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Boonsiri M, Diaz D, Sukmee T, Okawa J, Ditre CM. Comparative Study of Compounded Anesthetic Benzocaine/Lidocaine/Tetracaine (BLT) Cream with and without Abrasive Particles. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2017; 10:30-36. [PMID: 28458772 PMCID: PMC5404778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Objective: The purpose of this study was to compare the use of benzocaine, lidocaine, tetracaine (BLT) cream with and without abrasive particles to see which type of cream is more effective in reducing discomfort during cosmetic dermatologic procedures, specifically procedures using hyaluronic acid (HA) injectables. Methods: The study was conducted as a single-site, double-blind, paired study. Participants: Thirty-one subjects were enrolled. Men and women over 18, but not more than 75 years of age, were included. Participants were randomized to receive two types of BLT creams in a split-face fashion to two opposite anatomical face locations that require a similar amount of filler. Results: The study found a statistically significant difference (P<0.05) in the mean pain level as measured by the VAS and Wong-Baker Faces Pain Rating Scale when compared between baseline and the time when the procedure was started at the first needle stick. Subjects expressed significantly less pain with baseline and more pain when the procedure was done. However, the authors found that the mean pain level at first needle stick is lower with the abrasive type of BLT. Conclusion: The study demonstrated that subjects experienced a higher mean pain level (but not statistically significant) when using the BLT with smooth texture compared to the BLT with abrasive particles when applied before HA dermal filler injection.
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Tiao J, Feng R, Bird S, Choi JK, Dunham J, George M, Gonzalez-Rivera TC, Kaufman JL, Khan N, Luo JJ, Micheletti R, Payne AS, Price R, Quinn C, Rubin AI, Sreih AG, Thomas P, Okawa J, Werth VP. The reliability of the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) among dermatologists, rheumatologists and neurologists. Br J Dermatol 2016; 176:423-430. [PMID: 28004387 DOI: 10.1111/bjd.15140] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous studies have shown that skin disease in dermatomyositis (DM) is best assessed using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). Although the CDASI has been validated for use by dermatologists, it has not been validated for use by other physicians such as rheumatologists and neurologists, who also manage patients with DM and assess skin activity in clinical trials. OBJECTIVES To assess the reliability of the CDASI among dermatologists, rheumatologists and neurologists. METHODS Fifteen patients with cutaneous DM were assessed using the CDASI and the Physician Global Assessment (PGA) by five dermatologists, five rheumatologists and five neurologists. RESULTS The mean CDASI activity scores for dermatologists, rheumatologists and neurologists were 21·0, 21·8 and 20·8, respectively. These mean scores were not different among the specialists. The CDASI damage score means for dermatologists, rheumatologists and neurologists were 5·3, 7·0 and 4·8, respectively. The mean scores between dermatologists and rheumatologists were significantly different, but the means between dermatologists and neurologists were not. The intraclass correlation coefficients (ICCs) for interrater reliability for CDASI activity and damage were good to excellent for dermatologists and rheumatologists, and moderate to excellent for neurologists. The ICCs for intrarater reliability for CDASI activity and damage were excellent for dermatologists and rheumatologists and moderate to excellent for neurologists. The PGA displayed lower interrater and intrarater reliability relative to the CDASI. CONCLUSIONS Our results confirm the reliability of the CDASI when used by dermatologists and rheumatologists. The data for its use by neurologists were not as robust.
