Psoriasis Collection

Within 18 months of its launch, almost 2,000 people were enrolled in a new, international online registry for rare autoinflammatory diseases designed to facilitate research and treatment, as well as increase awareness of the conditions.

The registry, called Eurofever and launched in November 2009 with the support of the Executive Agency for Health and Consumers of the European Union (EAHC), includes demographic, clinical, and genetic information on people who have developed familial Mediterranean fever, tumor necrosis factor receptor–associated periodic syndrome (TRAPS), mevalonate kinase deficiency, Behçet’s disease, and other conditions, more than 10 in all. Enrollment is ongoing, and new autoinflammatory conditions will be added as they are recognized.

The Eurofever registry is "available for analysis on clinical presentation, disease course, and response to treatment, and to perform large-scale comparative studies between different conditions," according to its founders. It can be accessed in the member area of the Pediatric Rheumatology International Trial Organisation (PRINTO) website. Enrollment information is on the registry’s website.

The goal of the efforts is to counteract "a major limitation to understanding these rare conditions[,] the fragmentation of clinical experience with very few centers in any country caring for more than a handful of cases," according to principal investigator and pediatric rheumatologist Marco Gattorno of the University of Genoa (Italy) and his associates. The investigators solicited enrollment from pediatric and adult centers known to have an interest in rare autoinflammatory diseases (Ann. Rheum. Dis. 2012 Feb. 29 [doi: 10.1136/annrheumdis-2011-200549]).

So far, the registry includes 916 males and 964 females from 67 centers in 31 countries. Three-quarters are under 18 years of age, consistent with the fact that the conditions tend to present in childhood. Three-quarters also reside in Western Europe; 16% in Turkey, Israel, or North Africa; 6% in Eastern Europe, and the rest in Asia, South America, and Australia.

Although North America and many South American and Asian countries "are not yet covered by the registry, the large number of patients recruited in this first period of the project and the wide geographical distribution is very encouraging and suggests that the network can continue to grow," Dr. Gattorno and his colleagues noted.

The efforts are already paying off. An analysis of registry data resulted in identification of three previously unreported mutations for TRAPS, four for mevalonate kinase deficiency, and two for cryopyrin associated periodic syndromes.

The investigators found that physicians are making the diagnosis more quickly. Although the median delay between disease onset and diagnosis was 7.3 years, there is a "trend towards shorter diagnostic delay in patients born" in the current century – 1.4 years for familial Mediterranean fever, for instance – robably "due to the fact that many of these diseases are recently recognized clinical entities and that genetic diagnosis has ...become relatively widely available in the last few years," they noted.

Even so, "the marked bias towards Western Europe," where there are relatively large number of centers with facilities for genetic analysis, may suggest that recognition remains a problem elsewhere, they noted.*

The EAHC is funding the project, along with PRINTO, Novartis, and the Seventh Framework Programme (2007–2013) of the European Community for Research, Technological Development, and Demonstration Activities.

The authors said they had no relevant financial disclosures.

*CORRECTION: 03/12/2012 An earlier version of this story misstated the number of specialty centers with facilities for genetic analysis.

Within 18 months of its launch, almost 2,000 people were enrolled in a new, international online registry for rare autoinflammatory diseases designed to facilitate research and treatment, as well as increase awareness of the conditions.

The registry, called Eurofever and launched in November 2009 with the support of the Executive Agency for Health and Consumers of the European Union (EAHC), includes demographic, clinical, and genetic information on people who have developed familial Mediterranean fever, tumor necrosis factor receptor–associated periodic syndrome (TRAPS), mevalonate kinase deficiency, Behçet’s disease, and other conditions, more than 10 in all. Enrollment is ongoing, and new autoinflammatory conditions will be added as they are recognized.

The Eurofever registry is "available for analysis on clinical presentation, disease course, and response to treatment, and to perform large-scale comparative studies between different conditions," according to its founders. It can be accessed in the member area of the Pediatric Rheumatology International Trial Organisation (PRINTO) website. Enrollment information is on the registry’s website.

The goal of the efforts is to counteract "a major limitation to understanding these rare conditions[,] the fragmentation of clinical experience with very few centers in any country caring for more than a handful of cases," according to principal investigator and pediatric rheumatologist Marco Gattorno of the University of Genoa (Italy) and his associates. The investigators solicited enrollment from pediatric and adult centers known to have an interest in rare autoinflammatory diseases (Ann. Rheum. Dis. 2012 Feb. 29 [doi: 10.1136/annrheumdis-2011-200549]).

So far, the registry includes 916 males and 964 females from 67 centers in 31 countries. Three-quarters are under 18 years of age, consistent with the fact that the conditions tend to present in childhood. Three-quarters also reside in Western Europe; 16% in Turkey, Israel, or North Africa; 6% in Eastern Europe, and the rest in Asia, South America, and Australia.

Although North America and many South American and Asian countries "are not yet covered by the registry, the large number of patients recruited in this first period of the project and the wide geographical distribution is very encouraging and suggests that the network can continue to grow," Dr. Gattorno and his colleagues noted.

The efforts are already paying off. An analysis of registry data resulted in identification of three previously unreported mutations for TRAPS, four for mevalonate kinase deficiency, and two for cryopyrin associated periodic syndromes.

The investigators found that physicians are making the diagnosis more quickly. Although the median delay between disease onset and diagnosis was 7.3 years, there is a "trend towards shorter diagnostic delay in patients born" in the current century – 1.4 years for familial Mediterranean fever, for instance – robably "due to the fact that many of these diseases are recently recognized clinical entities and that genetic diagnosis has ...become relatively widely available in the last few years," they noted.

Even so, "the marked bias towards Western Europe," where there are relatively large number of centers with facilities for genetic analysis, may suggest that recognition remains a problem elsewhere, they noted.*

The EAHC is funding the project, along with PRINTO, Novartis, and the Seventh Framework Programme (2007–2013) of the European Community for Research, Technological Development, and Demonstration Activities.

The authors said they had no relevant financial disclosures.

*CORRECTION: 03/12/2012 An earlier version of this story misstated the number of specialty centers with facilities for genetic analysis.

Within 18 months of its launch, almost 2,000 people were enrolled in a new, international online registry for rare autoinflammatory diseases designed to facilitate research and treatment, as well as increase awareness of the conditions.

The registry, called Eurofever and launched in November 2009 with the support of the Executive Agency for Health and Consumers of the European Union (EAHC), includes demographic, clinical, and genetic information on people who have developed familial Mediterranean fever, tumor necrosis factor receptor–associated periodic syndrome (TRAPS), mevalonate kinase deficiency, Behçet’s disease, and other conditions, more than 10 in all. Enrollment is ongoing, and new autoinflammatory conditions will be added as they are recognized.

The Eurofever registry is "available for analysis on clinical presentation, disease course, and response to treatment, and to perform large-scale comparative studies between different conditions," according to its founders. It can be accessed in the member area of the Pediatric Rheumatology International Trial Organisation (PRINTO) website. Enrollment information is on the registry’s website.

The goal of the efforts is to counteract "a major limitation to understanding these rare conditions[,] the fragmentation of clinical experience with very few centers in any country caring for more than a handful of cases," according to principal investigator and pediatric rheumatologist Marco Gattorno of the University of Genoa (Italy) and his associates. The investigators solicited enrollment from pediatric and adult centers known to have an interest in rare autoinflammatory diseases (Ann. Rheum. Dis. 2012 Feb. 29 [doi: 10.1136/annrheumdis-2011-200549]).

So far, the registry includes 916 males and 964 females from 67 centers in 31 countries. Three-quarters are under 18 years of age, consistent with the fact that the conditions tend to present in childhood. Three-quarters also reside in Western Europe; 16% in Turkey, Israel, or North Africa; 6% in Eastern Europe, and the rest in Asia, South America, and Australia.

Although North America and many South American and Asian countries "are not yet covered by the registry, the large number of patients recruited in this first period of the project and the wide geographical distribution is very encouraging and suggests that the network can continue to grow," Dr. Gattorno and his colleagues noted.

The efforts are already paying off. An analysis of registry data resulted in identification of three previously unreported mutations for TRAPS, four for mevalonate kinase deficiency, and two for cryopyrin associated periodic syndromes.

The investigators found that physicians are making the diagnosis more quickly. Although the median delay between disease onset and diagnosis was 7.3 years, there is a "trend towards shorter diagnostic delay in patients born" in the current century – 1.4 years for familial Mediterranean fever, for instance – robably "due to the fact that many of these diseases are recently recognized clinical entities and that genetic diagnosis has ...become relatively widely available in the last few years," they noted.

Even so, "the marked bias towards Western Europe," where there are relatively large number of centers with facilities for genetic analysis, may suggest that recognition remains a problem elsewhere, they noted.*

The EAHC is funding the project, along with PRINTO, Novartis, and the Seventh Framework Programme (2007–2013) of the European Community for Research, Technological Development, and Demonstration Activities.

The authors said they had no relevant financial disclosures.

*CORRECTION: 03/12/2012 An earlier version of this story misstated the number of specialty centers with facilities for genetic analysis.

In this month's program, Dr. Alexa B. Kimball discusses why psoriasis treatment shouldn't be delayed.

Dr. James M. Spencer offers his insights on the pros and cons of bringing radiation treatment back to the dermatologist's office.

Then, a marketing guru offers tips on how to keep cosmetic patients coming back.

Cosmetic counter host Dr. Lily Talakoub explains what it really means when a product claims to be all "natural."

And finally, Dr. Alan Rockoff shares one of the more humorous places people have gone to read his new book.

In this month's program, Dr. Alexa B. Kimball discusses why psoriasis treatment shouldn't be delayed.

Dr. James M. Spencer offers his insights on the pros and cons of bringing radiation treatment back to the dermatologist's office.

Then, a marketing guru offers tips on how to keep cosmetic patients coming back.

Cosmetic counter host Dr. Lily Talakoub explains what it really means when a product claims to be all "natural."

