OBJECTIVE:This study aims to prospectively evaluate the emotional impact of dupliumab treatment on patients with atopic dermatitis (AD) using a validated psychometric instrument, the Psychological General Wellbeing (PGWB) index. This index is widely used in nondermatologic conditions and assesses self-representations of intrapersonal affective and emotional states reflecting a sense of subjective wellbeing or distress. METHODS:This was a Phase IV, open-label clinical trial using dupilumab for the treatment of moderate-to-severe AD. The primary endpoint was the change in PGWB score at Week 16 of dupilumab treatment compared to baseline. RESULTS:A total of 24 participants completed the study. The change in average PGWB score after 16 weeks of treatment with dupilumab compared to baseline was not statistically significant (5.8±19.7; P=0.15). There was significant improvement in PGWB score at Week 52 of treatment (8.5±17.4; P=0.03). Mean Eczema Area and Severity Index (EASI) improvements at Weeks 16 and 52 were 60.3% and 76.8%, respectively. Regarding Investigator Global Assessment (IGA), 29.2% and 41.7% of participants achieved a score of 0 or 1 at Weeks 16 and 52, respectively. LIMITATIONS:This study did not have a control arm and was limited by small sample size. CONCLUSION:Treatment with dupilumab for 52 weeks was associated with improvement of psychological wellbeing, suggesting that intervention with this interleukin (IL) 4/IL-13 inhibitor is capable of restoring quality of life in these patients. TRIAL ADMINISTRATION:NCT03667014.

BACKGROUND:Select patients are diagnosed with both psoriasis (PSO) and hidradenitis suppurativa (HS), leading to a unique disease pattern. Genetic risk factors remain unidentified. METHODS:The study harnessed an international collection of patients with PSO and HS (PSO-SH). Clinical and genetic data were collected and analyzed. RESULTS:Eighty-seven PSO-SH patients (70% female) were identified. They had a high number of comorbidities (89%) and worse general physical health compared to PSO-only (OR: 3.09; 95% CI: 1.56-6.12) or HS-only (OR: 2.5; 95% CI: 1.23-5.00) patients. PSO-SH patients were at significantly higher risk of having Crohn's disease (OR: 4.6-11.9; 95% CI). Data revealed the highest overall genetic risk score for PSO-SH patients (PSO-polygenic risk score; 108.22), followed by PSO (101.18), HS (99.84), and healthy controls (98.58). High non-human leukocyte antigen scores were associated with an increased risk for developing both PSO and HS, indicating a distinct biological profile compared to HS-only and PSO-only individuals. LIMITATIONS:Some clinical information was collected retrospectively. CONCLUSIONS:This study highlights a shared genetic susceptibility of HS and PSO at non-human leukocyte antigen loci. Recognizing PSO-SH patients as a distinct patient group with high morbidity and increased risk for developing Crohn's disease will help to improve patient management.

The use of artificial intelligence (AI) has the potential to greatly impact the field of dermatology through applications such as aiding in disease diagnosis and advancement of personalized medicine approaches. Machine learning (ML) algorithms can be developed from an abundance of database information in the form of electronic medical records, clinical and histopathologic images, as well as translational data. This chapter briefly summarizes the key trials as well as recent research which may be of interest to both dermatologists and other medical providers. The application of AI for clinical disease classification and diagnosis is reviewed for melanoma, nonmelanoma skin cancer, and other skin diseases, including for point-of-care diagnosis and telehealth. The utilization of AI in combination with big data stores for the development of personalized/precision medicine is also discussed. Finally the current limitations of AI applications within the field of dermatology and the requirements for the future are summarized.

Atopic dermatitis (AD) is a chronic, immune-mediated skin condition characterized by pruritic, erythematous lesions. Previous clinical trials examining treatment for AD have employed quality of life questionnaires that have been largely limited to dermatology specific instruments. Our goal was to evaluate the emotional impact in AD patients after treatment with dupilumab using a validated psychometric instrument, the Psychological General Well-Being (PGWB) index. This index is widely utilized in non-dermatologic conditions and assesses self-representations of intrapersonal affective and emotional states reflecting a sense of subjective well-being or distress. This was a phase IV, open-label clinical trial using dupilumab for the treatment of moderate-to-severe AD. The primary endpoint was the change in PGWB at week 16 of dupilumab treatment compared to baseline. A total of 34 patients were recruited for participation in the study, with 24 subjects completing all 52 weeks. The change in average PGWB score at week 16 compared to baseline was not statistically significant (5.8±19.7 [p=0.15]). However, the change at week 52 did show statistically significant improvement (8.5±17.4 [p=0.03]). Mean EASI improvements at weeks 16 and 52 were 60.3% and 76.8%, respectively. Regarding IGA, 25.9% and 41.7% of subjects achieved a score of 0/1 at weeks 16 and 52, respectively. Treatment with dupilumab for 52 weeks was associated with improvement of psychological well-being, suggesting that intervention with this IL4/IL13 inhibitor is capable of restoring quality of life in these patients with sustained use. Limitations included a lack of a control arm and a small sample size.