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Ang CC, Anyanwu CO, Robinson E, Okawa J, Feng R, Fujimoto M, Hamaguchi Y, Werth VP. Clinical signs associated with an increased risk of interstitial lung disease: a retrospective study of 101 patients with dermatomyositis. Br J Dermatol 2016; 176:231-233. [PMID: 27292591 DOI: 10.1111/bjd.14801] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Siegel JA, Chren MM, Weinstock MA, Weinstock MA, Marcolivio K, Weinstock MA, Chen SC, Dellavalle RP, Warshaw EM, DiGiovanna JJ, Ferguson R, Lew RA, Ringer RJ, Yoon J, Phibbs CS, Kraemer K, Hogan D, Eilers D, Swetter SM, Chen SC, Jacob S, Romero L, Warshaw EM, Stricklin GP, Dellavalle RP, Konnikov N, Werth V, Sidhu-Malik N, Keri JE, Swan JW, Nord K, Pollack B, Kempiak S, High W, Fett N, Hall RP, Alonso-Llamazares J, Rodriguez G, Sisler L, O'Sullivan M, Wilson S, Agrawal M, Bartenfeld D, Nicalo K, Johnson D, Parks P, Bidek B, Boyd N, Watson B, Wolfe D, Zacheis M, Okawa J, Iannacchione MA, Quintero J, Cuddapah S, Muller K, Lichon V, Anhalt T, Khosravi V, Rahman Z, Lawley L, McCoy R, Foman N, Bershow A, Zic J, Miller J, Arbuckle HA, Hemphill L, Fujita M, Norris D, Ramaswamy P, Nevas J, Rao CH, Gifford AJ, Asher KA, Cardones ARG, Richardson AF, Patrick CA, Fiore L, Ferguson R, Thwin SS, Lew RA, Kebabian CE, Pavao J, Sather M, Fye C, Ringer RJ, Hunt D, Robinson-Bostom L, Telang G, Wilkel C, Haynes HA, Brookhart MA, Mostow EN, Rector T. Correlates of skin-related quality of life (QoL) in those with multiple keratinocyte carcinomas (KCs): A cross-sectional study. J Am Acad Dermatol 2016; 75:639-642. [DOI: 10.1016/j.jaad.2016.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/18/2016] [Accepted: 05/02/2016] [Indexed: 11/25/2022]
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Achtman J, Kling MA, Feng R, Okawa J, Werth VP. A cross-sectional study of untreated depression and anxiety in cutaneous lupus erythematosus and dermatomyositis. J Am Acad Dermatol 2016; 74:377-9. [PMID: 26775780 DOI: 10.1016/j.jaad.2015.09.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/05/2015] [Accepted: 09/10/2015] [Indexed: 10/22/2022]
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Tiao J, Feng R, Carr K, Okawa J, Werth VP. Using the American College of Rheumatology (ACR) and Systemic Lupus International Collaborating Clinics (SLICC) criteria to determine the diagnosis of systemic lupus erythematosus (SLE) in patients with subacute cutaneous lupus erythematosus (SCLE). J Am Acad Dermatol 2016; 74:862-9. [PMID: 26897388 DOI: 10.1016/j.jaad.2015.12.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 12/01/2015] [Accepted: 12/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Approximately 50% of patients with subacute cutaneous lupus erythematosus (SCLE) meet criteria for systemic lupus erythematosus (SLE). The Systemic Lupus International Collaborating Clinics (SLICC) developed new SLE criteria to improve the American College of Rheumatology (ACR) criteria but the SLICC criteria have not been evaluated in patients with SCLE. OBJECTIVE We sought to determine how patients with SCLE/SLE meet the ACR and SLICC criteria to compare the 2 sets of criteria. METHODS This was a retrospective analysis of 107 patients with SCLE enrolled in a database at the University of Pennsylvania. RESULTS Patients with SCLE/SLE were more likely than those with only SCLE to have oral ulcers, positive anti-double-stranded DNA antibodies, and positive antinuclear antibody test findings using both sets of criteria. Patients with SCLE/SLE were also more likely to have low complement using the SLICC criteria. There was a statistically insignificant increase in individuals meeting the SLICC criteria. LIMITATIONS Not all patients received comprehensive laboratory testing. CONCLUSIONS Most patients with SCLE who formally meet criteria for SLE do so based on the laboratory and mucocutaneous criteria. Neither the ACR nor SLICC criteria distinguish patients with SCLE and major internal disease from patients with SCLE without major internal disease.