And finally, Dr. Alan Rockoff shares one of the more humorous places people have gone to read his new book.

In this month's program, Dr. Alexa B. Kimball discusses why psoriasis treatment shouldn't be delayed.

Dr. James M. Spencer offers his insights on the pros and cons of bringing radiation treatment back to the dermatologist's office.

Then, a marketing guru offers tips on how to keep cosmetic patients coming back.

Cosmetic counter host Dr. Lily Talakoub explains what it really means when a product claims to be all "natural."

And finally, Dr. Alan Rockoff shares one of the more humorous places people have gone to read his new book.

Skin & Allergy News editor Amy Pfeiffer and Terry Rudd review hot news in dermatology with the experts in this month's Skinny Vodcast.

Skin & Allergy News editor Amy Pfeiffer and Terry Rudd review hot news in dermatology with the experts in this month's Skinny Vodcast.

Skin & Allergy News editor Amy Pfeiffer and Terry Rudd review hot news in dermatology with the experts in this month's Skinny Vodcast.

The National Psoriasis Foundation has launched a "seal of approval" program for over-the-counter products that an expert panel has determined to be "helpful in the management of psoriasis and psoriatic arthritis," according to the organization’s website.

The program’s objective "is to improve the quality of life for people who live with psoriasis and psoriatic arthritis," according to the NPF.

Under the seal program, companies submit over-the-counter products for approval, with an annual, nonrefundable application fee. A panel of dermatologists and other experts review the product and determine whether it meets required criteria, including the ability to hydrate skin, reduce redness, reduce joint pain, and/or provide aid for patients with psoriatic arthritis, according to a release announcing the launch of the program.

The four-person panel also reviews the ingredients and data on its safety, toxicity, and formulation.

Once approved, the seal can remain on the product for 2 years. The application fee is $5,000, which covers honoraria and time spent reviewing the clinical information that the company provides, plus an additional fee of $10,000 per year for each product that earns the seal, according to Jackie Groah, director of strategic alliances at the NPF. The reviewers will excuse themselves from the review if they have had any dealings with the company applying for the seal, she said in an interview.

Five scalp psoriasis products manufactured by Neutrogena and a gel product for patients with plaque psoriasis, manufactured by Alva-Amco, were the first products to receive the seal. The seal can be awarded to personal care and household products, fabrics, and devices, according to the NPF.

Click here for more details about the program.

The National Psoriasis Foundation has launched a "seal of approval" program for over-the-counter products that an expert panel has determined to be "helpful in the management of psoriasis and psoriatic arthritis," according to the organization’s website.

The program’s objective "is to improve the quality of life for people who live with psoriasis and psoriatic arthritis," according to the NPF.

Under the seal program, companies submit over-the-counter products for approval, with an annual, nonrefundable application fee. A panel of dermatologists and other experts review the product and determine whether it meets required criteria, including the ability to hydrate skin, reduce redness, reduce joint pain, and/or provide aid for patients with psoriatic arthritis, according to a release announcing the launch of the program.

The four-person panel also reviews the ingredients and data on its safety, toxicity, and formulation.

Once approved, the seal can remain on the product for 2 years. The application fee is $5,000, which covers honoraria and time spent reviewing the clinical information that the company provides, plus an additional fee of $10,000 per year for each product that earns the seal, according to Jackie Groah, director of strategic alliances at the NPF. The reviewers will excuse themselves from the review if they have had any dealings with the company applying for the seal, she said in an interview.

Five scalp psoriasis products manufactured by Neutrogena and a gel product for patients with plaque psoriasis, manufactured by Alva-Amco, were the first products to receive the seal. The seal can be awarded to personal care and household products, fabrics, and devices, according to the NPF.

Click here for more details about the program.

The National Psoriasis Foundation has launched a "seal of approval" program for over-the-counter products that an expert panel has determined to be "helpful in the management of psoriasis and psoriatic arthritis," according to the organization’s website.

The program’s objective "is to improve the quality of life for people who live with psoriasis and psoriatic arthritis," according to the NPF.

Under the seal program, companies submit over-the-counter products for approval, with an annual, nonrefundable application fee. A panel of dermatologists and other experts review the product and determine whether it meets required criteria, including the ability to hydrate skin, reduce redness, reduce joint pain, and/or provide aid for patients with psoriatic arthritis, according to a release announcing the launch of the program.

The four-person panel also reviews the ingredients and data on its safety, toxicity, and formulation.

Once approved, the seal can remain on the product for 2 years. The application fee is $5,000, which covers honoraria and time spent reviewing the clinical information that the company provides, plus an additional fee of $10,000 per year for each product that earns the seal, according to Jackie Groah, director of strategic alliances at the NPF. The reviewers will excuse themselves from the review if they have had any dealings with the company applying for the seal, she said in an interview.

Five scalp psoriasis products manufactured by Neutrogena and a gel product for patients with plaque psoriasis, manufactured by Alva-Amco, were the first products to receive the seal. The seal can be awarded to personal care and household products, fabrics, and devices, according to the NPF.

Click here for more details about the program.

As a pediatric dermatologist, Dr. Robert A. Silverman is all too familiar with this scenario: A child is referred to him with a diagnosis of nail fungus, and the parents are frustrated that the oral antifungal agents did not work.

What bothers him the most is not the antifungals, but that the patients didn’t need them to begin with because the child didn’t have a fungal infection, he said at the annual Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF). Several conditions of the nail in children can easily be mistaken for fungal infections.

Dr. Silverman of the department of pediatrics at Georgetown University Medical Center in Washington discussed how to distinguish fungal disease mimics from other pediatric nail conditions in children.

Onychomycosis, the most common nail infection in adults, is not all that common in children, Dr. Silverman said. Studies have shown the prevalence in children to be less than 3% in developed countries, although it is increased among children who have Down syndrome and HIV, or children from households with moccasintype Trichophyton rubrum. Clinical variants are similar to those that occur in adults, such as white superficial onychomycosis, distal lateral subungual onychomycosis, proximal subungual onychomycosis, and endonyx onychomycosis.

Other conditions that may be mistaken for fungal infections include:

• Psoriasis. Nail findings in patients who have psoriasis can be misinterpreted as fungal disease. Telltale signs of psoriasis in the nails, however, are large, irregular pits and the oil spot sign.

• Subungual tumors. These include subungual exostosis and onychomatricoma. These benign growths push on the skin surface, leading to separation of the nail. "Some people think fungus when it’s really a tumor of the underlying bone," Dr. Silverman said.

• Pachyonychia congenita. Though often confused with fungal disease, this condition, which involves a single thickened toenail, is somewhat rare. "If someone came in with a thick toenail, I’d culture him or her," Dr. Silverman said. "If the culture is negative, then you have to start thinking of these other conditions."

• Alopecia areata. Children may have nail signs of alopecia areata before hair loss occurs. In alopecia areata, the nail surface is studded to near confluence with tiny pits, also known as Scotch plaid nails. Also, the nail will have lost its luster and has a sandpaperlike texture.

"If you see what looks like alopecia areata of the nail, but don’t see any hair findings, you ought to scrape the nail to rule out fungus, because fungus can look like alopecia areata of the nails," Dr. Silverman said. "And, of course, then you would want to treat it."

Treatment for fungal infections requires the use of an oral agent for 6-12 weeks, so Dr. Silverman emphasized the importance of obtaining a culture. "If you’re going to treat someone for that length of time, it makes sense to know exactly what you’re treating," he said.

Also, Dr. Silverman said, any time he sees that a child’s parent appears to have a fungal infection, he considers that to be a red flag when trying to diagnose the patient.

As a pediatric dermatologist, Dr. Robert A. Silverman is all too familiar with this scenario: A child is referred to him with a diagnosis of nail fungus, and the parents are frustrated that the oral antifungal agents did not work.

What bothers him the most is not the antifungals, but that the patients didn’t need them to begin with because the child didn’t have a fungal infection, he said at the annual Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF). Several conditions of the nail in children can easily be mistaken for fungal infections.

Dr. Silverman of the department of pediatrics at Georgetown University Medical Center in Washington discussed how to distinguish fungal disease mimics from other pediatric nail conditions in children.

Onychomycosis, the most common nail infection in adults, is not all that common in children, Dr. Silverman said. Studies have shown the prevalence in children to be less than 3% in developed countries, although it is increased among children who have Down syndrome and HIV, or children from households with moccasintype Trichophyton rubrum. Clinical variants are similar to those that occur in adults, such as white superficial onychomycosis, distal lateral subungual onychomycosis, proximal subungual onychomycosis, and endonyx onychomycosis.

Other conditions that may be mistaken for fungal infections include:

• Psoriasis. Nail findings in patients who have psoriasis can be misinterpreted as fungal disease. Telltale signs of psoriasis in the nails, however, are large, irregular pits and the oil spot sign.

• Subungual tumors. These include subungual exostosis and onychomatricoma. These benign growths push on the skin surface, leading to separation of the nail. "Some people think fungus when it’s really a tumor of the underlying bone," Dr. Silverman said.

• Pachyonychia congenita. Though often confused with fungal disease, this condition, which involves a single thickened toenail, is somewhat rare. "If someone came in with a thick toenail, I’d culture him or her," Dr. Silverman said. "If the culture is negative, then you have to start thinking of these other conditions."

• Alopecia areata. Children may have nail signs of alopecia areata before hair loss occurs. In alopecia areata, the nail surface is studded to near confluence with tiny pits, also known as Scotch plaid nails. Also, the nail will have lost its luster and has a sandpaperlike texture.

"If you see what looks like alopecia areata of the nail, but don’t see any hair findings, you ought to scrape the nail to rule out fungus, because fungus can look like alopecia areata of the nails," Dr. Silverman said. "And, of course, then you would want to treat it."

Treatment for fungal infections requires the use of an oral agent for 6-12 weeks, so Dr. Silverman emphasized the importance of obtaining a culture. "If you’re going to treat someone for that length of time, it makes sense to know exactly what you’re treating," he said.