Background: Preliminary evidence shows a possible association between hidradenitis suppurativa (HS) and obstructive sleep apnea (OSA), which is associated with various cardiovascular comorbidities. Objectives: To determine the odds of OSA among patients with HS compared with patients without HS. Methods: We performed a cross-sectional analysis using the All of Us research program database using electronic health records (EHR) and survey data from individual patient records extracted on 7 May 2022. Adult patients with available EHR records who either had at least one recorded diagnosis of HS determined by SNOMED-CT code (HS cohort) or did not have a diagnosis (non-HS cohort). The main outcome was a diagnosis of OSA as determined by SNOMED-CT code. Demographic features, survey data, and relevant comorbidities were also collected. Results: A total of 1647 patients with HS and 269,492 patients without HS were included. Of the HS patients, the mean age was 50.2 years, 79.0% were female, 39.8% were African American, 38.4% were White, and 17.4% were Hispanic or Latino. The prevalence of OSA in HS patients was 22.2% compared with 4.8% in non-HS patients. Univariate and multivariate odds ratios of OSA between HS and non-HS patients were 3.04 (95% confidence interval [CI]: 2.70-3.42) and 2.00 (95% CI: 1.72-2.33), respectively. The odds of OSA were highest in HS patients who were male, white, over 65 years of age, obese, and had hypertension, or hypothyroidism. Conclusions: The odds of being affected by both HS and OSA are augmented by multiple demographic factors, including white race, male gender, obesity, hypertension, hypothyroidism, and age over 65. Longitudinal studies are needed to confirm these findings.

IntroductionIn-person dermatology clinical research studies often face recruitment and participation challenges due to travel-, time-, and cost-associated barriers. Studies incorporating virtual/asynchronous formats can potentially enhance research subject participation and satisfaction, but few mobile health tools are available to enable remote study conduct. We developed SkinTracker, a patient-facing mobile app and researcher-facing web platform, that enables longitudinal collection of skin photos, patient reported outcomes, and biometric health and environmental data.MethodsEight design thinking sessions including dermatologists, clinical research staff, software engineers, and graphic designers were held to create the components of SkinTracker. Following iterative prototyping, SkinTracker was piloted across six adult and four pediatric subjects with atopic dermatitis (AD) of varying severity levels to test and provide feedback on SkinTracker for six months.ResultsThe SkinTracker app enables collection of informed consent for study participation, baseline medical history, standardized skin photographs, patient-reported outcomes (e.g., Patient Oriented Eczema Measure (POEM), Pruritus Numerical Rating Scale (NRS), Dermatology Life Quality Index (DLQI)), medication use, adverse events, voice diary to document qualitative experiences, chat function for communication with research team, environmental and biometric data such as exercise and sleep metrics through integration with an Apple Watch. The researcher web portal allows for management and visualization of subject enrollment, skin photographs for examination and severity scoring, survey completion, and other patient modules. The pilot study requested that subjects complete surveys and photographs on a weekly to monthly basis via the SkinTracker app. Afterwards, participants rated their experience in a 7-item user experience survey covering app function, design, and desire for participation in future studies using SkinTracker. Almost all subjects agreed or strongly agreed that SkinTracker enabled more convenient participation in skin research studies compared to an in-person format.DiscussionTo our knowledge, SkinTracker is one of the first integrated app- and web-based platforms allowing collection and management of data commonly obtained in clinical research studies. SkinTracker enables detailed, frequent capture of data that may better reflect the fluctuating course of conditions such as AD, and can be modularly customized for different skin conditions to improve dermatologic research participation and patient access.

BACKGROUND:Psoriasis patients with poor therapeutic response to multiple biologic agents are not well-characterized. OBJECTIVE:To describe the characteristics associated with development of multiple biologic failure (MBF) versus good clinical response (GR) to the first biologic. METHODS:This prospective cohort analysis evaluated patients in the multicenter CorEvitas Psoriasis Registry who initiated their first biologic between 2015 and 2020 and were followed for ≥24 months. Multivariable logistic regression identified sociodemographic, clinical, and patient-reported outcomes that differed between MBF (discontinued ≥2 biologics of different classes, each used for ≥90 days, due to inadequate efficacy) and GR (continued use of first biologic for ≥2 years) patients. RESULTS:One thousand thirty-nine patients were analyzed (490 GR [47.2%], 65 MBF [6.3%]). Female sex, shorter psoriasis duration, earlier year of biologic initiation, prior nonbiologic systemic therapy use, history of hyperlipidemia, and Medicaid insurance were significantly associated with MBF, though the latter 2 variables exhibited wider confidence intervals, indicating a lower level of support. The first-to-second biologic sequence most observed with MBF was Tumor necrosis factor-α inhibitor to IL-17 inhibitor use. LIMITATIONS:Biologic adherence between visits was not evaluated. CONCLUSION:Approximately 6% of psoriasis patients met MBF criteria. The results identify characteristics associated with MBF that may distinguish patients warranting more frequent follow-up.

