounds and psoriasis were matched 1:3 to patients with wounds but without psoriasis based on age, gender, and BMI. The primary outcome was aggregated incidence of wound complications including wound infection, tissue necrosis, hematoma development, and leukocytosis. We also examined differences in antibiotic use for wound infections between the two groups. Results: The study included a total of 164 patients with cutaneous wounds, which comprised of 41 psoriasis patients matched to 123 patients without psoriasis. No significant differences existed between patients with and without psoriasis with regards to baseline demographic and clinical characteristics, including tobacco use (active: 14.6% vs 19.5%, former: 19.5% vs 19.5%, or never: 65.6% vs 61%, P ¼.8152), peripheral vascular disease (2.4% in both groups), or diabetes mellitus (4.9% vs 6.5%, P ¼.7648). After controlling for diabetes, peripheral vascular disease, and smoking, no statistically significant differences were detected in incidence of wound complications (aggregated complications: 14.6% vs 13%, RR 1.11, CI 0.34-3.58) between patients with and without psoriasis. Furthermore, antibiotic use for wound infections was not significantly different between those with and without psoriasis (35% vs 42.5%, RR 0.65, CI 0.29-1.46). Conclusions: Compared to patients without psoriasis, psoriasis patients did not experience a significant difference in wound complications or wound-associated antibiotic use. Antimicrobial peptide and protein levels in psoriatic skin may be one of several factors contributing to wound healing and the absence of increased wound complications seen in this study. These findings contribute to the understanding of wound healing abilities in psoriasis patients and may aid clinicians in management of cutaneous wounds in psoriasis patients. Commercial support: None identified.
MAY 2015
471 Psoriasis induced by leuproreline acetate Joonsoo Park, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Youngil Kim, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Hyunjung Kwon, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Inyong Kim, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Insoo Chae, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Kyungduck Park, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Hyun Chung, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea Leuproreline acetate is a synthetic analogue of naturally occurring gonadotropinreleasing hormone (GnRH). The analogue acts on pituitary GnRH receptors, downregulating the secretion of luteinizing hormone and follicle-stimulating hormone. It is used to treat prostate cancer, breast cancer, endometriosis, congenital adrenal hyperplasia, and in vitro fertilization therapy. Recently, depot formulations of leuproreline acetate have been widely used to treat central precocious puberty. Until now, several cases of leuproreline induced foreign body granuloma have been reported in the Japanese, European, Korean literature, leuproreline-induced psoriasis has not been reported in Korean literature. In this article, we report the first Korean case of psoriasis induced by leuproreline acetate in an 8-year-old female. She presented with ring-shaped erythematous plaques with scale for 4 months after leuproreline acetate injection for treatment of central precocious puberty. The histopathology showed infiltration of neutrophils above parakeratotic stratum corneum with focal elongation of rete ridges and acanthosis. Herein, we report a rare case of psoriasis induced by leuproreline acetate. Commercial support: None identified.
J AM ACAD DERMATOL
AB245
1448
Prurigo nodularis in a patient with pustular psoriasis, treated with tumor necrosis factor inhibitors ngel Cardona Hernandez, MD, PhD, Ana Paula Orozco Anahuati, MD, Miguel A Gisela Navarrete Franco, MD, PhD, Maribet Gonzalez Gonzalez, MD, PhD, Cesar Alfonso Maldonado Garcıa, MD, PhD
Psoriasis in elderly and adult population: Clinical features and management Maddalena Napolitano, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Fabio Ayala, MD, PhD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Lucia Gallo, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Maria Schiattarella, PhD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Matteo Megna, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy; Nicola Balato, MD, Department of Dermatology, University of Naples Federico II, Naples, Italy
Prurigo nodularis is a low prevalence pruriginous chronic inflammatory disease that requires clinicopathologic correlation to diagnose. We present the case of a 23-yearold woman with a previous diagnosis of atopic dermatitis and pustular psoriasis, treated with anti-tumor necrosis factor therapy with partial response, developing prurigo nodularis. She presented at ‘‘Centro Dermatol ogico Dr Ladislao de la Pascua’’ in March 2014, referring new lesions in lower extremities. On examination we found a disseminated symmetrical dermatosis with inferior limb predominance without plantar involvement. It was characterized by multiple erythematous-violaceous nodular aspect lesions, about 1.5 cm in diameter, with scale and excoriations in the surface, firm consistency and infiltrate aspect with well-defined borders. Few isolated pustules were seen in some lesions. She was diagnosed on 2010 with atopic dermatitis, plaque and palmar psoriasis. Required topical treatment with moisturizers, steroids, calcineurin inhibitors and vitamin D analogs. In 2011, she presented dissemination of dermatosis, multiples pustules, arthralgia and malaise that required hospitalization. Histopathologic features consistent with pustular psoriasis. Laboratory tests showed increased IgE levels (3145 IU/mL). Therapy was begun with adalimumab for a year and since there was partial improvement the decision was taken to change to etanercept for a year. At the time of presentation to our center on March 2014 she was still on treatment with etanercept. Mantoux test showed an area of induration of 18 mm and normal chest radiograph. A biopsy revealed hyperkeratosis parakeratosis, fibrin deposits, zones with lack of granulosum stratum, and psuedoepitheliomatous hyperplasia. In superficial dermis fibrosis, and dilated congestive vessels surrounded by moderate lymphohistiocytic infiltrate that extends to middle dermis. This psoriasiform pattern required clinicopathologic correlation and a diagnosis of prurigo nodularis was made. She required a new evaluation by a hematologist, finding increased levels of IgG 3162 (552-1631 mg/dL) and IgE 6540 (\100 mg/dL), immunologic tests and skull radiograph normal, a stool cultured revealed Blastocystis hominis cysts that required treatment with nitazoxanide. She is still on follow up by a hematologist. The pustular psoriasis presented a good response to isotretinoin and the prurigo nodularis to high potency topical steroids, antihistamines and moisturizers.