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MESH Headings
- Adult
- Aged
- Antibodies, Antinuclear/immunology
- Cohort Studies
- Cooperative Behavior
- Databases, Factual
- Diagnosis, Differential
- Female
- Humans
- Lupus Erythematosus, Cutaneous/classification
- Lupus Erythematosus, Cutaneous/diagnosis
- Lupus Erythematosus, Cutaneous/immunology
- Lupus Erythematosus, Systemic/classification
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/immunology
- Male
- Middle Aged
- Practice Guidelines as Topic/standards
- Retrospective Studies
- Rheumatology/standards
- Risk Assessment
- Societies, Medical/standards
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Anyanwu CO, Fiorentino DF, Chung L, Dzuong C, Wang Y, Okawa J, Carr K, Propert KJ, Werth VP. Validation of the Cutaneous Dermatomyositis Disease Area and Severity Index: characterizing disease severity and assessing responsiveness to clinical change. Br J Dermatol 2015; 173:969-74. [PMID: 25994337 DOI: 10.1111/bjd.13915] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) was developed for use in clinical trials and longitudinal patient assessment. OBJECTIVES To characterize disease severity using the CDASI and assess the responsiveness of this instrument to clinically meaningful changes in disease activity. METHODS Patients with cutaneous dermatomyositis at the University of Pennsylvania (UPenn, n = 93) and Stanford University (Stanford, n = 106) were prospectively evaluated using the CDASI, physician global assessment (PGA) Likert scales and a visual analogue scale (VAS). Data was analysed using logistic regression models and receiver operating characteristic curves to select cut-offs. RESULTS Baseline CDASI activity scores for the patients evaluated at UPenn ranged from 0 to 47 (median 17), and baseline PGA VAS scores ranged from 0 to 9·6 (median 1·1). At UPenn a CDASI activity score of 19 differentiated mild from moderate and severe disease. At Stanford baseline CDASI scores ranged from 0 to 48 (median 21), baseline PGA VAS scores ranged from 0 to 9·7 (median 4·2) and CDASI activity scores of 14 or less characterized mild disease. When a 2-cm change in the PGA VAS was regarded as a clinically significant improvement, a 4-point (UPenn) or 5-point (Stanford) change in CDASI reflected a minimal clinically significant response. CONCLUSIONS The CDASI is a valid and responsive measure that can be used to characterize cutaneous dermatomyositis severity and detect improvement in disease activity. Variations in cut-offs may be due to differences in disease severity between the two populations or inter-rater variations in the use of the external gold measures.
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Sebaratnam DF, Okawa J, Payne A, Murrell DF, Werth VP. Reliability of the autoimmune bullous disease quality of life (ABQOL) questionnaire in the USA. Qual Life Res 2015; 24:2257-60. [PMID: 25795375 DOI: 10.1007/s11136-015-0965-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the reliability of the autoimmune bullous diseases quality of life (ABQOL) questionnaire in a North American patient cohort. METHODS Patients attending the dermatology clinics of the University of Pennsylvania with a histological diagnosis of an autoimmune bullous disease (AIBD) and self-reported proficiency in English were recruited to participate in the study. Patients completed the ABQOL questionnaire at Day 0 and Day 3. Internal consistency was calculated through Cronbach's alpha. Test-retest reliability was determined by the intraclass correlation coefficient. RESULTS Of the 45 patients enrolled in the study, 39 patients (87 %) participated to completion. The mean age was 60.7 years with an equal sex distribution observed. Patients had a range of AIBD including pemphigus vulgaris, bullous pemphigoid, pemphigus foliaceus, epidermolysis bullosa acquisita, mucous membrane pemphigoid and linear IgA disease. Cronbach's alpha was calculated to be 0.90. The intraclass correlation coefficient was calculated to be 0.93 (95 % confidence interval 0.88-0.94). CONCLUSION The ABQOL was found to be reliable tested by internal consistency and test-retest reliability in an American patient cohort. It represents a promising disease-specific outcome measure for patients with AIBD.