Also, Dr. Silverman said, any time he sees that a child’s parent appears to have a fungal infection, he considers that to be a red flag when trying to diagnose the patient.

As a pediatric dermatologist, Dr. Robert A. Silverman is all too familiar with this scenario: A child is referred to him with a diagnosis of nail fungus, and the parents are frustrated that the oral antifungal agents did not work.

What bothers him the most is not the antifungals, but that the patients didn’t need them to begin with because the child didn’t have a fungal infection, he said at the annual Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF). Several conditions of the nail in children can easily be mistaken for fungal infections.

Dr. Silverman of the department of pediatrics at Georgetown University Medical Center in Washington discussed how to distinguish fungal disease mimics from other pediatric nail conditions in children.

Onychomycosis, the most common nail infection in adults, is not all that common in children, Dr. Silverman said. Studies have shown the prevalence in children to be less than 3% in developed countries, although it is increased among children who have Down syndrome and HIV, or children from households with moccasintype Trichophyton rubrum. Clinical variants are similar to those that occur in adults, such as white superficial onychomycosis, distal lateral subungual onychomycosis, proximal subungual onychomycosis, and endonyx onychomycosis.

Other conditions that may be mistaken for fungal infections include:

• Psoriasis. Nail findings in patients who have psoriasis can be misinterpreted as fungal disease. Telltale signs of psoriasis in the nails, however, are large, irregular pits and the oil spot sign.

• Subungual tumors. These include subungual exostosis and onychomatricoma. These benign growths push on the skin surface, leading to separation of the nail. "Some people think fungus when it’s really a tumor of the underlying bone," Dr. Silverman said.

• Pachyonychia congenita. Though often confused with fungal disease, this condition, which involves a single thickened toenail, is somewhat rare. "If someone came in with a thick toenail, I’d culture him or her," Dr. Silverman said. "If the culture is negative, then you have to start thinking of these other conditions."

• Alopecia areata. Children may have nail signs of alopecia areata before hair loss occurs. In alopecia areata, the nail surface is studded to near confluence with tiny pits, also known as Scotch plaid nails. Also, the nail will have lost its luster and has a sandpaperlike texture.

"If you see what looks like alopecia areata of the nail, but don’t see any hair findings, you ought to scrape the nail to rule out fungus, because fungus can look like alopecia areata of the nails," Dr. Silverman said. "And, of course, then you would want to treat it."

Treatment for fungal infections requires the use of an oral agent for 6-12 weeks, so Dr. Silverman emphasized the importance of obtaining a culture. "If you’re going to treat someone for that length of time, it makes sense to know exactly what you’re treating," he said.

Also, Dr. Silverman said, any time he sees that a child’s parent appears to have a fungal infection, he considers that to be a red flag when trying to diagnose the patient.

WAIKOLOA, HAWAII – Joint pain arising in a patient with psoriasis is by no means necessarily due to psoriatic arthritis.

Psoriasis patients can get osteoarthritis or rheumatoid arthritis, just like individuals without the skin disease. The distribution pattern of affected joints provides a useful guide as to which arthropathy is involved.

Bruce Jancin/Elsevier Global Medical News

"When a patient who’s got psoriasis comes to me and says, ‘I have a tremendous amount of joint pain,’ the first place I look is the heel. Heel involvement doesn’t happen very often in rheumatoid arthritis. If the heel hurts, it’s probable that the patient has dactylitis and some form of psoriatic arthritis," according to Dr. Daniel E. Furst, the Carl M. Pearson professor of rheumatology at the University of California, Los Angeles.

Another useful clue: Psoriatic arthritis often affects the distal phalangeal joints of the fingers and toes, with accompanying characteristic psoriatic nail changes, but it spares the metacarpophalangeal (MCP) joints. In contrast, MCP involvement is a typical feature of rheumatoid arthritis, he explained at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

"If only we understood why one joint tends to be affected and not another, we would sure know a whole lot more about psoriatic arthritis, and rheumatoid arthritis for that matter," Dr. Furst observed.

Involvement of the distal interphalangeal (DIP) joints is a common feature in osteoarthritis as well as psoriatic arthritis. However, psoriatic arthritis, unlike osteoarthritis, is an inflammatory arthritis. The affected fingers and toes in a patient with psoriatic arthritis often develop a painful, red, warm, sausage-like swelling of the soft tissue on the entire digit.

"If there’s erythema and squishiness when you push on a painful joint, that’s synovitis, not osteoarthritis," the rheumatologist noted.

Also, osteoarthritis has a strong tendency to involve the carpometacarpal joint of the thumb, a site spared in psoriatic arthritis, he continued.

Psoriatic arthritis often first shows up as a monoarticular, asymmetric arthritis of a larger joint, such as the knee, ankle, or wrist. Rheumatoid arthritis tends to come on much stronger.

"In rheumatoid arthritis, it’s frequently all at once. The patient will say, ‘In a week I went from nothing to pain everywhere.’ Not so in psoriatic arthritis," according to Dr. Furst.

Spondyloarthropathy is common in psoriatic arthritis. It often takes the form of a spondylitis characterized by asymmetric thickening and calcification of the longitudinal ligaments of the spine, resulting in asymmetric syndesmophytes on imaging. The result is a painful and/or stiff low back.

Psoriatic arthritis is widely thought of as a rheumatoid factor–negative disease, but that’s not strictly true. Roughly 15% of psoriatic arthritis patients are rheumatoid factor–positive.

Differentiating psoriatic arthritis from other types of arthritis that occur in psoriasis patients is important from a treatment standpoint. Psoriatic arthritis causes much more bony destruction than recognized until fairly recently, twice as much as rheumatoid arthritis by some measures. The nonbiologic disease-modifying antirheumatic drugs are only marginally effective for joint disease in psoriatic arthritis patients, with the exception of leflunomide (Arava), which has fair benefit for the peripheral arthritis but less for the skin disease.

At present, the tumor necrosis factor (TNF) inhibitors are the most effective agents available for peripheral and axial joint disease in psoriatic arthritis. But the response can be less impressive than in patients with psoriasis-only or rheumatoid arthritis. New therapies on the horizon include agents targeting the inflammatory cytokines interleukins-6, -12, and -15, as well as orally administered small molecules that inhibit Janus kinase, spleen tyrosine kinase, TNF-alpha converting enzyme, or mitogen-activated protein kinase.

"There’s a lot of stuff coming down the pike, including new drugs which have mechanisms of action very different from those most extant in psoriasis. Some of it is going to work. But so far we really don’t know which of it will," Dr. Furst said.

He reported that he serves as a consultant to or recipient of research grants from more than a dozen pharmaceutical companies and the National Institutes of Health.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Joint pain arising in a patient with psoriasis is by no means necessarily due to psoriatic arthritis.

Psoriasis patients can get osteoarthritis or rheumatoid arthritis, just like individuals without the skin disease. The distribution pattern of affected joints provides a useful guide as to which arthropathy is involved.

Bruce Jancin/Elsevier Global Medical News

"When a patient who’s got psoriasis comes to me and says, ‘I have a tremendous amount of joint pain,’ the first place I look is the heel. Heel involvement doesn’t happen very often in rheumatoid arthritis. If the heel hurts, it’s probable that the patient has dactylitis and some form of psoriatic arthritis," according to Dr. Daniel E. Furst, the Carl M. Pearson professor of rheumatology at the University of California, Los Angeles.

Another useful clue: Psoriatic arthritis often affects the distal phalangeal joints of the fingers and toes, with accompanying characteristic psoriatic nail changes, but it spares the metacarpophalangeal (MCP) joints. In contrast, MCP involvement is a typical feature of rheumatoid arthritis, he explained at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

"If only we understood why one joint tends to be affected and not another, we would sure know a whole lot more about psoriatic arthritis, and rheumatoid arthritis for that matter," Dr. Furst observed.

Involvement of the distal interphalangeal (DIP) joints is a common feature in osteoarthritis as well as psoriatic arthritis. However, psoriatic arthritis, unlike osteoarthritis, is an inflammatory arthritis. The affected fingers and toes in a patient with psoriatic arthritis often develop a painful, red, warm, sausage-like swelling of the soft tissue on the entire digit.

"If there’s erythema and squishiness when you push on a painful joint, that’s synovitis, not osteoarthritis," the rheumatologist noted.

Also, osteoarthritis has a strong tendency to involve the carpometacarpal joint of the thumb, a site spared in psoriatic arthritis, he continued.

Psoriatic arthritis often first shows up as a monoarticular, asymmetric arthritis of a larger joint, such as the knee, ankle, or wrist. Rheumatoid arthritis tends to come on much stronger.

"In rheumatoid arthritis, it’s frequently all at once. The patient will say, ‘In a week I went from nothing to pain everywhere.’ Not so in psoriatic arthritis," according to Dr. Furst.

Spondyloarthropathy is common in psoriatic arthritis. It often takes the form of a spondylitis characterized by asymmetric thickening and calcification of the longitudinal ligaments of the spine, resulting in asymmetric syndesmophytes on imaging. The result is a painful and/or stiff low back.

Psoriatic arthritis is widely thought of as a rheumatoid factor–negative disease, but that’s not strictly true. Roughly 15% of psoriatic arthritis patients are rheumatoid factor–positive.

Differentiating psoriatic arthritis from other types of arthritis that occur in psoriasis patients is important from a treatment standpoint. Psoriatic arthritis causes much more bony destruction than recognized until fairly recently, twice as much as rheumatoid arthritis by some measures. The nonbiologic disease-modifying antirheumatic drugs are only marginally effective for joint disease in psoriatic arthritis patients, with the exception of leflunomide (Arava), which has fair benefit for the peripheral arthritis but less for the skin disease.

At present, the tumor necrosis factor (TNF) inhibitors are the most effective agents available for peripheral and axial joint disease in psoriatic arthritis. But the response can be less impressive than in patients with psoriasis-only or rheumatoid arthritis. New therapies on the horizon include agents targeting the inflammatory cytokines interleukins-6, -12, and -15, as well as orally administered small molecules that inhibit Janus kinase, spleen tyrosine kinase, TNF-alpha converting enzyme, or mitogen-activated protein kinase.

