Therapeutic Ladder Research Articles

Australasian hidradenitis suppurativa management guidelines.

Hidradenitis Suppurativa is a burdensome inflammatory skin disease with significant quality of life impact. These management guidelines were developed to direct appropriate clinical management in the Australasian context. A systematic review was used for the basis of the consensus guidelines. Thirteen clinical experts were involved in a modified Delphi consensus process to develop the guidelines and treatment algorithms. Overall management strategies include appropriate severity assessment of disease and comorbidities, multimodal therapy with systemic and local treatments, and evidence-based progression along the therapeutic ladder in the event of inadequate response. Sequential monotherapy with antibiotics and/or single agent therapy is discouraged and aggressive treatment of moderate to severe disease to capture the window of opportunity is highly emphasised. Specific considerations in the setting of disease comorbidities, pregnancy and breastfeeding are also addressed. Overall, the complex nature of HS requires a complex and multimodal therapeutic response with medical, physical and surgical therapies to achieve best patient outcomes.

Efficacy of antioxidants in the management of psoriasis: A case control study

Introduction: Psoriasis is a chronic, immune-mediated inflammatory dermatosis. The pathophysiology of the disease is still incompletely elucidated and multiple factors are said to be involved in its initiation and perpetuation, e.g., stressors, genetic factors, environmental factors. In the last decade, a new theory is trying to explain the pathophysiology of this disease by looking at the role played by oxidative stress and chronic inflammation in the initiation of keratinocyte proliferation and differentiation. Keeping in consideration the increased oxidative stress in the patients of psoriasis, the anti-oxidant drugs can form an important part of the therapeutic ladder of psoriasis. Materials and Methods: The aim of this study was to measure the possible role of oxidative stress in psoriasis patient by measuring SOD level and comparing it with normal individuals and administer antioxidants supplements to the patients group to see the efficacy. It was a Case- Control study (1st part) and Clinical Trial without control group (2nd part). The study was carried out in Psoriasis awareness Club from June 2023 to December 2023. Purposive sampling done who fulfill the inclusion & exclusion criteria. 23 patients with psoriasis and 23 age and sex matched control subjects were recruited for this study. Clinical severity of the disease was determined by PASI score. All patients and control subjects were examined for plasma SOD level. 23 psoriatic patients were given antioxidant therapy in the form of once daily tablet for 30 days. PASI score, DLQI and SOD (Superoxide dismutase) level were measured before therapy (day 0) and after therapy (day 30) in patients group. Statistical analysis and Results: Data were expressed as mean ± standard deviation (SD) for quantitative variables and numbers. For comparison of two means (t test) and (ANOVA "F") test were used for several means. Chi-square (χ2 ) or fisher exact test were used when appropriate, (P<0.05) was considered statistically significant. The mean age of the patients and control subjects were 37.64 (±5.89) and 33.6 (11.02) years, respectively. The mean duration of the disease was 12.43 (±8) years. No significant difference was observed between SOD level of psoriatic patients & controls. No significant correlations of SOD level with severity of psoriasis and duration of disease were found. We observed no statistically significant difference in PASI and DLQI scores before and after antioxidant therapy but there was significant increase in the level of SOD after treatment. Conclusion: It is indisputable that antioxidant supplementation can reduce the overall morbidity, enhance the prognosis of psoriasis. Notably, in most cases, antioxidants alone are not able to induce significant clinical changes in the aspect and/or course of the disease, except perhaps in mild forms. They must be used in conjunction with standard pharmacological treatments to achieve measurable results.

Atopic Dermatitis: Managing the Itch.

Atopic dermatitis has a substantial impact on sleep, appearance, psychological well-being, and other qualities of life. The visual appearance of lichenification, cheilitis, hyperpigmentation, ichthyosis, and erythema can be socially stigmatizing, and treatment of these symptoms is challenging. In managing pruritus in patients, practitioners should assess and document pruritus through questionnaires at each routine visit. Initially, practitioners should advise patients to employ nonpharmaceutical treatments such as emollients with wet wraps, elimination of triggers, changing scratching habits, and psychological interventions. If these methods of treatment are not successful or if the disease presentation is severe, pharmacological therapies should be employed. This chapter describes the therapeutic ladder for pruritus in atopic dermatitis and discusses each treatment modality in further detail for practitioners to advise their patients.First-line topical pharmaceutical agents include topical glucocorticoids and topical calcineurin inhibitors. Second-line topical agents include coal tar, menthol, capsaicin, or doxepin. After the use of topical agents has been exhausted, primary systemic agents can be applied. These include sedating antihistamines, nonsedating antihistamines, oral glucocorticoids, or cyclosporine A. Finally, neuromodulating or immunomodulating agents can be attempted, including SSRI/SNRIs, TCAs, immunosuppressants, neural modulators, and opioid receptor modulators. Outside of pharmacological treatments, phototherapy has been shown to provide a dramatic improvement of pruritus in atopic dermatitis and can be used at any stage of treatment including as a first-line agent.