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Hall RP, Fairley J, Woodley D, Werth VP, Hannah D, Streilein RD, McKillip J, Okawa J, Rose M, Keyes-Elstein LL, Pinckney A, Overington A, Wedgwood J, Ding L, Welch B. A multicentre randomized trial of the treatment of patients with pemphigus vulgaris with infliximab and prednisone compared with prednisone alone. Br J Dermatol 2015; 172:760-8. [PMID: 25123295 DOI: 10.1111/bjd.13350] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pemphigus vulgaris (PV) is a blistering disease and tumour necrosis factor-α has a role in its pathogenesis. OBJECTIVES To evaluate the safety of infliximab (IFX) with prednisone compared with prednisone alone in the treatment of PV. In addition, treatment response was assessed and mechanistic studies were performed. METHODS Subjects with PV who had ongoing disease activity while being maintained on prednisone were randomized to receive either IFX or placebo in addition to prednisone. Response status and immunoglobulin (Ig) G anti-desmoglein (Dsg)1 and Dsg3 antibodies were assessed at 18 and 26 weeks. RESULTS Ten subjects were randomized to each group. There were no safety signals during the course of the study. At week 18, one subject in each group had responded. At week 26, three IFX-treated subjects vs. none in the placebo group had responded (P = 0·21). At weeks 18 and 26, the median IgG anti-Dsg1 and anti-Dsg3 levels were lower in the IFX-treated patients [IgG anti-Dsg-1 (week 18, P = 0·035; week 26, P = 0·022); IgG anti-Dsg3 (week 18, P = 0·035; week, 26 P = 0·05)]. CONCLUSIONS This study is limited by the relatively small sample size. There was no significant difference between study arms in the proportion of subjects with treatment-related adverse events > grade 3. IFX therapy was not shown to be effective for the treatment of patients with PV in this randomized, placebo-controlled trial, although IFX treatment may be associated with a decrease in anti-Dsg1 and Dsg3 antibodies.
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Robinson ES, Feng R, Okawa J, Werth VP. Improvement in the cutaneous disease activity of patients with dermatomyositis is associated with a better quality of life. Br J Dermatol 2014; 172:169-74. [PMID: 24909747 DOI: 10.1111/bjd.13167] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cutaneous dermatomyositis (DM) disease activity is associated with decreased quality of life. OBJECTIVES To assess if an improvement in quality of life, as measured by the Skindex-29 and patient-reported itch and pain on a 10-point visual analogue scale (VAS), correlated with an improvement in cutaneous DM disease activity. METHODS Patients with a completed cutaneous DM disease area and severity index [Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI)] at two visits separated by at least 2 months were classified into responder (n = 15) and nonresponder (n = 30) groups according to the point change in the CDASI activity scores between visits. Responders had at least a four-point improvement in CDASI activity, indicating clinically relevant improvement. RESULTS The change from baseline to the follow-up visit of the Skindex-29 subscale scores for the responders vs. the nonresponders were significantly different for emotions (P < 0·01), functioning (P < 0·01) and symptoms (P < 0·01). The change in VAS score between responders and nonresponders was also significant for itch (P = 0·01) and pain (P = 0·04). There was no significant difference between the groups in terms of disease subtype, sex, race, age, treatment for DM, smoking history or a history of malignancy within 5 years of a diagnosis of DM. CONCLUSIONS This is the first study to demonstrate that the quality of life of patients with DM improved as their cutaneous disease activity decreased.
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Verma SM, Okawa J, Propert KJ, Werth VP. The impact of skin damage due to cutaneous lupus on quality of life. Br J Dermatol 2014; 170:315-21. [PMID: 24111880 DOI: 10.1111/bjd.12653] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with more severe cutaneous lupus erythematosus (CLE) have a poorer quality of life (QoL). Racial and ethnic disparities have been reported in disease activity and outcomes in systemic lupus erythematosus, but similar information is not available for CLE. OBJECTIVES To evaluate the impact of lupus-related skin damage on skin-specific QoL, and to analyse differences stratified by ethnic background. METHODS Data collected included sex, race, diagnosis and Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) and Skindex-29 scores. These parameters were analysed at the initial and last visits. CLASI damage scores (dyspigmentation and scarring) and activity scores were collected, grouped by ethnicity, and correlated with Skindex-29. Overall, 223 patients were analysed at baseline, with 141 completing more than one study visit. RESULTS The majority of patients were white (63·7%), followed by African American (29·1%) and Asian American (4·0%). African American patients accounted for a disproportionate percentage of both localized (50%) and generalized discoid lupus erythematosus (DLE) (49%). Median CLASI damage scores differed significantly between the African American, white and Asian American patients, at both the first (8·5, 4·0, 7·0, respectively; P < 0·0001) and last visit (10·0, 6·0, 8·5, respectively; P < 0·01). CLASI damage scores in African Americans correlated with CLASI activity scores (Spearman r = 0·45, P = 0·0003). CONCLUSIONS There was no significant correlation between CLASI damage scores and Skindex domains overall. Individually, dyspigmentation and scarring also did not have a significant effect on QoL. Ethnic differences in patients with CLE were found: African American patients exhibited a high rate of DLE and experienced damage early in their disease course, frequently in conjunction with disease activity.