"There’s a lot of stuff coming down the pike, including new drugs which have mechanisms of action very different from those most extant in psoriasis. Some of it is going to work. But so far we really don’t know which of it will," Dr. Furst said.

He reported that he serves as a consultant to or recipient of research grants from more than a dozen pharmaceutical companies and the National Institutes of Health.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Joint pain arising in a patient with psoriasis is by no means necessarily due to psoriatic arthritis.

Psoriasis patients can get osteoarthritis or rheumatoid arthritis, just like individuals without the skin disease. The distribution pattern of affected joints provides a useful guide as to which arthropathy is involved.

Bruce Jancin/Elsevier Global Medical News

"When a patient who’s got psoriasis comes to me and says, ‘I have a tremendous amount of joint pain,’ the first place I look is the heel. Heel involvement doesn’t happen very often in rheumatoid arthritis. If the heel hurts, it’s probable that the patient has dactylitis and some form of psoriatic arthritis," according to Dr. Daniel E. Furst, the Carl M. Pearson professor of rheumatology at the University of California, Los Angeles.

Another useful clue: Psoriatic arthritis often affects the distal phalangeal joints of the fingers and toes, with accompanying characteristic psoriatic nail changes, but it spares the metacarpophalangeal (MCP) joints. In contrast, MCP involvement is a typical feature of rheumatoid arthritis, he explained at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

"If only we understood why one joint tends to be affected and not another, we would sure know a whole lot more about psoriatic arthritis, and rheumatoid arthritis for that matter," Dr. Furst observed.

Involvement of the distal interphalangeal (DIP) joints is a common feature in osteoarthritis as well as psoriatic arthritis. However, psoriatic arthritis, unlike osteoarthritis, is an inflammatory arthritis. The affected fingers and toes in a patient with psoriatic arthritis often develop a painful, red, warm, sausage-like swelling of the soft tissue on the entire digit.

"If there’s erythema and squishiness when you push on a painful joint, that’s synovitis, not osteoarthritis," the rheumatologist noted.

Also, osteoarthritis has a strong tendency to involve the carpometacarpal joint of the thumb, a site spared in psoriatic arthritis, he continued.

Psoriatic arthritis often first shows up as a monoarticular, asymmetric arthritis of a larger joint, such as the knee, ankle, or wrist. Rheumatoid arthritis tends to come on much stronger.

"In rheumatoid arthritis, it’s frequently all at once. The patient will say, ‘In a week I went from nothing to pain everywhere.’ Not so in psoriatic arthritis," according to Dr. Furst.

Spondyloarthropathy is common in psoriatic arthritis. It often takes the form of a spondylitis characterized by asymmetric thickening and calcification of the longitudinal ligaments of the spine, resulting in asymmetric syndesmophytes on imaging. The result is a painful and/or stiff low back.

Psoriatic arthritis is widely thought of as a rheumatoid factor–negative disease, but that’s not strictly true. Roughly 15% of psoriatic arthritis patients are rheumatoid factor–positive.

Differentiating psoriatic arthritis from other types of arthritis that occur in psoriasis patients is important from a treatment standpoint. Psoriatic arthritis causes much more bony destruction than recognized until fairly recently, twice as much as rheumatoid arthritis by some measures. The nonbiologic disease-modifying antirheumatic drugs are only marginally effective for joint disease in psoriatic arthritis patients, with the exception of leflunomide (Arava), which has fair benefit for the peripheral arthritis but less for the skin disease.

At present, the tumor necrosis factor (TNF) inhibitors are the most effective agents available for peripheral and axial joint disease in psoriatic arthritis. But the response can be less impressive than in patients with psoriasis-only or rheumatoid arthritis. New therapies on the horizon include agents targeting the inflammatory cytokines interleukins-6, -12, and -15, as well as orally administered small molecules that inhibit Janus kinase, spleen tyrosine kinase, TNF-alpha converting enzyme, or mitogen-activated protein kinase.

"There’s a lot of stuff coming down the pike, including new drugs which have mechanisms of action very different from those most extant in psoriasis. Some of it is going to work. But so far we really don’t know which of it will," Dr. Furst said.

He reported that he serves as a consultant to or recipient of research grants from more than a dozen pharmaceutical companies and the National Institutes of Health.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Multiple studies have found that psoriasis has a greater impact on women than men, and a new finding that women with psoriasis are less likely to become pregnant adds to the list of disease-related concerns.

Dr. Jennifer C. Cather and her colleagues recently completed a claims database study that found psoriasis to be significantly associated with lower rates of pregnancy and live births in women aged 35 or younger.

The Abbott-funded study matched 30,733 pairs (1:1) of women with and without psoriasis, said Dr. Cather at the annual Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF). Overall, women with psoriasis were found to have lower rates of pregnancy (3.1% vs. 3.6%) and live births (1.4% vs. 2.1%), compared with the women without psoriasis.

Photo Copyright Elsevier 2012

 In the 7,374 matched pairs of women aged 35 or younger, the psoriasis patients had a 22% lower likelihood of pregnancy and a 39% lower likelihood of having a live birth, compared with the patients without psoriasis.

Three other recent studies on pregnancy outcomes in psoriasis offer conflicting findings; however, Dr. Cather noted that the study populations were very different for each.

The first study found that pregnant women with psoriasis are at an increased risk of having preterm delivery and low birth weight infants.

Dr. Cather reported the findings of the U.S. study of 162 pregnancies in 122 women with psoriasis, compared with 501 pregnancies in 290 women without psoriasis. The women with psoriasis were found to have a 1.89 increased risk in odds of having a poor outcome composite, compared with the patients without psoriasis (J. Invest. Dermatol. 2012;132:85-91). Psoriasis was not found to be associated with having a caesarian delivery, preeclampsia/eclampsia, or spontaneous abortion.

However, the opposite was found in a European study of 68 deliveries in 35 women with moderate-to-severe psoriasis, compared with 237 deliveries in 236 women without psoriasis. Psoriasis patients “had a higher mean of past spontaneous and induced abortions than controls,” noted Dr. Cather, who is in private practice in Dallas. The psoriasis patients also had an increased rate of pregnancy-induced hypertension, premature rupture of the membranes, large-for-gestational age babies, and macrosomia (J. Eur. Acad. Dermatol. Venereol. 2011;25:1041-7).

In the third study, 1,463 mothers with psoriasis were compared with 11,704 control patients. Pregnant Taiwanese women with psoriasis were found to have a 1.4 times increased risk of having low birth weight infants, compared with controls. Mild psoriasis did not increase the risk of low birth weight, preterm birth, small-for-gestational age infants, caesarian section, or preeclampsia/eclampsia (J. Am. Acad. Dermatol. 2011;64:71-7).

Dr. Cather noted that more studies are needed to assess the true impact of psoriasis on pregnancy.

She disclosed that she serves as a consultant to Abbott, Amgen, Centocor, and has received research grants from Amgen, Celgene, and Pfizer. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Multiple studies have found that psoriasis has a greater impact on women than men, and a new finding that women with psoriasis are less likely to become pregnant adds to the list of disease-related concerns.

Dr. Jennifer C. Cather and her colleagues recently completed a claims database study that found psoriasis to be significantly associated with lower rates of pregnancy and live births in women aged 35 or younger.

The Abbott-funded study matched 30,733 pairs (1:1) of women with and without psoriasis, said Dr. Cather at the annual Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF). Overall, women with psoriasis were found to have lower rates of pregnancy (3.1% vs. 3.6%) and live births (1.4% vs. 2.1%), compared with the women without psoriasis.

Photo Copyright Elsevier 2012

 In the 7,374 matched pairs of women aged 35 or younger, the psoriasis patients had a 22% lower likelihood of pregnancy and a 39% lower likelihood of having a live birth, compared with the patients without psoriasis.

Three other recent studies on pregnancy outcomes in psoriasis offer conflicting findings; however, Dr. Cather noted that the study populations were very different for each.

The first study found that pregnant women with psoriasis are at an increased risk of having preterm delivery and low birth weight infants.

Dr. Cather reported the findings of the U.S. study of 162 pregnancies in 122 women with psoriasis, compared with 501 pregnancies in 290 women without psoriasis. The women with psoriasis were found to have a 1.89 increased risk in odds of having a poor outcome composite, compared with the patients without psoriasis (J. Invest. Dermatol. 2012;132:85-91). Psoriasis was not found to be associated with having a caesarian delivery, preeclampsia/eclampsia, or spontaneous abortion.

However, the opposite was found in a European study of 68 deliveries in 35 women with moderate-to-severe psoriasis, compared with 237 deliveries in 236 women without psoriasis. Psoriasis patients “had a higher mean of past spontaneous and induced abortions than controls,” noted Dr. Cather, who is in private practice in Dallas. The psoriasis patients also had an increased rate of pregnancy-induced hypertension, premature rupture of the membranes, large-for-gestational age babies, and macrosomia (J. Eur. Acad. Dermatol. Venereol. 2011;25:1041-7).

In the third study, 1,463 mothers with psoriasis were compared with 11,704 control patients. Pregnant Taiwanese women with psoriasis were found to have a 1.4 times increased risk of having low birth weight infants, compared with controls. Mild psoriasis did not increase the risk of low birth weight, preterm birth, small-for-gestational age infants, caesarian section, or preeclampsia/eclampsia (J. Am. Acad. Dermatol. 2011;64:71-7).

Dr. Cather noted that more studies are needed to assess the true impact of psoriasis on pregnancy.

She disclosed that she serves as a consultant to Abbott, Amgen, Centocor, and has received research grants from Amgen, Celgene, and Pfizer. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Multiple studies have found that psoriasis has a greater impact on women than men, and a new finding that women with psoriasis are less likely to become pregnant adds to the list of disease-related concerns.