Treatment of cutaneous vasculitis

Cutaneous vasculitis encompasses a spectrum of disease states, with varied morphology, severity, and potential for systemic involvement. Even vasculitis which is skin-limited can have a significant quality-of-life impact, necessitating treatment. This manuscript summarizes the available evidence for management of various types of skin-limited vasculitis and provides a proposed therapeutic ladder based on published studies and expert opinion.

Atopic Dermatitis in Latin America: A Roadmap to Address Data Collection, Knowledge Gaps, and Challenges.

Atopic dermatitis (AD) is a systemic, multifactorial disease that causes significant morbidity and health care burden in Latin America (LA). Data on AD are scarce in LA. Lack of disease registries and non-standardized study methodologies, coupled with region-specific genetic, immunological, and environmental factors, hamper data collection. A panel of LA experts in AD was given a series of relevant questions to address before a conference. Each narrative was discussed and edited through numerous rounds of deliberation until achieving consensus. Identified knowledge gaps in AD research were updated prevalence, adult-disease epidemiology, local phenotypes and endotypes, severe-disease prevalence, specialist distribution, and AD public health policy. Underlying reasons for these gaps include limited funding for AD research, from epidemiology and public policy to clinical and translational studies. Regional heterogeneity requires that complex interactions between race, ethnicity, and environmental factors be further studied. Informed awareness, education, and decision making should be encouraged.

27641 Achieving remission of relapsing polychondritis: A case series observing diagnostic and therapeutic approaches

Introduction: Relapsing polychondritis (RP) is a rare autoimmune condition characterized by recurrent cartilaginous inflammation. Though auricular and nasal structures are most commonly affected, laryngotracheal and cardiovascular involvement may lead to fatal complications. Due to multisystem disease, diagnosis is challenging and a standard therapeutic regimen is not established. We aim to discuss current evaluation criteria and propose a therapeutic ladder.

The Therapeutic Ladder - A Clinician and a Patient Perspective

The Therapeutic Ladder - A Clinician and a Patient Perspective

2020 Korean Consensus Guidelines for Diagnosis and Treatment of Chronic Hand Eczema.

BackgroundHand eczema refers to eczema located on the hands, regardless of its etiology or morphology. Despite its high prevalence and significant impact on patients' quality of life, treatment is frequently challenging because of its heterogeneity, chronic and recurrent course, and lack of well-organized randomized controlled trials of the various treatment options.ObjectiveThese consensus guidelines aim to provide evidence-based recommendations on the diagnosis and management of hand eczema to improve patient care by helping physicians make more efficient and transparent decisions.MethodsA modified Delphi method, comprising two rounds of email questionnaires with face-to-face meetings in between, was adopted for the consensus process that took place between February and September 2020. Forty experts in the field of skin allergy and contact dermatitis were invited to participate in the expert panel.ResultsConsensus was reached for the domains of classification, diagnostic evaluation, and treatment; and a therapeutic ladder to manage chronic hand eczema was developed.ConclusionThese are the first consensus guidelines for chronic hand eczema in the Asian population, which will help standardize care and assist clinical decision-making in the diagnosis and treatment of chronic hand eczema.

IPCSK9 treatment of familial hypercholesterolemia in a patient diagnosed as congenital muscular dystrophy with contraindication for statin use

Statins are contraindicated in patients with myopathies. Until a few years ago, in those patients with familial hypercholesterolemia who also presented muscular dystrophies and did not reach adequate cholesterol plasmatic levels, the next therapeutic ladder was lipoapheresis. When iPCSK9 first appeared, lipoapheresis could be suspended in some of these patients, sustaining nevertheless proper levels of cholesterol.We present the case of a 27 year-old male, diagnosed with congenital muscular dystrophy in the early childhood. He was referred to the Unit of Lipidology presenting hypercholesterolemia which, after genetic test, was assessed as heterozygous familial hypercholesterolemia. Despite of treatment with diet and ezetimibe, cLDL blood levels abide high, being consequently included in lipoapheresis programme, therewith obtained levels of cLDL of 70mg/dl. In providing iPCSK9, lipoapheresis was withdrawn and treatment with alirocumab 150mg fortnightly introduced, unveiling a positive response, and sustaining cLDL levels around 75mg/dl.