Psoriasis may affect people of any age, being common among elderly. However, their management may be difficult mainly due to comorbidities and concomitant medications. Nevertheless, only very few studies have been conducted on psoriasis treatment long-term effects and/or safety in the elderly, especially regarding biologic drugs as well as on investigating clinical features of elderly ([65 years) compared with adult psoriasis subjects. A prospective observational study on 502 psoriatic patients (173 elderly subjects, 115 male and 58 female, mean age 69.1 and 329 adult patients, 207 male and 122 female, mean age 39.2) attending the outpatient Clinic of the University of Naples Federico II from 2009 to 2012 was performed. Demographic and clinical features, highlighting eventual differences in comorbidities and treatment adverse events, were analyzed through a follow-up period of at least 6 months. The two groups of patients differed especially for comorbidities and treatment profile. Particularly, adults were treated more frequently with biologic drugs compared to elderly. Among biologics, etanercept seemed to be well tolerated in elderly group as reported in literature, possibly because of its lower immunosuppressive characteristics. Moreover, our data suggested that ustekinumab presented a high efficacy and safety profile in this particular population. However, elderly did not develop more metabolic abnormalities than younger patients after systemic therapy, as well as, nearly all the registered serious adverse events occurred in subjects \65 years of age. Our study did not show substantial clinical differences between elderly and adults. Older patients might be treated with biologic drugs when required since their safety and tolerability profiles are favorable in this population. Commercial support: None identified.
Commercial support: None identified.
504 Psoriasis and wound healing: A population study of incident wound complications between patients with and without psoriasis Kory Parsi, DO, University of California, Davis, Sacramento, CA, United States; April Armstrong, MD, MPH, University of Colorado, Denver, Aurora, CO, United States; Clayton Schupp, PhD, UC Davis, Sacramento, CA, United States Introduction: Previous psoriasis wound healing outcomes research is limited to postsurgical outcomes, which report conflicting results and recommendations. The main objective of this study is to determine differences in incident wound complications between patients with and without psoriasis. Methods: We performed a retrospective cohort study in patients with cutaneous wounds to examine differences in wound complications between patients with and without psoriasis. Patients with wounds and psoriasis were matched 1:3 to patients with wounds but without psoriasis based on age, gender, and BMI. The primary outcome was aggregated incidence of wound complications including wound infection, tissue necrosis, hematoma development, and leukocytosis. We also examined differences in antibiotic use for wound infections between the two groups. Results: The study included a total of 164 patients with cutaneous wounds, which comprised of 41 psoriasis patients matched to 123 patients without psoriasis. No significant differences existed between patients with and without psoriasis with regards to baseline demographic and clinical characteristics, including tobacco use (active: 14.6% vs 19.5%, former: 19.5% vs 19.5%, or never: 65.6% vs 61%, P ¼.8152), peripheral vascular disease (2.4% in both groups), or diabetes mellitus (4.9% vs 6.5%, P ¼.7648). After controlling for diabetes, peripheral vascular disease, and smoking, no statistically significant differences were detected in incidence of wound complications (aggregated complications: 14.6% vs 13%, RR 1.11, CI 0.34-3.58) between patients with and without psoriasis. Furthermore, antibiotic use for wound infections was not significantly different between those with and without psoriasis (35% vs 42.5%, RR 0.65, CI 0.29-1.46). Conclusions: Compared to patients without psoriasis, psoriasis patients did not experience a significant difference in wound complications or wound-associated antibiotic use. Antimicrobial peptide and protein levels in psoriatic skin may be one of several factors contributing to wound healing and the absence of increased wound complications seen in this study. These findings contribute to the understanding of wound healing abilities in psoriasis patients and may aid clinicians in management of cutaneous wounds in psoriasis patients. Commercial support: None identified.
MAY 2015
471 Psoriasis induced by leuproreline acetate Joonsoo Park, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Youngil Kim, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Hyunjung Kwon, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Inyong Kim, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Insoo Chae, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Kyungduck Park, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea; Hyun Chung, Department of Dermatology, College of Medicine, The Catholic University of Daegu, Daegu, South Korea Leuproreline acetate is a synthetic analogue of naturally occurring gonadotropinreleasing hormone (GnRH). The analogue acts on pituitary GnRH receptors, downregulating the secretion of luteinizing hormone and follicle-stimulating hormone. It is used to treat prostate cancer, breast cancer, endometriosis, congenital adrenal hyperplasia, and in vitro fertilization therapy. Recently, depot formulations of leuproreline acetate have been widely used to treat central precocious puberty. Until now, several cases of leuproreline induced foreign body granuloma have been reported in the Japanese, European, Korean literature, leuproreline-induced psoriasis has not been reported in Korean literature. In this article, we report the first Korean case of psoriasis induced by leuproreline acetate in an 8-year-old female. She presented with ring-shaped erythematous plaques with scale for 4 months after leuproreline acetate injection for treatment of central precocious puberty. The histopathology showed infiltration of neutrophils above parakeratotic stratum corneum with focal elongation of rete ridges and acanthosis. Herein, we report a rare case of psoriasis induced by leuproreline acetate. Commercial support: None identified.
J AM ACAD DERMATOL
AB245