Dr. Jennifer C. Cather and her colleagues recently completed a claims database study that found psoriasis to be significantly associated with lower rates of pregnancy and live births in women aged 35 or younger.

The Abbott-funded study matched 30,733 pairs (1:1) of women with and without psoriasis, said Dr. Cather at the annual Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF). Overall, women with psoriasis were found to have lower rates of pregnancy (3.1% vs. 3.6%) and live births (1.4% vs. 2.1%), compared with the women without psoriasis.

Photo Copyright Elsevier 2012

 In the 7,374 matched pairs of women aged 35 or younger, the psoriasis patients had a 22% lower likelihood of pregnancy and a 39% lower likelihood of having a live birth, compared with the patients without psoriasis.

Three other recent studies on pregnancy outcomes in psoriasis offer conflicting findings; however, Dr. Cather noted that the study populations were very different for each.

The first study found that pregnant women with psoriasis are at an increased risk of having preterm delivery and low birth weight infants.

Dr. Cather reported the findings of the U.S. study of 162 pregnancies in 122 women with psoriasis, compared with 501 pregnancies in 290 women without psoriasis. The women with psoriasis were found to have a 1.89 increased risk in odds of having a poor outcome composite, compared with the patients without psoriasis (J. Invest. Dermatol. 2012;132:85-91). Psoriasis was not found to be associated with having a caesarian delivery, preeclampsia/eclampsia, or spontaneous abortion.

However, the opposite was found in a European study of 68 deliveries in 35 women with moderate-to-severe psoriasis, compared with 237 deliveries in 236 women without psoriasis. Psoriasis patients “had a higher mean of past spontaneous and induced abortions than controls,” noted Dr. Cather, who is in private practice in Dallas. The psoriasis patients also had an increased rate of pregnancy-induced hypertension, premature rupture of the membranes, large-for-gestational age babies, and macrosomia (J. Eur. Acad. Dermatol. Venereol. 2011;25:1041-7).

In the third study, 1,463 mothers with psoriasis were compared with 11,704 control patients. Pregnant Taiwanese women with psoriasis were found to have a 1.4 times increased risk of having low birth weight infants, compared with controls. Mild psoriasis did not increase the risk of low birth weight, preterm birth, small-for-gestational age infants, caesarian section, or preeclampsia/eclampsia (J. Am. Acad. Dermatol. 2011;64:71-7).

Dr. Cather noted that more studies are needed to assess the true impact of psoriasis on pregnancy.

She disclosed that she serves as a consultant to Abbott, Amgen, Centocor, and has received research grants from Amgen, Celgene, and Pfizer. SDEF and this news organization are owned by Elsevier.

Despite the advances in biologics, classic therapies still have a large role to play in treating moderate to severe psoriasis, according to Dr. Jeffrey M. Sobell.

"Biologics have expanded our treatment options, not replaced them," said Dr. Sobell at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Sobell of Tufts Medical Center in Boston discussed how he uses three classic psoriasis therapies.

Methotrexate

The efficacy of methotrexate is quite respectable, with a PASI 75 (that is, an improvement of 75% on the baseline Psoriasis Area and Severity Index) of 40% at 16 weeks, said Dr. Sobell. He said that he uses the drug for patients as a monotherapy for concomitant psoriatic arthritis and for life-impacting nail psoriasis. For some patients, he uses methotrexate in combination with anti–tumor necrosis factor therapy both for the synergistic effects on the skin and to reduce potential antibody formation.

The clinical dose of methotrexate is 7.5-25 mg/week (averaging 10-15 mg/week). Clinical effects should be seen by week 8, and doses greater than 20 mg/week are rarely necessary, he noted.

Clinicians who want to use methotrexate for psoriasis do need to be mindful of the possible side effects, which include hepatotoxicity, bone marrow suppression, gastrointestinal intolerance, pulmonary toxicity, and induction of malignancy. Also, methotrexate is teratogenic and is contraindicated during pregnancy, he said.

Cyclosporine

"Cyclosporine is an indispensable therapy in my clinic," said Dr. Sobell. He said that he uses it mostly for psoriasis in crisis situations, but also as a transitional therapy. "Clinicians have concerns about potential nephrotoxicity, but at low doses for short treatment periods, cyclosporine is extremely safe as long as serum creatinine levels are followed," he said.

A standard clinical dose of cyclosporine for psoriasis is 2.5-4.0 mg/kg per day. Other side effects to watch for include hypertension, paresthesias, and gastrointestinal intolerance.

Acitretin

Dr. Sobell said he uses acitretin in psoriasis patients as a monotherapy and in conjunction with phototherapy, biologics, and other oral medications.

His standard clinical dose is 10-25 mg/day. Follow-up lab tests should be done monthly for the first 3 months of acitretin use, and then every 3 months, he said. Acitretin is teratogenic, and other possible side effects include ocular or musculoskeletal problems, hyperlipidemia, and hepatotoxicity.

Dr. Sobell disclosed financial relationships with Abbott, Amgen, Celgene, Eli Lilly, and Janssen. SDEF and this news organization are owned by Elsevier.

Despite the advances in biologics, classic therapies still have a large role to play in treating moderate to severe psoriasis, according to Dr. Jeffrey M. Sobell.

"Biologics have expanded our treatment options, not replaced them," said Dr. Sobell at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Sobell of Tufts Medical Center in Boston discussed how he uses three classic psoriasis therapies.

Methotrexate

The efficacy of methotrexate is quite respectable, with a PASI 75 (that is, an improvement of 75% on the baseline Psoriasis Area and Severity Index) of 40% at 16 weeks, said Dr. Sobell. He said that he uses the drug for patients as a monotherapy for concomitant psoriatic arthritis and for life-impacting nail psoriasis. For some patients, he uses methotrexate in combination with anti–tumor necrosis factor therapy both for the synergistic effects on the skin and to reduce potential antibody formation.

The clinical dose of methotrexate is 7.5-25 mg/week (averaging 10-15 mg/week). Clinical effects should be seen by week 8, and doses greater than 20 mg/week are rarely necessary, he noted.

Clinicians who want to use methotrexate for psoriasis do need to be mindful of the possible side effects, which include hepatotoxicity, bone marrow suppression, gastrointestinal intolerance, pulmonary toxicity, and induction of malignancy. Also, methotrexate is teratogenic and is contraindicated during pregnancy, he said.

Cyclosporine

"Cyclosporine is an indispensable therapy in my clinic," said Dr. Sobell. He said that he uses it mostly for psoriasis in crisis situations, but also as a transitional therapy. "Clinicians have concerns about potential nephrotoxicity, but at low doses for short treatment periods, cyclosporine is extremely safe as long as serum creatinine levels are followed," he said.

A standard clinical dose of cyclosporine for psoriasis is 2.5-4.0 mg/kg per day. Other side effects to watch for include hypertension, paresthesias, and gastrointestinal intolerance.

Acitretin

Dr. Sobell said he uses acitretin in psoriasis patients as a monotherapy and in conjunction with phototherapy, biologics, and other oral medications.

His standard clinical dose is 10-25 mg/day. Follow-up lab tests should be done monthly for the first 3 months of acitretin use, and then every 3 months, he said. Acitretin is teratogenic, and other possible side effects include ocular or musculoskeletal problems, hyperlipidemia, and hepatotoxicity.

Dr. Sobell disclosed financial relationships with Abbott, Amgen, Celgene, Eli Lilly, and Janssen. SDEF and this news organization are owned by Elsevier.

Despite the advances in biologics, classic therapies still have a large role to play in treating moderate to severe psoriasis, according to Dr. Jeffrey M. Sobell.

"Biologics have expanded our treatment options, not replaced them," said Dr. Sobell at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Sobell of Tufts Medical Center in Boston discussed how he uses three classic psoriasis therapies.

Methotrexate

The efficacy of methotrexate is quite respectable, with a PASI 75 (that is, an improvement of 75% on the baseline Psoriasis Area and Severity Index) of 40% at 16 weeks, said Dr. Sobell. He said that he uses the drug for patients as a monotherapy for concomitant psoriatic arthritis and for life-impacting nail psoriasis. For some patients, he uses methotrexate in combination with anti–tumor necrosis factor therapy both for the synergistic effects on the skin and to reduce potential antibody formation.

The clinical dose of methotrexate is 7.5-25 mg/week (averaging 10-15 mg/week). Clinical effects should be seen by week 8, and doses greater than 20 mg/week are rarely necessary, he noted.

Clinicians who want to use methotrexate for psoriasis do need to be mindful of the possible side effects, which include hepatotoxicity, bone marrow suppression, gastrointestinal intolerance, pulmonary toxicity, and induction of malignancy. Also, methotrexate is teratogenic and is contraindicated during pregnancy, he said.

Cyclosporine

"Cyclosporine is an indispensable therapy in my clinic," said Dr. Sobell. He said that he uses it mostly for psoriasis in crisis situations, but also as a transitional therapy. "Clinicians have concerns about potential nephrotoxicity, but at low doses for short treatment periods, cyclosporine is extremely safe as long as serum creatinine levels are followed," he said.

A standard clinical dose of cyclosporine for psoriasis is 2.5-4.0 mg/kg per day. Other side effects to watch for include hypertension, paresthesias, and gastrointestinal intolerance.

Acitretin

Dr. Sobell said he uses acitretin in psoriasis patients as a monotherapy and in conjunction with phototherapy, biologics, and other oral medications.

His standard clinical dose is 10-25 mg/day. Follow-up lab tests should be done monthly for the first 3 months of acitretin use, and then every 3 months, he said. Acitretin is teratogenic, and other possible side effects include ocular or musculoskeletal problems, hyperlipidemia, and hepatotoxicity.

Dr. Sobell disclosed financial relationships with Abbott, Amgen, Celgene, Eli Lilly, and Janssen. SDEF and this news organization are owned by Elsevier.

SNOWMASS, COLO. - Low-dose methotrexate is highly effective for treatment of antimalarial-resistant discoid lupus or subacute cutaneous lupus erythematosus.