Clinical providers often face difficult-to-treat psoriasis patients who have failed multiple biologic agents and classes. Our objective was to identify patients with multiple biologic failure (MBF) and risk factors for MBF in the CorEvitas Psoriasis Registry. We included plaque psoriasis patients who initiated their first biologic therapy during registry enrollment and had ≥2 years of follow-up (2015-2022). We defined MBF as medically failing ≥2 biologic classes (TNFi, IL12/23i, IL17i, IL23i) with ≥90 days of treatment, and good response (GR) as ≥24 months of continued use of first biologic. Socio-demographics, lifestyle characteristics including comorbidities, psoriasis disease and treatment characteristics, and patient reported outcomes were assessed at first biologic initiation. To identify independent risk factors for MBF vs GR, a multivariable logistic regression model was constructed. The final model included a priori selected variables (age, sex, race, ethnicity, BMI) and others retaining statistical significance of P<0.10. Among the 1,039 biologic-naïve initiators, 65 (6%) were MBF and 490 (47%) were GR, mean age was 49 years, 44% were women and 78% were white. Variables independently associated with MBF included female sex (OR=2.29; 95% CI: 1.11, 4.72), hyperlipidemia (OR=3.14; 95% CI 1.35, 7.30), Medicaid insurance (OR=4.53; 95% CI 1.40, 14.60), and prior non-biologics use (OR=2.47; 95% CI: 1.16, 5.25). Year of first biologic and shorter psoriasis duration were independently associated with MBF, likely reflecting secular trends in biologics availability. These findings identify a subset of psoriasis patients who are more likely to experience MBF and who may warrant more intensive follow-up with their providers.

Patients with psoriasis are more likely to experience depression and suicidality compared to non-psoriatic patients, though systemic therapies have been shown to improve depressive symptoms. It is unclear whether or not biologic or oral agents are more effective at improving such depressive symptoms in psoriasis patients, however. We aimed to determine an estimate of the odds of incident depression in psoriasis patients on different systemic therapies by performing a cross-sectional analysis of postmarketing data. The reporting odds ratio (ROR) for 15 different systemic agents was calculated using reports from the Food and Drug Administration Adverse Events Reporting System (FAERS). After excluding brodalumab and apremilast due to high risk of reporting bias, we found oral agents were associated with a significantly higher ROR of depression compared to biologics (OR = 2.42, 95% confidence interval: 1.93-3.04). These results suggest biologics may be more effective at reducing incident depression than oral agents. Future controlled trials are needed to confirm these findings.