Management Strategies Of Palmar Hyperhidrosis: Challenges And Solutions.

Palmar hyperhidrosis is a potentially disabling condition for which management remains a therapeutic challenge. Given the significant impact on quality of life, various treatment options are available, ranging from topical agents and medical devices to systemic therapies and surgical interventions. Nonsurgical approaches, i.e. topical antiperspirants, botulinum toxin injections, iontophoresis, and systemic agents, are all supported by the current literature. Patients with mild-to-moderate disease can often benefit from topical therapies only. As disease severity progresses, systemic oral medication, such as anticholinergic drugs, usually becomes necessary. Last-line surgical approaches (sympathetic denervation) should be reserved for severe refractory cases. Recently, therapeutic strategies have been evolving with several new agents emerging as promising alternatives in clinical trials. In practice, however, each modality comes with its own benefits and risks. An individual therapeutic ladder is generally recommended, taking into account disease severity, benefit-to-risk profile, treatment cost, patient preference, and clinician expertise. This review will provide an update on current and emerging concepts of management for excessive hand sweating to help clinicians optimize therapeutic decision-making.

Tratamiento de la hipercolesterolemia familiar con iPCSK9 en un paciente diagnosticado de distrofia muscular congénita con contraindicación para la toma de estatinas

Statins are contraindicated in patients with myopathies. Until a few years ago, in those patients with Familial Hypercholesterolemia who also presented muscular dystrophies and didńt reach adequate cholesterol plasmatic levels, the next therapeutic ladder was lipoapheresis. When iPCSK9 first appeared, lipoapheresis could be suspended in some of these patients, sustaining nevertheless proper levels of cholesterol.We present the case of a 27 year-old male, diagnosed with Congenital Muscular Dystrophy in the early childhood. He was referred to the Unit of Lipidology presenting hypercholesterolemia which, after genetic test, was assessed as Heterozygous Familial Hypercholesterolemia. Despite of treatment with diet and ezetimibe, cLDL blood levels abide high, being consequently included in lipoapheresis programme, therewith obtained levels of cLDL of 70mg/dl. In providing iPCSK9, lipoapheresis was withdrawn and treatment with alirocumab 150mg fortnightly introduced, unveiling a positive response, and sustaining cLDL levels around 75mg/dl.

Evaluation of Clinical Compendia Used for Medicare Part D Coverage Determinations for Off-label Prescribing in Dermatology

When making coverage determinations for off-label prescribing, Medicare Part D recognizes 2 compendia: the American Hospital Formulary Service (AHFS) Drug Information and the DRUGDEX Information System. Deficiencies in the accuracy and completeness of these compendia could result in coverage denials for necessary, effective, evidence-based treatments. To evaluate these compendia for dermatologic conditions, with a focus on less common conditions that often require systemic treatment. This cross-sectional study was conducted from July 1, 2018, through September 30, 2018. To identify diseases for which dermatologists may often need access to off-label systemic treatments, a list of 22 chronic, noninfectious, nonneoplastic diseases with at least 4 systemic therapies (including 1 in the first-line therapies and less than 25% approved by the US Food and Drug Administration) were selected for evaluation. With use of Treatment of Skin Disease, 5th Edition, a list of first-, second-, and third-line medications was created, including the level of evidence for each disease. A search of AHFS and DRUGDEX compendia was performed to evaluate for inclusion of the evidence-based therapies. In addition, the references cited in the compendia to justify inclusion of the therapy were examined qualitatively. Percentage of treatment options included in each compendium, stratified by level of evidence and position on the therapeutic ladder. Concordance between the 2 compendia was assessed using Cohen κ. Overall, 73 of 238 treatments (30.7%) evaluated were included in either compendium. Among individual diseases, 10 of 22 (45%) had 1 or fewer treatments included in the DRUGDEX compendium and 15 of 22 (68%) had 1 or fewer treatments included in the AHFS compendium. Discrepancies in which a medication was included in one compendium but not in the other compendium occurred for 53 of the 238 medications (22.3%) evaluated. Literature use did not follow a discernible pattern and was often based on decades-old sources. The findings suggest that treatment options listed in these compendia are incomplete, outdated, idiosyncratic, and unpredictable. To ensure that patients can access treatments for their disease, it appears that policies to reduce the reliance on these compendia for coverage determinations should be developed.

Atopic dermatitis: Update on comorbidities and therapeutic advances

Atopic dermatitis (AD) is a chronic inflammatory disorder that primarily affects the skin. Recent literature has expanded our knowledge of associated comorbidities. In this review, we will discuss sleep loss, attention deficit hyperactivity disorder, obesity, and anemia as they relate to AD. We will also review two recently approved medications and how they fit into the therapeutic ladder.