"If you have to pick one thing past Plaquenil [hydroxychloroquine], I’d say try methotrexate," declared Dr. Ruth Ann Vleugels at a symposium sponsored by the American College of Rheumatology. "At our institution, methotrexate is by far the next agent we choose for cutaneous lupus if the patient is able to tolerate it. We have really good luck with it, and it’s easy to prescribe," she said.

Dr. Vleugels has amassed what is believed to be the largest U.S. case series of patients treated with methotrexate for refractory cutaneous lupus erythematosus (LE). The as-yet unpublished series consists of 20 patients, most of whom received between 20 mg/week and 25 mg/week. Most were on oral methotrexate, but, if they experienced troublesome side effects, they were switched to the subcutaneous formulation.

Seventeen of the 20 patients (85%) experienced significant improvement on methotrexate. The drug was steroid sparing in 10 of 12 patients (83%). The response time was typically 8-12 weeks, according to Dr. Vleugels, a dermatologist who is director of the connective tissue disease clinic at Brigham and Women’s Hospital and codirector of the rheumatology-dermatology clinic at Children’s Hospital, both in Boston.

Although cutaneous LE is not a systemic disease, it’s essential to treat it aggressively from the get-go in order to halt the disease process and prevent irreversible scarring in discoid LE and disfiguring pigment contrast in subacute cutaneous LE, she emphasized.

The first question patients ask upon receiving the diagnosis of discoid LE is, how likely am I to develop systemic lupus erythematosus? The best available data suggest a 5%-10% risk overall, and less than that if the lesions are confined to the head and neck, she said. About one-third of discoid LE patients are antinuclear antibody–positive; this has no bearing on their risk of future systemic lupus erythematosus.

When a patient comes in with mild cutaneous LE that’s not adequately controlled with photoprotection, topical agents, and hydroxychloroquine, Dr. Vleugels may opt for combination antimalarial therapy, adding on quinacrine at 100 mg/day. Quinacrine is not immunosuppressive and has essentially no ocular toxicity. Its two downsides are that it can be obtained only at a compounding pharmacy, and it causes many patients to turn yellow. The yellow hue is more noticeable on light-skinned patients. Fortunately, the color change is completely reversible upon drug discontinuation.

If a patient’s cutaneous LE is a little more serious and it isn’t reined in using hydroxychloroquine as sole systemic therapy, Dr. Vleugels will bypass the add-on quinacrine and go straight to methotrexate because the results are so good.

Not all patients are good candidates for methotrexate, however. And some just don’t want to take an immunosuppressive medication. Under those circumstances, her second-choice option is thalidomide. It’s typically dosed at 25-100 mg once at night because it’s sedating. This is a highly effective drug with Food and Drug Administration approval for multiple myeloma and erythema nodosum leprosum, so cutaneous LE is off-label therapy.

Thalidomide is somewhat difficult to give because it is category X, and cutaneous LE occurs most commonly in young women. Physician participation in the FDA’s System for Thalidomide Education and Prescribing Safety (STEPS) program is mandatory. Pregnancy testing is required. Still, "the paperwork is actually pretty simple," according to Dr. Vleugels.

Thromboembolism is a side effect that seems to be largely confined to cancer patients. The chief limiting side effect in lupus patients is peripheral neuropathy, which has occurred in 25%-33% of treated patients in various series.

"That’s the main reason we have to take patients off this drug. That’s a pretty good chunk of patients, but the other patients do extremely well," the dermatologist noted.

Because thalidomide is not immunosuppressive, it can be added to virtually any other therapies without causing problems.

When thalidomide is not an option, her next choice is mycophenolate mofetil. It’s easier to prescribe, but definitely less effective than thalidomide in cutaneous LE.

Backup add-on systemic agents include dapsone, which is most effective in bullous LE, and acitretin, a potent retinoid with efficacy in cutaneous LE comparable to that of hydroxychloroquine. However, acitretin has a major drawback: It is stored in fat for 3 years and is category X. That means a young woman can’t get pregnant for 3 years after stopping the drug. For this reason, Dr. Vleugels reserves acitretin for men and older women.

Although she is quick to turn to systemic therapy for cutaneous LE, all of her patients start out with a message underscoring the importance of photoprotection, smoking cessation, and – living in Boston – vitamin D supplementation at 2,000 IU/day.

Topical therapy with corticosteroids and tacrolimus, a calcineurin inhibitor which is useful as a break from steroids, is also in place before she considers the introduction of systemic therapy starting with antimalarials.

To prevent lasting scarring in discoid LE patients with scalp involvement, Dr. Vleugels moves beyond systemic therapy, adding intralesional steroid injections. She typically takes triamcinolone (Kenalog) that comes in a concentration of 10 mg/cc, and dilutes it 1-to-1 with normal saline, for a final concentration of 5 mg/cc. She uses 0.1 cc of the diluted product per injection through a 30- or 31-gauge needle, picking the most inflamed areas of the scalp and placing the injections about 1 cm apart.

"One patient can tolerate only about 25 injections per day, sometimes fewer than that," Dr. Vleugels said, eliciting audience gasps. "You’d be surprised: Even our kids with scalp disease can tolerate injections fairly well because of the very small needle we use."

She has the patient return for another series of scalp injections in 5-6 weeks.

Dr. Vleugels reported having no financial conflicts.

SNOWMASS, COLO. - Low-dose methotrexate is highly effective for treatment of antimalarial-resistant discoid lupus or subacute cutaneous lupus erythematosus.

"If you have to pick one thing past Plaquenil [hydroxychloroquine], I’d say try methotrexate," declared Dr. Ruth Ann Vleugels at a symposium sponsored by the American College of Rheumatology. "At our institution, methotrexate is by far the next agent we choose for cutaneous lupus if the patient is able to tolerate it. We have really good luck with it, and it’s easy to prescribe," she said.

Dr. Vleugels has amassed what is believed to be the largest U.S. case series of patients treated with methotrexate for refractory cutaneous lupus erythematosus (LE). The as-yet unpublished series consists of 20 patients, most of whom received between 20 mg/week and 25 mg/week. Most were on oral methotrexate, but, if they experienced troublesome side effects, they were switched to the subcutaneous formulation.

Seventeen of the 20 patients (85%) experienced significant improvement on methotrexate. The drug was steroid sparing in 10 of 12 patients (83%). The response time was typically 8-12 weeks, according to Dr. Vleugels, a dermatologist who is director of the connective tissue disease clinic at Brigham and Women’s Hospital and codirector of the rheumatology-dermatology clinic at Children’s Hospital, both in Boston.

Although cutaneous LE is not a systemic disease, it’s essential to treat it aggressively from the get-go in order to halt the disease process and prevent irreversible scarring in discoid LE and disfiguring pigment contrast in subacute cutaneous LE, she emphasized.

The first question patients ask upon receiving the diagnosis of discoid LE is, how likely am I to develop systemic lupus erythematosus? The best available data suggest a 5%-10% risk overall, and less than that if the lesions are confined to the head and neck, she said. About one-third of discoid LE patients are antinuclear antibody–positive; this has no bearing on their risk of future systemic lupus erythematosus.

When a patient comes in with mild cutaneous LE that’s not adequately controlled with photoprotection, topical agents, and hydroxychloroquine, Dr. Vleugels may opt for combination antimalarial therapy, adding on quinacrine at 100 mg/day. Quinacrine is not immunosuppressive and has essentially no ocular toxicity. Its two downsides are that it can be obtained only at a compounding pharmacy, and it causes many patients to turn yellow. The yellow hue is more noticeable on light-skinned patients. Fortunately, the color change is completely reversible upon drug discontinuation.

If a patient’s cutaneous LE is a little more serious and it isn’t reined in using hydroxychloroquine as sole systemic therapy, Dr. Vleugels will bypass the add-on quinacrine and go straight to methotrexate because the results are so good.

Not all patients are good candidates for methotrexate, however. And some just don’t want to take an immunosuppressive medication. Under those circumstances, her second-choice option is thalidomide. It’s typically dosed at 25-100 mg once at night because it’s sedating. This is a highly effective drug with Food and Drug Administration approval for multiple myeloma and erythema nodosum leprosum, so cutaneous LE is off-label therapy.

Thalidomide is somewhat difficult to give because it is category X, and cutaneous LE occurs most commonly in young women. Physician participation in the FDA’s System for Thalidomide Education and Prescribing Safety (STEPS) program is mandatory. Pregnancy testing is required. Still, "the paperwork is actually pretty simple," according to Dr. Vleugels.

Thromboembolism is a side effect that seems to be largely confined to cancer patients. The chief limiting side effect in lupus patients is peripheral neuropathy, which has occurred in 25%-33% of treated patients in various series.

"That’s the main reason we have to take patients off this drug. That’s a pretty good chunk of patients, but the other patients do extremely well," the dermatologist noted.

Because thalidomide is not immunosuppressive, it can be added to virtually any other therapies without causing problems.

When thalidomide is not an option, her next choice is mycophenolate mofetil. It’s easier to prescribe, but definitely less effective than thalidomide in cutaneous LE.

Backup add-on systemic agents include dapsone, which is most effective in bullous LE, and acitretin, a potent retinoid with efficacy in cutaneous LE comparable to that of hydroxychloroquine. However, acitretin has a major drawback: It is stored in fat for 3 years and is category X. That means a young woman can’t get pregnant for 3 years after stopping the drug. For this reason, Dr. Vleugels reserves acitretin for men and older women.

Although she is quick to turn to systemic therapy for cutaneous LE, all of her patients start out with a message underscoring the importance of photoprotection, smoking cessation, and – living in Boston – vitamin D supplementation at 2,000 IU/day.

Topical therapy with corticosteroids and tacrolimus, a calcineurin inhibitor which is useful as a break from steroids, is also in place before she considers the introduction of systemic therapy starting with antimalarials.