To the Editor: Patients with psoriasis have an increased risk for comorbidities such as cardiometabolic disease and psoriatic arthritis.1Yamazaki F. Psoriasis: comorbidities.J Dermatol. 2021; 48: 732-740https://doi.org/10.1111/1346-8138.15840Crossref PubMed Scopus (39) Google Scholar However, the association of other rheumatic diseases with psoriasis remains to be fully elucidated. We conducted a cross-sectional cohort study in the United States-based racially and ethnically diverse All of Us (AoU) national database (∼40% non-White; https://allofus.nih.gov), investigating the association between psoriasis and rheumatic diseases. Subjects were adults aged 18 and older with electronic health records (EHRs) in the AoU database. Two cohorts, including a psoriasis (PsO) group (2 or more ICD9/10 diagnoses of psoriasis) and a control group (individuals without a diagnosis of PsO), were identified on May 14, 2022. Rheumatic diseases of interest (axial spondyloarthritis [axSpA], dermatomyositis [DM], fibromyalgia [FM], gout, osteoarthritis [OA], polymyositis [PM], psoriatic arthritis [PsA], rheumatoid arthritis [RA], Sjogren's syndrome [SS], systemic lupus erythematosus [SLE], and systemic sclerosis [SSc]) were identified according to ICD9/10 coded criteria (Supplementary Table 1, available via Mendeley at https://doi.org/10.17632/5hbv6s26fd.1). Data from participant surveys, including age, sex at birth, race, and ethnicity, smoking history, alcohol use history, income, and rural location were extracted. R version 4.1.2 was used to analyze information provided in the All of Us (AoU) database using EHR data for PsO patients and non-PsO controls. The Benjamini–Hochberg procedure was used to correct for multiple testing. Demographic data are shown in Table I, and univariate and multivariate analysis are summarized in Table II. After controlling for age, race, ethnicity, obesity, smoking, alcohol, income, and delay in care due to rural location, there was a significant association of PsO with psoriatic arthritis (PsA), osteoarthritis (OA), gout, fibromyalgia (FM), rheumatoid arthritis (RA), AS, Sjogren’s syndrome (SS), and systemic sclerosis (SSc). There was a significant and strong association of PsO with CD but not UC, which was performed as an internal control. Due to clinical overlap between PsA and other rheumatic conditions, we examined the percentage of PsA patients diagnosed with concomitant diseases (Supplementary Table 3, available via Mendeley at https://doi.org/10.17632/5hbv6s26fd.1). Common co-diagnosis in PsA patients includes OA (47.6%), RA (15.1%), and FM (12.7%).Table IDemographics for psoriasis (PsO) patients versus nonpsoriasis controls. P-values calculated using χ2 statistics. For each variable examined, the totals reflect number of patients without missing dataPsOControlsP-valueTotal (n)3267265,957–Age, mean (SD)62.28 (14.72)54.69 (16.67)<1.00e-5BMI, mean (SD)30.81 (7.39)29.76197 (7.48)<1.00e-5Obesity (BMI > 30), n (%)<1.00e-5 Nonobese1658 (52.62%)153719 (59.22%) Obese1493 (47.38%)105840 (40.78%)Age group, n (%)<1.00e-5 18-44527 (16.13%)85550 (32.17%) 45-651167 (35.72%)100173 (37.67%) >651573 (48.15%)80234 (30.17%)Sex at birth, n (%).35 Male1295 (40.26%)103441 (39.43%) Female1923 (59.74%)158916 (60.57%)Race, n (%)<1.00e-5 White2390 (85.11%)131409 (61.87%) Black or African American229 (8.16%)63166 (29.74%) Asian88 (3.13%)8442 (3.97%) Other∗Defined as a sum of the answer choices “Another single population”, “More than one population”, and “None of these”.101 (3.60%)9386 (4.41%)Ethnicity, n (%)<1.00e-5 Not Hispanic/Latinx2706 (85.41%)203763 (78.94%) Hispanic/Latinx462 (14.58%)54347 (21.1%)Alcohol use (ever), n (%)<1.00e-5 Yes2973 (92.91%)226189 (87.64%) No227 (7.09%)31883 (12.35%)Alcohol use within past year, n (%)5.03e-4 Yes2345 (72.53%)182515 (69.97%) No888 (27.47%)79324 (30.03%)Cigarette use (>100 cigarettes/lifetime), n (%)<1.00e-5 Yes1561 (48.87%)106697 (41.61%) No1633 (51.13%)149704 (58.39%)Annual income level<1.00e-5 Low (<$50k)1246 (44.7%)118397 (56.7%) Middle ($50k-$150k)1070 (38.4%)66201 (31.7%) High (>$150k)470 (16.9%)24145 (11.6%)Rural†Defined as a participant-reported delay in care due to living in a rural location..62 No1616 (97.23%)89964 (97.14%) Yes46 (2.76%)2762 (2.86%)BMI, Body mass index; n, number; PMD, patient missing data; PsO, psoriasis; SD, standard deviation.∗ Defined as a sum of the answer choices “Another single population”, “More than one population”, and “None of these”.† Defined as a participant-reported delay in care due to living in a rural location. Open table in a new tab Table IIPrevalence and odds ratio (OR) of concomitant musculoskeletal and rheumatologic diseasesPsO(% of total)Controls(% of total)Univariate OR (95% CI)Univariate P-valueMultivariate OR∗Multivariate analysis controlled for age group, race, ethnicity, obesity, smoker, alcohol use within the past year, income level, and delay in care due to rural location. (95% CI)Multivariate P-valuePsA705 (21.6%)314 (0.1%)146.46 (119.95-179.58)<2e-16135.02 (108.25-169.27)<2E-16OA1233 (37.7%)41289 (15.5%)2.56 (2.30-2.85)<2e-162.23 (1.97-2.53)<2E-16Gout192 (5.9%)5118 (1.9%)2.45 (1.90-3.10)5.63E-132.15 (1.63-2.78)1.78E-08FM219 (6.7%)5628 (2.1%)2.96 (2.38-3.64)<2e-162.82 (2.21-3.56)<2E-16SLE54 (1.7%)2124 (8.0%)1.32 (0.74-2.17)0.3011.19 (0.59-2.12)0.59RA193 (5.9%)4089 (1.5%)3.70 (2.91-4.63)<2e-163.33 (2.54-4.29)<2E-16AxSpA33 (1.0%)367 (0.1%)5.76 (3.30-9.36)3.37E-115.19 (2.78-8.91)2.35E-08SS74 (2.3%)1972 (0.7%)2.25 (1.57-3.11)3.55E-061.93 (1.28-2.80)9.41E-04SSc<20†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.