Atopic Dermatitis: Managing the Itch.

Atopic dermatitis has a substantial impact on sleep, appearance, psychological well-being, and other qualities of life. The visual appearance of lichenification, cheilitis, hyperpigmentation, ichthyosis, and erythema can be socially stigmatizing, and treatment of these symptoms is challenging. In managing pruritus in patients, practitioners should assess and document pruritus through questionnaires at each routine visit. Initially, practitioners should advise patients to employ non-pharmaceutical treatments such as emollients with wet wraps, elimination of triggers, changing scratching habits, and psychological interventions. If these methods of treatment are not successful or if the disease presentation is severe, pharmacological therapies should be employed. This chapter describes the therapeutic ladder for pruritus in atopic dermatitis and discusses each treatment modality in further detail for practitioners to advise their patients.First-line topical pharmaceutical agents include topical glucocorticoids and topical calcineurin inhibitors. Second-line topical agents include coal tar, menthol, capsaicin, or doxepin. After the use of topical agents has been exhausted, primary systemic agents can be applied. These include sedating antihistamines, non-sedating antihistamines, oral glucocorticoids, or cyclosporine A. Finally, neuromodulating or immunomodulating agents can be attempted, including SSRI/SNRIs, TCAs, immunosuppressants, neural modulators, and opioid receptor modulators. Outside of pharmacological treatments, phototherapy has been shown to provide a dramatic improvement of pruritus in atopic dermatitis and can be used at any stage of treatment including as a first-line agent.

Study of oxidative stress in patients of psoriasis

<p class="abstract"><strong>Background:</strong> Psoriasis is a well-recognized chronic inflammatory papulosquamous disorder characterized by the formation of salmon colored papules and plaques with silvery white scales. The aim of this study was to do a comparative evaluation of the parameters of oxidative stress, namely glutathione peroxidase, malondialdehyde and superoxide dismutase in patients of psoriasis with normal healthy subjects</p><p class="abstract"><strong>Methods:</strong> 60 subjects in the age group of 30-70 years were included in the study; Group A consisted of 30 newly diagnosed psoriasis patients presenting to the Dermatology OPD and Group B consisted of 30 normal healthy individuals. Thorough history taking and clinical examination were done. The punch biopsy was performed for histopathological examination and markers of oxidative stress were measured in each case and these values were then compared to healthy controls and statistical analysis was performed.<strong></strong></p><p class="abstract"><strong>Results:</strong> On comparison of the two groups, the levels of anti-oxidants superoxide dismutase and glutathione peroxidase were found to be decreased in psoriasis patients (168.46±51.89 U/ml and 4121.63±1812.53 U/ml respectively) as compared to controls (237±39.30 U/ml and 8435±1397.54 U/ml respectively) which was statistically highly significant (p <0.001) and the level of pro-oxidant malondialdehyde was found to be increased in patients of psoriasis (0.42±0.13 nmol/ml) in contrast to controls (0.08±0.06 nmol/ml)which was also statistically highly significant (p <0.001).</p><p><strong>Conclusions:</strong> Keeping in consideration the increased oxidative stress in the patients of psoriasis, the anti-oxidant drugs can form an important part of the therapeutic ladder of psoriasis. </p>

Early experience with endoscopic lumbar sympathectomy for plantar hyperhidrosis.

We describe our endoscopic lumbar sympathectomy technique and our early experience using it to treat plantar hyperhidrosis. We reviewed 20 lumbar sympathectomies performed in our vascular unit for plantar hyperhidrosis in 10 patients from 2011 and 2014. Demographics and outcomes were analyzed and a review of the literature conducted. All procedures were carried out endoscopically with no intraoperative or postoperative morbidity. Plantar anhidrosis was achieved in all the patients, although two patients (20%) suffered a relapse. Unwanted side-effects occurred in the form of compensatory sweating in three patients (30%) and post-sympathectomy neuralgia in two patients (20%). None of the patients experienced sexual dysfunction. Management of plantar hyperhidrosis may be based upon a therapeutic ladder starting with conservative measures and working up to surgery depending on the severity of the disease. Minimally invasive (endoscopic) sympathectomy for the thoracic chain is well established, but minimally invasive sympathectomy for the lumbar chain is a relatively new technique. Endoscopic lumbar sympathectomy provides an effective, minimally invasive method of surgical management, but long-term data are lacking.