To prevent lasting scarring in discoid LE patients with scalp involvement, Dr. Vleugels moves beyond systemic therapy, adding intralesional steroid injections. She typically takes triamcinolone (Kenalog) that comes in a concentration of 10 mg/cc, and dilutes it 1-to-1 with normal saline, for a final concentration of 5 mg/cc. She uses 0.1 cc of the diluted product per injection through a 30- or 31-gauge needle, picking the most inflamed areas of the scalp and placing the injections about 1 cm apart.

"One patient can tolerate only about 25 injections per day, sometimes fewer than that," Dr. Vleugels said, eliciting audience gasps. "You’d be surprised: Even our kids with scalp disease can tolerate injections fairly well because of the very small needle we use."

She has the patient return for another series of scalp injections in 5-6 weeks.

Dr. Vleugels reported having no financial conflicts.

SNOWMASS, COLO. - Low-dose methotrexate is highly effective for treatment of antimalarial-resistant discoid lupus or subacute cutaneous lupus erythematosus.

"If you have to pick one thing past Plaquenil [hydroxychloroquine], I’d say try methotrexate," declared Dr. Ruth Ann Vleugels at a symposium sponsored by the American College of Rheumatology. "At our institution, methotrexate is by far the next agent we choose for cutaneous lupus if the patient is able to tolerate it. We have really good luck with it, and it’s easy to prescribe," she said.

Dr. Vleugels has amassed what is believed to be the largest U.S. case series of patients treated with methotrexate for refractory cutaneous lupus erythematosus (LE). The as-yet unpublished series consists of 20 patients, most of whom received between 20 mg/week and 25 mg/week. Most were on oral methotrexate, but, if they experienced troublesome side effects, they were switched to the subcutaneous formulation.

Seventeen of the 20 patients (85%) experienced significant improvement on methotrexate. The drug was steroid sparing in 10 of 12 patients (83%). The response time was typically 8-12 weeks, according to Dr. Vleugels, a dermatologist who is director of the connective tissue disease clinic at Brigham and Women’s Hospital and codirector of the rheumatology-dermatology clinic at Children’s Hospital, both in Boston.

Although cutaneous LE is not a systemic disease, it’s essential to treat it aggressively from the get-go in order to halt the disease process and prevent irreversible scarring in discoid LE and disfiguring pigment contrast in subacute cutaneous LE, she emphasized.

The first question patients ask upon receiving the diagnosis of discoid LE is, how likely am I to develop systemic lupus erythematosus? The best available data suggest a 5%-10% risk overall, and less than that if the lesions are confined to the head and neck, she said. About one-third of discoid LE patients are antinuclear antibody–positive; this has no bearing on their risk of future systemic lupus erythematosus.

When a patient comes in with mild cutaneous LE that’s not adequately controlled with photoprotection, topical agents, and hydroxychloroquine, Dr. Vleugels may opt for combination antimalarial therapy, adding on quinacrine at 100 mg/day. Quinacrine is not immunosuppressive and has essentially no ocular toxicity. Its two downsides are that it can be obtained only at a compounding pharmacy, and it causes many patients to turn yellow. The yellow hue is more noticeable on light-skinned patients. Fortunately, the color change is completely reversible upon drug discontinuation.

If a patient’s cutaneous LE is a little more serious and it isn’t reined in using hydroxychloroquine as sole systemic therapy, Dr. Vleugels will bypass the add-on quinacrine and go straight to methotrexate because the results are so good.

Not all patients are good candidates for methotrexate, however. And some just don’t want to take an immunosuppressive medication. Under those circumstances, her second-choice option is thalidomide. It’s typically dosed at 25-100 mg once at night because it’s sedating. This is a highly effective drug with Food and Drug Administration approval for multiple myeloma and erythema nodosum leprosum, so cutaneous LE is off-label therapy.

Thalidomide is somewhat difficult to give because it is category X, and cutaneous LE occurs most commonly in young women. Physician participation in the FDA’s System for Thalidomide Education and Prescribing Safety (STEPS) program is mandatory. Pregnancy testing is required. Still, "the paperwork is actually pretty simple," according to Dr. Vleugels.

Thromboembolism is a side effect that seems to be largely confined to cancer patients. The chief limiting side effect in lupus patients is peripheral neuropathy, which has occurred in 25%-33% of treated patients in various series.

"That’s the main reason we have to take patients off this drug. That’s a pretty good chunk of patients, but the other patients do extremely well," the dermatologist noted.

Because thalidomide is not immunosuppressive, it can be added to virtually any other therapies without causing problems.

When thalidomide is not an option, her next choice is mycophenolate mofetil. It’s easier to prescribe, but definitely less effective than thalidomide in cutaneous LE.

Backup add-on systemic agents include dapsone, which is most effective in bullous LE, and acitretin, a potent retinoid with efficacy in cutaneous LE comparable to that of hydroxychloroquine. However, acitretin has a major drawback: It is stored in fat for 3 years and is category X. That means a young woman can’t get pregnant for 3 years after stopping the drug. For this reason, Dr. Vleugels reserves acitretin for men and older women.

Although she is quick to turn to systemic therapy for cutaneous LE, all of her patients start out with a message underscoring the importance of photoprotection, smoking cessation, and – living in Boston – vitamin D supplementation at 2,000 IU/day.

Topical therapy with corticosteroids and tacrolimus, a calcineurin inhibitor which is useful as a break from steroids, is also in place before she considers the introduction of systemic therapy starting with antimalarials.

To prevent lasting scarring in discoid LE patients with scalp involvement, Dr. Vleugels moves beyond systemic therapy, adding intralesional steroid injections. She typically takes triamcinolone (Kenalog) that comes in a concentration of 10 mg/cc, and dilutes it 1-to-1 with normal saline, for a final concentration of 5 mg/cc. She uses 0.1 cc of the diluted product per injection through a 30- or 31-gauge needle, picking the most inflamed areas of the scalp and placing the injections about 1 cm apart.

"One patient can tolerate only about 25 injections per day, sometimes fewer than that," Dr. Vleugels said, eliciting audience gasps. "You’d be surprised: Even our kids with scalp disease can tolerate injections fairly well because of the very small needle we use."

She has the patient return for another series of scalp injections in 5-6 weeks.

Dr. Vleugels reported having no financial conflicts.

SNOWMASS, COLO. – The risk of herpes zoster isn’t raised in rheumatoid arthritis patients who are on a tumor necrosis factor inhibitor, compared with those on nonbiologic disease-modifying antirheumatic drugs, according to a preliminary analysis from by far the largest study to examine the question.

Findings from the same study also suggested that TNF–inhibiting therapy may actually protect against zoster in patients with psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease.

Data from two previous, large, population-based studies looking at the risk of herpes zoster in RA patients on anti-TNF biologics reveal discordant conclusions. These conflicting findings prompted Dr. Kevin L. Winthrop and his coinvestigators in the SABER (Safety Assessment of Biologic Therapy) collaboration to examine the issue in their very large data set.

SABER is a retrospective cohort study involving four large U.S. automated health databases. The as-yet-unpublished SABER herpes zoster analysis included more than 35,000 patients with diseases for which TNF inhibitors are indicated.

During 22,215 person-years of follow-up, the crude rate of herpes zoster among RA patients who were new first-time users of an anti-TNF agent was 12.1 cases per 1,000 person-years, which wasn’t significantly different from the 12.8 per 1,000 rate during 7,165 person-years of follow-up in the control group, which comprised RA patients who were failing on methotrexate and adding another conventional DMARD, usually hydroxychloroquine (Plaquenil).

There were no significant differences in zoster rates among the various anti-TNF agents, Dr. Winthrop said at the symposium, which was sponsored by the American College of Rheumatology.

Intriguingly, going on an anti-TNF agent actually appeared to protect against herpes zoster in SABER participants with psoriasis, psoriatic arthritis, or ankylosing spondylitis. During 4,106 person-years of follow-up, their crude rate of zoster was 4.4 cases per 1,000 person-years, an adjusted 36% lower risk than that in patients on a nonbiologic DMARD, whose rate was 6.8 cases per 1,000 person-years during 3,950 person-years of follow-up, according to Dr. Winthrop, an infectious diseases specialist at Oregon Health and Science University, Portland.

Moreover, new users of infliximab or adalimumab for inflammatory bowel disease had an adjusted 20% reduction in risk of zoster, compared with those on azathioprine or 6-mercaptopurine, he added.

An earlier retrospective cohort study involving 20,357 RA patients in the Veterans Affairs health care system found that patients on adalimumab had an adjusted 47% lower risk of zoster, and those on etanercept had a 38% reduction in risk, compared with patients on conventional DMARDs. Patients on infliximab had a 30% increased risk; however, this trend didn’t reach statistical significance (Clin. Infect. Dis. 2009;48:1364-71).

In sharp contrast, investigators from the prospective German RABBIT registry involving 5,040 RA patients reported that adalimumab was associated with a 3-fold increased risk of herpes zoster compared to nonbiologic DMARD therapy. Infliximab had an adjusted 2.4-fold increased risk, which wasn’t statistically significant. Etanercept wasn’t associated with increased risk (JAMA 2009;301:737-44).

The explanation for the discordant findings in RABBIT and the VA study is unclear. The studies did use somewhat different methodologies. Regardless, it’s worth noting that the number of subjects included in the new SABER analysis was larger than for both of the earlier studies put together.

"Look how robust this is," Dr. Winthrop observed. "We have good, good power. Our interpretation is there is no increased risk of zoster with anti-TNF drugs."

Nonetheless, this is a preliminary analysis. The SABER investigators plan to look next at what happened to prednisone dosing when the RA patients went on anti-TNF therapy or an additional nonbiologic DMARD, something they can do with this cohort but couldn’t do in an earlier SABER publication. Dr. Winthrop said he suspects that the prednisone dose was more likely to be reduced or eliminated in the TNF-inhibitor users, and that this might account for the finding that anti-TNF therapy didn’t increase zoster risk. A half-dozen studies have shown that prednisone therapy is associated with an increased risk of herpes zoster.