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Wieczorek IT, Propert KJ, Okawa J, Werth VP. Systemic symptoms in the progression of cutaneous to systemic lupus erythematosus. JAMA Dermatol 2014; 150:291-6. [PMID: 24477339 DOI: 10.1001/jamadermatol.2013.9026] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Patients with cutaneous lupus erythematosus (CLE) who develop systemic lupus erythematosus (SLE) may have few and mild systemic symptoms. OBJECTIVE To characterize the types and severity of systemic symptoms in a longitudinal cohort of patients with CLE. DESIGN, SETTING, AND PARTICIPANTS Prospective, longitudinal cohort study of 77 patients with CLE who presented between January 2007 and April 2011 at a university autoimmune skin disease clinic. MAIN OUTCOMES AND MEASURES Systemic symptoms and severity were determined from data recorded at each study visit and from medical records. RESULTS Of 77 patients with CLE, 13 (17%) went on to meet criteria for SLE, with a mean (SD) time from CLE diagnosis to SLE of 8.03 (6.20) years. Of the 13 patients, 1 (8%) solely met the mucocutaneous American College of Rheumatology (ACR) criteria of malar rash, discoid rash, photosensitivity, and oral ulcers, and 3 (23%) met the mucocutaneous ACR criteria plus positive antinuclear and other antibody titers. After a mean (SD) follow-up time of 2.81 (1.34) years, only 5 of the 13 patients with CLE (38%) who progressed to meet SLE criteria developed moderate to severe additional systemic disease. CONCLUSIONS AND RELEVANCE Patients with CLE who developed SLE during our study did so mostly by meeting the mucocutaneous ACR criteria, and the majority developed none to mild additional systemic disease during the study period. Thus, our study suggests that a small percentage of patients with CLE eventually develop SLE and that even if they do, most patients will have mild systemic disease.
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Okon L, Rosenbach M, Krathen M, Rose M, Propert K, Okawa J, Werth V. Lenalidomide in treatment-refractory cutaneous lupus erythematosus: Efficacy and safety in a 52-week trial. J Am Acad Dermatol 2014; 70:583-4. [PMID: 24528907 DOI: 10.1016/j.jaad.2013.11.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 10/29/2013] [Accepted: 11/01/2013] [Indexed: 11/19/2022]
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Chang AY, Ghazi E, Okawa J, Werth VP. Quality of life differences between responders and nonresponders in the treatment of cutaneous lupus erythematosus. JAMA Dermatol 2013; 149:104-6. [PMID: 23324773 DOI: 10.1001/2013.jamadermatol.467] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Braunstein I, Klein R, Okawa J, Werth VP. The interferon-regulated gene signature is elevated in subacute cutaneous lupus erythematosus and discoid lupus erythematosus and correlates with the cutaneous lupus area and severity index score. Br J Dermatol 2012; 166:971-5. [PMID: 22242767 DOI: 10.1111/j.1365-2133.2012.10825.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is increased expression of type I interferon (IFN)-regulated proteins in the blood and target tissues of patients with cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE). Patients with SLE have increased IFN-regulated gene expression pointing towards a possible underlying genetic defect. OBJECTIVES To determine expression levels of five type I IFN-regulated genes that are highly expressed in SLE in the peripheral blood of patients with CLE and to correlate the expression levels with cutaneous disease activity. METHODS Peripheral blood was obtained from 10 healthy controls and 30 patients with CLE, including eight with concomitant SLE. Total RNA was extracted and reverse transcribed into complementary DNA. Gene expression levels were measured by real-time polymerase chain reaction. Gene expression was normalized to GAPDH, standardized to healthy controls and then summed to calculate an IFN score for each patient. Disease activity was assessed with the Cutaneous Lupus Area and Severity Index (CLASI). RESULTS Patients with subacute CLE (SCLE) and discoid lupus erythematosus (DLE) had elevated IFN scores compared with healthy controls regardless of concomitant SLE (P < 0·01 with SLE and P < 0·05 without SLE). There was no difference between patients with tumid lupus erythematosus (TLE) and healthy controls. The IFN score correlated with CLASI scores (Spearman's rho = 0·55, P = 0·0017). CONCLUSIONS Patients with SCLE and DLE have an IFN signature, as seen in SLE. The level of gene expression correlates with cutaneous disease activity. These findings support a shared pathogenesis between SLE and some subtypes of CLE.