<400†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.3.12 (1.32-6.20)0.00352.93 (1.14-6.16)0.01PM<20†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.<200†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.3.41 (0.55-11.26)0.092.28 (0.13-10.93)0.42DM<20†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.<100†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.2.37 (0.39-7.68)0.232.96 (0.48-9.81)0.14CD90 (2.8%)1581 (0.6%)3.30 (2.29-4.58)1.21E-113.11 (2.06-4.49)9.44E-09UC57 (1.7%)1530 (0.6%)1.59 (0.95-2.46)0.05511.09 (0.56-1.89)0.78AxSpA, Axial spondyloarthritis; CD, Crohn's disease; CI, confidence interval; DM, dermatomyositis; FM, fibromyalgia; OA, osteoarthritis; OR, odds ratio; PM, polymyositis; PsA, psoriatic arthritis; PsO, psoriasis; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; SS, Sjogren's syndrome; SSc, systemic sclerosis (scleroderma); UC, ulcerative colitis.∗ Multivariate analysis controlled for age group, race, ethnicity, obesity, smoker, alcohol use within the past year, income level, and delay in care due to rural location.† Exact values not reported to protect patient privacy, as per the All of Us database user agreements. Open table in a new tab BMI, Body mass index; n, number; PMD, patient missing data; PsO, psoriasis; SD, standard deviation. AxSpA, Axial spondyloarthritis; CD, Crohn's disease; CI, confidence interval; DM, dermatomyositis; FM, fibromyalgia; OA, osteoarthritis; OR, odds ratio; PM, polymyositis; PsA, psoriatic arthritis; PsO, psoriasis; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; SS, Sjogren's syndrome; SSc, systemic sclerosis (scleroderma); UC, ulcerative colitis. The association of PsO with systemic conditions is a growing focus because of its impact on the overall wellbeing of patients beyond the skin manifestations. Co-occurrence of psoriasis and rheumatic diagnoses may in part be due to common underlying mechanisms such as higher BMI.2Kulkarni K. Karssiens T. Kumar V. Pandit H. Obesity and osteoarthritis.Maturitas. 2016; 89: 22-28https://doi.org/10.1016/j.maturitas.2016.04.006Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar, 3D'Onghia M. Ciaffi J. Lisi L. et al.Fibromyalgia and obesity: a comprehensive systematic review and meta-analysis.Semin Arthritis Rheum. 2021; 51: 409-424https://doi.org/10.1016/j.semarthrit.2021.02.007Crossref PubMed Scopus (24) Google Scholar, 4Armstrong A.W. Harskamp C.T. Armstrong E.J. The association between psoriasis and obesity: a systematic review and meta-analysis of observational studies.Nutr Diabetes. 2012; 2e54https://doi.org/10.1038/nutd.2012.26Crossref PubMed Scopus (350) Google Scholar, 5Han J.H. Lee J.H. Han K.D. et al.Increased risk of psoriasis in subjects with abdominal obesity: a nationwide population-based study.J Dermatol. 2019; 46: 695-701https://doi.org/10.1111/1346-8138.14939Crossref PubMed Scopus (19) Google Scholar In our analysis, obesity as an independent covariate was significantly associated with an increased risk of all joint diagnoses investigated (PsA, OA, gout, RA, and AxSpA) as well as FM (Supplementary Table 2, available via Mendeley at https://doi.org/10.17632/5hbv6s26fd.1). Of note, however, PsO was associated with an increased odds of rheumatic diseases compared to controls even after adjustment for body mass index (BMI). The strength of this cross-sectional study is the inclusion of a relatively diverse set of patients in the AoU database, which allows our conclusions to be more generalizable. However, the potential for misclassification by incorrect diagnoses in the EHR is a limitation, especially regarding rheumatic disease in relation to PsA. The study was cross-sectional, limiting analysis of the temporal relationship between PsO and these rheumatic diseases. Overall, this study suggests the importance of screening PsO patients for MSK symptoms and referral to a rheumatologist if warranted. Tina Bhutani is a principal investigator for trials sponsored by Abbvie, Castle, CorEvitas, Dermavant, Galderma, Mindera, and Pfizer. She has received research grant funding from Novartis and Regeneron. She has been an advisor for Abbvie, Arcutis, Boehringer-Ingelheim, Bristol Myers Squibb, Janssen, Leo, Lilly, Novartis, Pfizer, Sun, and UCB. Wilson Liao has received research grant funding from Abbvie, Amgen, Janssen, Leo, Novartis, Pfizer, Regeneron, and TRex Bio. Lianne S. Gensler has received grant funding from Novartis, Pfizer and UCB and has been an advisor for AbbVie, Eli Lilly, Fresenius Kabi, Gilead, Janssen, MoonLake, Novartis, Pfizer and UCB. The remaining authors have nothing to disclose. The All of Us Research Program is supported by the following: the National Institutes of Health, Office of the Director: Regional Medical Centers: 1 OT2 OD026549; 1 OT2 OD026554; 1 OT2 OD026557; 1 OT2 OD026556; 1 OT2 OD026550; 1 OT2 OD 026552; 1 OT2 OD026553; 1 OT2 OD026548; 1 OT2 OD026551; 1 OT2 OD026555; IAA #: AOD 16037; Federally Qualified Health Centers: HHSN 263201600085U; Data and Research Center: 5 U2C OD023196; Biobank: 1 U24 OD023121; The Participant Center: U24 OD023176; Participant Technology Systems Center: 1 U24 OD023163; Communications and Engagement: 3 OT2 OD023205; 3 OT2 OD023206; and Community Partners: 1 OT2 OD025277; 3 OT2 OD025315; 1 OT2 OD025337; 1 OT2 OD025276. We thank all the participants of All of Us for their invaluable participation and collaboration with this program.