Dr. Winthrop said it’s his impression that patients who develop herpes zoster while on anti-TNF therapy don’t have a higher rate of disseminated disease or worse outcomes than do those who are not. In the SABER analysis, the rate of hospitalization for zoster was similarly very low in the biologic and nonbiologic treatment groups.

In response to audience questions, he said he believes it makes sense to give herpes zoster vaccine to RA patients starting at 50 years of age. RA per se is a risk factor for zoster, as is prednisone therapy. There is no evidence of any safety issues in vaccinating patients who take any of the standard DMARDs or anti-TNF agents, although there are no definitive data on that score. It’s possible that pharmacologic immunosuppression blunts the vaccine’s efficacy, but that hasn’t been studied.

Dr. Winthrop reported having no financial conflicts.

SNOWMASS, COLO. – The risk of herpes zoster isn’t raised in rheumatoid arthritis patients who are on a tumor necrosis factor inhibitor, compared with those on nonbiologic disease-modifying antirheumatic drugs, according to a preliminary analysis from by far the largest study to examine the question.

Findings from the same study also suggested that TNF–inhibiting therapy may actually protect against zoster in patients with psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease.

Data from two previous, large, population-based studies looking at the risk of herpes zoster in RA patients on anti-TNF biologics reveal discordant conclusions. These conflicting findings prompted Dr. Kevin L. Winthrop and his coinvestigators in the SABER (Safety Assessment of Biologic Therapy) collaboration to examine the issue in their very large data set.

SABER is a retrospective cohort study involving four large U.S. automated health databases. The as-yet-unpublished SABER herpes zoster analysis included more than 35,000 patients with diseases for which TNF inhibitors are indicated.

During 22,215 person-years of follow-up, the crude rate of herpes zoster among RA patients who were new first-time users of an anti-TNF agent was 12.1 cases per 1,000 person-years, which wasn’t significantly different from the 12.8 per 1,000 rate during 7,165 person-years of follow-up in the control group, which comprised RA patients who were failing on methotrexate and adding another conventional DMARD, usually hydroxychloroquine (Plaquenil).

There were no significant differences in zoster rates among the various anti-TNF agents, Dr. Winthrop said at the symposium, which was sponsored by the American College of Rheumatology.

Intriguingly, going on an anti-TNF agent actually appeared to protect against herpes zoster in SABER participants with psoriasis, psoriatic arthritis, or ankylosing spondylitis. During 4,106 person-years of follow-up, their crude rate of zoster was 4.4 cases per 1,000 person-years, an adjusted 36% lower risk than that in patients on a nonbiologic DMARD, whose rate was 6.8 cases per 1,000 person-years during 3,950 person-years of follow-up, according to Dr. Winthrop, an infectious diseases specialist at Oregon Health and Science University, Portland.

Moreover, new users of infliximab or adalimumab for inflammatory bowel disease had an adjusted 20% reduction in risk of zoster, compared with those on azathioprine or 6-mercaptopurine, he added.

An earlier retrospective cohort study involving 20,357 RA patients in the Veterans Affairs health care system found that patients on adalimumab had an adjusted 47% lower risk of zoster, and those on etanercept had a 38% reduction in risk, compared with patients on conventional DMARDs. Patients on infliximab had a 30% increased risk; however, this trend didn’t reach statistical significance (Clin. Infect. Dis. 2009;48:1364-71).

In sharp contrast, investigators from the prospective German RABBIT registry involving 5,040 RA patients reported that adalimumab was associated with a 3-fold increased risk of herpes zoster compared to nonbiologic DMARD therapy. Infliximab had an adjusted 2.4-fold increased risk, which wasn’t statistically significant. Etanercept wasn’t associated with increased risk (JAMA 2009;301:737-44).

The explanation for the discordant findings in RABBIT and the VA study is unclear. The studies did use somewhat different methodologies. Regardless, it’s worth noting that the number of subjects included in the new SABER analysis was larger than for both of the earlier studies put together.

"Look how robust this is," Dr. Winthrop observed. "We have good, good power. Our interpretation is there is no increased risk of zoster with anti-TNF drugs."

Nonetheless, this is a preliminary analysis. The SABER investigators plan to look next at what happened to prednisone dosing when the RA patients went on anti-TNF therapy or an additional nonbiologic DMARD, something they can do with this cohort but couldn’t do in an earlier SABER publication. Dr. Winthrop said he suspects that the prednisone dose was more likely to be reduced or eliminated in the TNF-inhibitor users, and that this might account for the finding that anti-TNF therapy didn’t increase zoster risk. A half-dozen studies have shown that prednisone therapy is associated with an increased risk of herpes zoster.

Dr. Winthrop said it’s his impression that patients who develop herpes zoster while on anti-TNF therapy don’t have a higher rate of disseminated disease or worse outcomes than do those who are not. In the SABER analysis, the rate of hospitalization for zoster was similarly very low in the biologic and nonbiologic treatment groups.

In response to audience questions, he said he believes it makes sense to give herpes zoster vaccine to RA patients starting at 50 years of age. RA per se is a risk factor for zoster, as is prednisone therapy. There is no evidence of any safety issues in vaccinating patients who take any of the standard DMARDs or anti-TNF agents, although there are no definitive data on that score. It’s possible that pharmacologic immunosuppression blunts the vaccine’s efficacy, but that hasn’t been studied.

Dr. Winthrop reported having no financial conflicts.

SNOWMASS, COLO. – The risk of herpes zoster isn’t raised in rheumatoid arthritis patients who are on a tumor necrosis factor inhibitor, compared with those on nonbiologic disease-modifying antirheumatic drugs, according to a preliminary analysis from by far the largest study to examine the question.

Findings from the same study also suggested that TNF–inhibiting therapy may actually protect against zoster in patients with psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease.

Data from two previous, large, population-based studies looking at the risk of herpes zoster in RA patients on anti-TNF biologics reveal discordant conclusions. These conflicting findings prompted Dr. Kevin L. Winthrop and his coinvestigators in the SABER (Safety Assessment of Biologic Therapy) collaboration to examine the issue in their very large data set.

SABER is a retrospective cohort study involving four large U.S. automated health databases. The as-yet-unpublished SABER herpes zoster analysis included more than 35,000 patients with diseases for which TNF inhibitors are indicated.

During 22,215 person-years of follow-up, the crude rate of herpes zoster among RA patients who were new first-time users of an anti-TNF agent was 12.1 cases per 1,000 person-years, which wasn’t significantly different from the 12.8 per 1,000 rate during 7,165 person-years of follow-up in the control group, which comprised RA patients who were failing on methotrexate and adding another conventional DMARD, usually hydroxychloroquine (Plaquenil).

There were no significant differences in zoster rates among the various anti-TNF agents, Dr. Winthrop said at the symposium, which was sponsored by the American College of Rheumatology.

Intriguingly, going on an anti-TNF agent actually appeared to protect against herpes zoster in SABER participants with psoriasis, psoriatic arthritis, or ankylosing spondylitis. During 4,106 person-years of follow-up, their crude rate of zoster was 4.4 cases per 1,000 person-years, an adjusted 36% lower risk than that in patients on a nonbiologic DMARD, whose rate was 6.8 cases per 1,000 person-years during 3,950 person-years of follow-up, according to Dr. Winthrop, an infectious diseases specialist at Oregon Health and Science University, Portland.

Moreover, new users of infliximab or adalimumab for inflammatory bowel disease had an adjusted 20% reduction in risk of zoster, compared with those on azathioprine or 6-mercaptopurine, he added.

An earlier retrospective cohort study involving 20,357 RA patients in the Veterans Affairs health care system found that patients on adalimumab had an adjusted 47% lower risk of zoster, and those on etanercept had a 38% reduction in risk, compared with patients on conventional DMARDs. Patients on infliximab had a 30% increased risk; however, this trend didn’t reach statistical significance (Clin. Infect. Dis. 2009;48:1364-71).

In sharp contrast, investigators from the prospective German RABBIT registry involving 5,040 RA patients reported that adalimumab was associated with a 3-fold increased risk of herpes zoster compared to nonbiologic DMARD therapy. Infliximab had an adjusted 2.4-fold increased risk, which wasn’t statistically significant. Etanercept wasn’t associated with increased risk (JAMA 2009;301:737-44).

The explanation for the discordant findings in RABBIT and the VA study is unclear. The studies did use somewhat different methodologies. Regardless, it’s worth noting that the number of subjects included in the new SABER analysis was larger than for both of the earlier studies put together.

"Look how robust this is," Dr. Winthrop observed. "We have good, good power. Our interpretation is there is no increased risk of zoster with anti-TNF drugs."

Nonetheless, this is a preliminary analysis. The SABER investigators plan to look next at what happened to prednisone dosing when the RA patients went on anti-TNF therapy or an additional nonbiologic DMARD, something they can do with this cohort but couldn’t do in an earlier SABER publication. Dr. Winthrop said he suspects that the prednisone dose was more likely to be reduced or eliminated in the TNF-inhibitor users, and that this might account for the finding that anti-TNF therapy didn’t increase zoster risk. A half-dozen studies have shown that prednisone therapy is associated with an increased risk of herpes zoster.

Dr. Winthrop said it’s his impression that patients who develop herpes zoster while on anti-TNF therapy don’t have a higher rate of disseminated disease or worse outcomes than do those who are not. In the SABER analysis, the rate of hospitalization for zoster was similarly very low in the biologic and nonbiologic treatment groups.

In response to audience questions, he said he believes it makes sense to give herpes zoster vaccine to RA patients starting at 50 years of age. RA per se is a risk factor for zoster, as is prednisone therapy. There is no evidence of any safety issues in vaccinating patients who take any of the standard DMARDs or anti-TNF agents, although there are no definitive data on that score. It’s possible that pharmacologic immunosuppression blunts the vaccine’s efficacy, but that hasn’t been studied.

Dr. Winthrop reported having no financial conflicts.