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Goreshi R, Okawa J, Rose M, Feng R, Lee LA, Hansen CB, Bangert CA, Connolly MK, Davis MD, Callen JP, Fett NM, Fakharzadeh SS, Clarke JT, Werth VP. Evaluation of reliability, validity, and responsiveness of the CDASI and the CAT-BM. J Invest Dermatol 2012; 132:1117-24. [PMID: 22217740 DOI: 10.1038/jid.2011.440] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
To properly evaluate therapies for cutaneous dermatomyositis (DM), it is essential to administer an outcome instrument that is reliable, valid, and responsive to clinical change, particularly when measuring disease activity. The purpose of this study was to compare two skin severity DM outcome measures, the Cutaneous Disease and Activity Severity Index (CDASI) and the Cutaneous Assessment Tool-Binary Method (CAT-BM), with the Physician Global Assessment (PGA) as the "gold standard". Ten dermatologists evaluated 14 patients with DM using the CDASI, CAT-BM, and PGA scales. Inter- and intra-rater reliability, validity, responsiveness, and completion time were compared for each outcome instrument. Responsiveness was assessed from a different study population, where one physician evaluated 35 patients with 110 visits. The CDASI was found to have a higher inter- and intra-rater reliability. Regarding construct validity, both the CDASI and the CAT-BM were significant predictors of the PGA scales. The CDASI had the best responsiveness among the three outcome instruments examined. The CDASI had a statistically longer completion time than the CAT-BM by about 1.5 minutes. The small patient population may limit the external validity of the findings observed. The CDASI is a better clinical tool to assess skin severity in DM.
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Piette EW, Foering KP, Chang AY, Okawa J, Ten Have TR, Feng R, Werth VP. Impact of smoking in cutaneous lupus erythematosus. ACTA ACUST UNITED AC 2011; 148:317-22. [PMID: 22105815 DOI: 10.1001/archdermatol.2011.342] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate cigarette smoking in cutaneous lupus erythematosus (CLE). DESIGN Prospective longitudinal cohort study. SETTING Urban cutaneous autoimmune disease clinic. PARTICIPANTS A total of 218 individuals with CLE or systemic lupus erythematosus and lupus nonspecific skin disease seen between January 5, 2007, and July 30, 2010. MAIN OUTCOME MEASURES Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) scores to assess disease severity and response to treatment and Skindex 29+3 scores to assess patient quality of life. RESULTS Current smokers with lupus erythematosus had higher median CLASI scores (9.5) than did never (7.0) and past (6.0) smokers with CLE (P = .02). Current smokers had higher median scores on all the Skindex 29+3 subsets. Current smokers taking hydroxychloroquine sulfate had higher quinacrine hydrochloride use than did nonsmokers (P = .04). Two to 7 months after enrollment, current smokers (median CLASI change, -3) treated with only antimalarial agents improved more than never (1) and past (0) smokers (P = .02). Eight months or more after enrollment, current smokers (CLASI change, 3.5) treated with antimalarial drugs plus at least 1 additional immunomodulator improved less than never (-1.5) and past (0) smokers (P = .04). CONCLUSIONS Current smokers with lupus erythematosus had worse disease, had worse quality of life, and were more often treated with a combination of hydroxychloroquine and quinacrine than were nonsmokers. Never and past smokers showed greater improvement when treated with antimalarial agents plus at least 1 additional immunomodulator. Current smokers had greater improvement when treated with antimalarial drugs only.