Background: Introduction: Hidradenitis suppurativa (HS) and psoriasis are chronic inflammatory skin disorders with shared features in pathogenesis [1-3]. However, there is a paucity of studies characterizing patients with both diseases. This study seeks to elucidate the clinical characteristics associated with this patient population.

Guselkumab is an anti-interleukin-23 monoclonal antibody that is approved for plaque psoriasis and psoriatic arthritis. We present a case of a 28-year-old female patient with acute onset of guttate psoriasis after a blistering sunburn. She had no personal or family history of psoriasis or chronic inflammatory skin disease. The guttate psoriasis was refractory to topical treatment. After the first dose of guselkumab (100 mg subcutaneous injection), the patient experienced near-clearance of her guttate psoriasis, with continued improvement and drug-free remission 8 months after cessation of treatment. Dermatologists could consider guselkumab as a treatment option for patients with guttate psoriasis. Future studies should examine the potential for guselkumab to induce drug-free remissions in guttate psoriasis.

To the Editor: Biologics are highly efficacious biologic for treating moderate-to-severe plaque psoriasis, particularly brodalumab.1Armstrong A.W. Soliman A.M. Betts K.A. et al.Comparative efficacy and relative ranking of biologics and oral therapies for moderate-to-severe plaque psoriasis: a network meta-analysis.Dermatol Ther (Heidelb). 2021; 11: 885-905https://doi.org/10.1007/s13555-021-00511-1Crossref PubMed Scopus (30) Google Scholar However, the use of brodalumab has been severely limited due to a black box warning and an associated Risk Evaluation and Mitigation Strategies program indicating a possible increased risk of suicidality. This warning was applied due to 4 possible suicides during phase III clinical trials, of which only 3 were verified. Closer examination of these cases shows that all 3 had significant life stressors and no chronological relationship between drug administration and suicide was present.2Koo J. Ho R.S. Thibodeaux Q. Depression and suicidality in psoriasis and clinical studies of brodalumab: a narrative review.Cutis. 2019; 104: 361-365PubMed Google Scholar Given that brodalumab has been approved for nearly half of a decade, we aimed to examine worldwide postmarketing data to evaluate the association between brodalumab use and risk of suicide compared to 10 other biologics approved for psoriasis. The total number of completed suicides for each biologic was extracted from the Food and Drug Administration Adverse Events Reporting System (FAERS) for all indications included through December 31, 2021.3Research C for DEFDA Adverse Event Reporting System (FAERS) public dashboard. FDA.https://www.fda.gov/drugs/questions-and-answers-fdas-adverse-event-reporting-system-faers/fda-adverse-event-reporting-system-faers-public-dashboardDate accessed: February 17, 2022Google Scholar The FAERS is a publicly available international database for reporting postmarketing drug adverse events. The total number of patients prescribed each drug for all indications was determined by contacting pharmaceutical companies. The number of total completed suicides for each biologic agent and the number of completed suicides per total patients prescribed are shown in Table I and Fig 1. Two suicides were reported for brodalumab on the FAERS. One suicide was reported in the United Kingdom but was deemed fraudulent due to a lack of mandatory reporting details required by the British Dermatology Association and British nursing agencies. The only verifiable suicide on brodalumab occurred in a Japanese male in his 50s with metastatic stage 4B lung adenocarcinoma and lived alone with no nearby relatives. He committed suicide 36 days after his first dose of brodalumab, and it remains unknown whether he self-administered follow-up doses.Table ITotal completed suicides, total patients prescribed, and suicides per total patients prescribed for all indications for each biologicBiologic nameCompleted suicides since approvalTotal patients prescribedCorresponding date for total patients prescribedSuicides per total patients prescribedTildrakizumab0n/an/an/aRisankizumab0n/an/an/aBrodalumab1∗Investigation from the parent pharmaceutical company of brodalumab found that there were 2 reports of suicide: one in Japan and one in the United Kingdom (UK). The reported case in the UK, however, was deemed fraudulent due to a lack of details from corroborating organizations such as mandatory reporting from nursing agencies and reports from the British Dermatology Association, despite multiple outreach attempts. Therefore, we only included one verifiable suicide from Japan for brodalumab for this report.20,871July 31, 20214.79 × 10−5Ixekizumab4175,000February 28, 20212.29 × 10−5Guselkumab4n/an/an/aCertolizumab12n/an/an/aUstekinumab12n/an/an/aSecukinumab17>500,000†The value of n could only be provided as a lower estimate for adalimumab and secukinumab and so for the purposes of this report, this lower estimate value was used to calculate suicides per total patients prescribed.December 23, 20213.20 × 10−5†The value of n could only be provided as a lower estimate for