Behçet's Disease: A Retrospective Study of 30 Cases from China

Background: Behcet's disease is a chronic systemic inflammatory vasculitis with multi-organ involvement. The etiology remains unknown and despite the genetic correlation with HLA-B51, it is thought that certain environmental triggers such as viral and bacterial infections are necessary for the development of this disease. The purpose of this case series is to retrospectively study clinical characteristics of Behcet's disease and analyze the efficacy of a standardized treatment regimen. Methods: We analyzed 30 patients, aged 20-50 years old, with Behcet's disease in terms of clinical characteristics and treatment outcomes. Patient selection was based on the presence of recurrent oral ulcers plus at least two additional findings, including recurrent genital ulceration, ocular involvement, skin lesions, or positive pathergy test. All patients were placed on a standardized treatment regimen based on individual disease characteristics. Results: In our study, ocular involvement occurred exclusively in male patients with the disease involving predominantly young to middle aged individuals (20-40 years old). No pathognomonic clinical and laboratory findings were specific to the disease, thus often delaying the diagnosis. Treatment regimens consisted of combination therapy with immunosuppressive and anti-inflammatory medications. Treatment was divided into two phases: management of acute disease and maintenance therapy with all patients achieving clinical remission after completing treatment. Conclusion: Behcet's disease is a multifactorial disease involving many possible mechanisms, both genetic and environmental. The mainstay of treatment is immunosuppression and anti-inflammatory medication. Our standardized treatment regimen was based on a therapeutic ladder and proved to be effective with all 30 patients in our study.

Does the treatment ladder for systemic therapy in moderate to severe psoriasis only go up? The percentage of patients with severe psoriasis on biologics increases over time

BackgroundWith the advent of biologic drugs in the management of moderate to severe psoriasis, there may have been a shift in therapeutic approach from rotational strategies to a unidirectional progression from topical treatments to the highest rung of the therapeutic ladder. We studied the frequency of switching from classic to biologic therapy and vice versa in a cohort of patients with psoriasis over a period of up to 5 years. MethodsPatients are included in the BIOBADADERM prospective registry when they are first prescribed any specific conventional or biologic systemic treatment. The data for each patient refer to the follow-up period from the time they entered the cohort until October 2013. To describe the pattern of switches from classic to biologic therapy and vice versa, we used the data in the registry on the first day of every 365-day period following the date each patient was included in the cohort. ResultsIn total, 47.3% of the patients (926/1956) were prescribed a classic systemic drug and 52.7% (1030/1956) a biologic agent on entry into the study. Of the 741 patients who accumulated 5 years of follow-up, 21.9% (155) were receiving nonbiologic drugs and 78.1% (553) were on biologic therapy on the first day of their 5th year of follow-up. ConclusionsThe proportion of patients receiving biologic therapy increased with longer follow-up.

Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms.

Vulvodynia is a common and debilitating chronic pain syndrome characterised by neuropathic-type pain. Localised provoked vulvodynia is the most common type, followed by generalised unprovoked vulvodynia. Vulvodynia is a diagnosis of exclusion. The cause is unknown but current research suggests an underlying predisposition to increased sensitivity to pain and peripheral and central neural sensitisation. Musculoskeletal factors also play an important role. Vulvodynia has a significant impact on the quality of life, mood, functional ability and relationships of patients and their partners. It is highly associated with anxiety and depression. Treatment needs to follow a biopsychosocial model and be tailored to the patient. A multimodal and multidisciplinary approach is often most effective. We have suggested a therapeutic ladder.

Does the treatment ladder for systemic therapy in moderate to severe psoriasis only go up? The percentage of patients with severe psoriasis on biologics increases over time

BackgroundWith the advent of biologic drugs in the management of moderate to severe psoriasis, there may have been a shift in therapeutic approach from rotational strategies to a unidirectional progression from topical treatments to the highest rung of the therapeutic ladder. We studied the frequency of switching from classic to biologic therapy and vice versa in a cohort of patients with psoriasis over a period of up to 5 years. MethodsPatients are included in the BIOBADADERM prospective registry when they are first prescribed any specific conventional or biologic systemic treatment. The data for each patient refer to the follow-up period from the time they entered the cohort until October 2013. To describe the pattern of switches from classic to biologic therapy and vice versa, we used the data in the registry on the first day of every 365-day period following the date each patient was included in the cohort. ResultsIn total, 47.3% of the patients (926/1956) were prescribed a classic systemic drug and 52.7% (1030/1956) a biologic agent on entry into the study. Of the 741 patients who accumulated 5 years of follow-up, 21.9% (155) were receiving nonbiologic drugs and 78.1% (553) were on biologic therapy on the first day of their 5th year of follow-up. ConclusionsThe proportion of patients receiving biologic therapy increased with longer follow-up.