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Chang AY, Piette EW, Foering KP, Tenhave TR, Okawa J, Werth VP. Response to antimalarial agents in cutaneous lupus erythematosus: a prospective analysis. ACTA ACUST UNITED AC 2011; 147:1261-7. [PMID: 21768444 DOI: 10.1001/archdermatol.2011.191] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To demonstrate response to antimalarial agents in patients with cutaneous lupus erythematosus (CLE) using activity scores from the Cutaneous Lupus Erythematosus Disease Area and Severity Index, a validated outcome measure. DESIGN Prospective, longitudinal cohort study. SETTING University cutaneous autoimmune disease clinic. PARTICIPANTS A total of 128 patients with CLE who presented from January 2007 to July 2010 and had at least 2 visits with activity scores. INTERVENTION Administration of antimalarial agents. MAIN OUTCOME MEASURES Response was defined by a 4-point or 20% decrease in activity score. Response to initiation was determined by the difference between the scores before treatment and at the first visit at least 2 months after treatment. Response to continuation was determined by the difference between the scores at the first visit and the most recent visit while undergoing treatment. RESULTS Of 11 patients who initiated treatment with hydroxychloroquine, 55% were responders (n = 6), showing a decrease in median (interquartile range [IQR]) activity score from 8.0 (3.5-13.0) to 3.0 (1.8-7.3) (P = .03). Of 15 patients for whom hydroxychloroquine failed, 67% were responders to initiation of hydroxychloroquine-quinacrine therapy (n = 10), showing a decrease in median (IQR) activity score from 6.0 (4.8-8.3) to 3.0 (0.75-5.0) (P = .004). Nine of 21 patients who continued hydroxychloroquine treatment (43%), and 9 of 21 patients who continued hydroxychloroquine-quinacrine (43%) were responders, showing a decrease in median (IQR) activity score from 6.0 (1.5-9.5) to 1.0 (0.0-4.5) (P = .01) and 8.5 (4.25-17.5) to 5.0 (0.5-11.5) (P = .01), respectively. CONCLUSIONS The use of quinacrine with hydroxychloroquine is associated with response in patients for whom hydroxychloroquine monotherapy fails. Further reduction in disease activity can be associated with continuation of treatment with antimalarial agents.
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Goreshi R, Chock M, Foering K, Feng R, Okawa J, Rose M, Fiorentino D, Werth V. Quality of life in dermatomyositis. J Am Acad Dermatol 2011; 65:1107-16. [PMID: 21722989 DOI: 10.1016/j.jaad.2010.10.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 10/07/2010] [Accepted: 10/10/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Quality of life (QoL) for patients with inflammatory skin disease can be significant, but has been evaluated in just one study in dermatomyositis (DM). OBJECTIVE We sought to examine the relationship between the Cutaneous Dermatomyositis Area (CDASI) and Severity Index, a DM-specific cutaneous severity instrument, and various QoL study instruments and to determine the impact of DM on QoL. METHODS Skin-specific QoL instruments, the Skindex and the Dermatology Life Quality Index, and global medical QoL instruments, the Short Form 36 and the Health Assessment Questionnaire-Disability Index, were used. Pruritus was evaluated by a visual analog scale and a 0-to-10 scale in DM and cutaneous lupus erythematosus (CLE) populations, respectively. RESULTS There was a significant correlation between the CDASI and all skin-specific QoL scores (lowest P = .0377). Using the Short Form 36, DM population was found to have significantly worse QoL scores than the general population with the exception of bodily pain (all subscore P values < .01). Furthermore, DM had a significantly lower vitality score, representing energy level, compared with CLE, hypertension, diabetes, and recent myocardial infarction scores (lowest P = .003). There was a significantly lower mental health score, representing overall mood, to all compared diseases except CLE and clinical depression (P values < .01 when significant). We found that DM produces more pruritus than CLE (P < .0001). LIMITATIONS A larger patient population needs to be studied to further assess QoL in patients with DM. CONCLUSION We conclude that DM has a large impact on QoL, even when compared with other diseases, and that DM skin disease activity correlates with a poorer QoL.