adalimumab and secukinumab and so for the purposes of this report, this lower estimate value was used to calculate suicides per total patients prescribed.Etanercept62n/an/an/aInfliximab843,100,000August 01, 20202.61 × 10−5Adalimumab175>1,400,000†The value of n could only be provided as a lower estimate for adalimumab and secukinumab and so for the purposes of this report, this lower estimate value was used to calculate suicides per total patients prescribed.January 01, 20201.04 × 10−4†The value of n could only be provided as a lower estimate for adalimumab and secukinumab and so for the purposes of this report, this lower estimate value was used to calculate suicides per total patients prescribed.The total number of completed suicides are reported for each biologic as of December 31, 2021 as reported by the FAERS. The total number of patients prescribed worldwide for each agent was obtained by directly reaching out to pharmaceutical companies. The corresponding date for the most recent value for the total number of patients prescribed is also listed. When calculating suicides per total patients prescribed, the number of completed suicides up to the corresponding date that was provided by pharmaceutical companies was used in order to account for differences in reporting from each pharmaceutical company. Values which were unable to be obtained are indicated with “n/a”.∗ Investigation from the parent pharmaceutical company of brodalumab found that there were 2 reports of suicide: one in Japan and one in the United Kingdom (UK). The reported case in the UK, however, was deemed fraudulent due to a lack of details from corroborating organizations such as mandatory reporting from nursing agencies and reports from the British Dermatology Association, despite multiple outreach attempts. Therefore, we only included one verifiable suicide from Japan for brodalumab for this report.† The value of n could only be provided as a lower estimate for adalimumab and secukinumab and so for the purposes of this report, this lower estimate value was used to calculate suicides per total patients prescribed. Open table in a new tab The total number of completed suicides are reported for each biologic as of December 31, 2021 as reported by the FAERS. The total number of patients prescribed worldwide for each agent was obtained by directly reaching out to pharmaceutical companies. The corresponding date for the most recent value for the total number of patients prescribed is also listed. When calculating suicides per total patients prescribed, the number of completed suicides up to the corresponding date that was provided by pharmaceutical companies was used in order to account for differences in reporting from each pharmaceutical company. Values which were unable to be obtained are indicated with “n/a”. When comparing the total number of suicides reported and suicides per total patients prescribed since approval, brodalumab appears similar to other common biologics like adalimumab. Worldwide postmarketing data revealed only one confirmed suicide in a patient with metastatic cancer and little support system. Additionally, the unknown dosing of brodalumab in this patient fails to provide strong evidence of a causative relationship. Considering that postmarketing data are often considered a better reflection of real-world outcomes than clinical trials (conducted in more structured settings), the available worldwide data do not support the notion that brodalumab has a unique risk of increased suicides. In addition to reporting bias from using FAERS data, limitations of this study include the fact that the total number of patients prescribed biologics is mostly the best estimates provided by pharmaceutical companies and that some of these values were not available at all despite the authors’ best efforts to obtain them. Moreover, FAERS data do not provide granular details such as preexisting risks, duration of drug use, and other details on the patient data. Despite these limitations, these novel results using the FAERS database highlight the possibility that brodalumab may not increase risk of suicidality and that further investigation is warranted. J Koo is an advisor/consultant/speaker for Ortho Dermatologics, AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen, LEO, Merck/Sun, Novartis, Regeneron, Sanofi, and EPI Pharmaceutical Corporations. The remaining authors have no conflicts of interest to disclose.

Chronic inflammatory skin disorders are known to affect sleep quality; however, the relationship between hidradenitis suppurativa (HS) and sleep is not well understood. We performed a systematic review of HS and sleep disorders and sleep quality in HS patients. We identified seven studies comprising 343,870 subjects. We found that HS patients have a higher likelihood of having a sleep disorder such as obstructive sleep apnea, as well as other non-sleep apnea. Several studies showed that patients reported worse sleep quality due to symptoms of HS such as pruritus and pain. HS patients may be at risk for additional cardiovascular comorbidities and poorer quality of life secondary to these sleep disorders and poor sleep quality. Further high-quality research evaluating these associations is warranted.

Psoriasis is a prevalent inflammatory skin disorder that is associated with a number of comorbidities including cardiovascular disease and metabolic syndrome. Exercise can influence the outcomes of chronic inflammatory diseases, and the presence of these diseases can also influence physical activity in afflicted patients. We reviewed the available literature published on exercise in psoriasis patients and aimed to explore physical activity levels, barriers to exercise, physical fitness, exercise as a prevention strategy as well as a treatment modality. Overall, patients with moderate to severe psoriasis are more sedentary than the general population and experience barriers to exercise secondary to their skin disease. Moderate to vigorous exercise may be an independent preventative factor in reducing the incident risk of developing psoriasis and the utilization of exercise as a weight loss strategy may improve disease severity especially in overweight patients. Expert panels agree that exercise can be beneficial as an adjunct treatment in patients with psoriasis who are overweight; however, more randomized clinical trials are needed to establish these links.

Though biologic agents have shown excellent efficacy in treating many patients with moderate to severe plaque psoriasis, a subset of these patients are refractory to treatment with multiple biologic agents. Certain variables such as demographics, degree of disease severity, genetics, and previous experience with biologic therapy have been shown to influence response to single biologic therapy in patients with plaque psoriasis. We examined clinical data from 222 psoriasis patients at UCSF; 171 reported use of only a single biologic agent and 51 reported prior use of 3 or more biologics at enrollment from 2006-2020.

Psoriasis is an immune-mediated disease characterized by skin and systemic inflammation that affects 125 million people worldwide. However, the underlying pathways contributing to psoriasis pathogenesis have not been fully elucidated. This project uses single-cell transcriptomes of T cells and other immune cell types from healthy and psoriatic skin in an effort to identify key biomarkers and pathways of psoriasis. T cells were clustered into subtypes and differential gene expression analysis was performed between lesional and healthy skin to identify psoriatic marker genes in each T cell subtype. Regulatory CD4+ T cells in psoriasis lesional skin were found to upregulate cytokines such as IL-32, as well as genes in the interferon-gamma-mediated signaling, NF-κB signaling, and putrescine catabolic pathways. As a result, psoriatic Tregs may amplify several of the pathways behind psoriasis and drive inflammation via IL-32, which has been previously found to be significantly upregulated in plaque psoriasis. Ongoing work includes using stratification by HLA type, VDJ analysis to more closely investigate psoriatic TCR abnormalities, and incorporation of more patient data.

Introduction Halobetasol propionate foam has been established as an efficacious and easy-to-use topical treatment for adults with plaque psoriasis. Its recent approval in the United States expanded its use for adolescents from ages 12 to 17 years old. Areas covered We briefly summarize the chemistry of halobetasol and review clinical trials involving halobetasol propionate 0.05% foam to evaluate its efficacy and safety profile with a specific focus on adolescents with plaque psoriasis. Expert opinion Halobetasol propionate 0.05% foam is an effective and cosmetically elegant superpotent topical corticosteroid, with a tolerable safety profile in adolescents. The use of this foam offers another option to address patient-specific needs and preferences, adding to the toolbox of currently available treatments for adolescent psoriasis.

Background Hidradenitis suppurativa (HS) is an inflammatory skin disorder characterized by recurring painful and suppurating lesions, with the disease disproportionately affecting black populations in the United States. Ethnoracial representation in clinical trials is vital to ensuring results are generalizable. The purpose of this study is to examine whether ethnic or racial disparities exist in HS clinical trials. Methods The US National Library of Medicine clinical trials database (clinicaltrials.gov) was queried to identify HS clinical trials. Trials that did not present ethnic or racial data on either the website or publication were not considered. Results A total of 57 HS trials were identified. Of these, 23 trials, containing 2530 patients, included racial or ethnic data (Table 1 ). White patients made up 76.1% (1435/1886) of the study population, followed by Blacks or African Americans (13.7% (238/1732)), Hispanics or Latinos (7.2% (20/279), Asians (2.6% (26/1016)), American Indians or Alaska Natives (1.3% (14/1051)), and Native Hawaiians or Other Pacific Islanders (0.4% (4/926)). Discussion Our results establish a significant lack of minority ethnoracial representation in HS clinical trials. Since HS prevalence is highest among Blacks or African Americans, it is imperative that future clinical trials are conducted with a larger proportion of this population. Furthermore, clinical trials that did not report racial or ethnic information were conducted in countries with predominantly White populations, which likely skewed the results of this study and caused underreporting of these patients.