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Klein R, Moghadam-Kia S, LoMonico J, Okawa J, Coley C, Taylor L, Troxel AB, Werth VP. Development of the CLASI as a tool to measure disease severity and responsiveness to therapy in cutaneous lupus erythematosus. ACTA ACUST UNITED AC 2011; 147:203-8. [PMID: 21339447 DOI: 10.1001/archdermatol.2010.435] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine how to use the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) to classify patients according to disease severity (mild, moderate, and severe) and to identify which patients respond to therapy. DESIGN Cohort. SETTING The connective-tissue disease clinic at the Hospital of the University of Pennsylvania, Philadelphia. PATIENTS Seventy-five patients with clinical or histopathologic evidence of cutaneous lupus erythematosus or systemic lupus erythematosus were included in the study. MAIN OUTCOME MEASURES The CLASI, Skindex-29, and the physician's subjective assessment of severity and improvement were completed at every visit. RESULTS Disease severity was assessed with 45 patient visits. Mild, moderate, and severe disease corresponded with CLASI activity score ranges of 0 to 9, 10 to 20, and 21 to 70, respectively. Improvement in disease activity was assessed in 74 patients. A clinical improvement was associated with a mean 3-point or 18% decrease in the CLASI activity score. However, receiver operating characteristic analysis demonstrated an increased percentage of patients correctly classified when a 4-point (sensitivity, 39%; specificity, 93%; correctly classified, 76%) or 20% (sensitivity, 46%; specificity, 78%; correctly classified, 67%) decrease in the CLASI activity score was used instead to identify improvement. CONCLUSION The CLASI can be used to classify patients into groups according to disease severity and to identify clinically significant improvements in disease activity.
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Klein R, Moghadam-Kia S, Taylor L, Coley C, Okawa J, LoMonico J, Chren MM, Werth VP. Quality of life in cutaneous lupus erythematosus. J Am Acad Dermatol 2011; 64:849-58. [PMID: 21397983 DOI: 10.1016/j.jaad.2010.02.008] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 01/25/2010] [Accepted: 02/01/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known about quality of life in patients with cutaneous lupus erythematosus. OBJECTIVE We sought to determine how cutaneous lupus affects quality of life and which independent variables are associated with poor quality of life. METHODS A total of 157 patients with cutaneous lupus completed surveys related to quality of life, including the Skindex-29 and the Short Form-36. RESULTS Quality of life in cutaneous lupus is severely impaired, particularly with respect to emotional well-being. Patients with cutaneous lupus have worse quality of life than those with other common dermatologic conditions, such as acne, nonmelanoma skin cancer, and alopecia. With respect to mental health status, patients with cutaneous lupus have similar or worse scores than patients with hypertension, type 2 diabetes mellitus, recent myocardial infarction, and congestive heart failure. Factors related to poor quality of life include female gender, generalized disease, severe disease, distribution of lesions, and younger age. LIMITATIONS The study was done at a single referral-only center. CONCLUSION Patients with cutaneous lupus have very impaired quality of life, particularly from an emotional perspective.
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Morganroth PA, Kreider ME, Okawa J, Taylor L, Werth VP. Interstitial lung disease in classic and skin-predominant dermatomyositis: a retrospective study with screening recommendations. ACTA ACUST UNITED AC 2010; 146:729-38. [PMID: 20644033 DOI: 10.1001/archdermatol.2010.134] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES (1) To determine the prevalence of interstitial lung disease (ILD) and isolated low diffusing capacity for carbon monoxide (DLCO) in a large cohort of outpatients with dermatomyositis. (2) To compare the pulmonary abnormalities of patients with classic dermatomyositis and those with skin-predominant dermatomyositis. DESIGN Retrospective cohort study. SETTING University hospital outpatient dermatology referral center. Patients Medical records of 91 outpatients with adult-onset dermatomyositis seen between May 26, 2006, and May 25, 2009, were reviewed. MAIN OUTCOME MEASURES Presence of ILD on thin-slice chest computed tomographic (CT) scans and DLCO. RESULTS Of the 71 patients with dermatomyositis who had CT or DLCO data, 16 (23%; 95% confidence interval [CI], 13%-33%) had ILD as defined by CT results [corrected]. All patients with ILD had a reduced DLCO, and the ILD prevalence was not different between patients with skin-predominant dermatomyositis (10 of 35 [29% ]) and those with classic dermatomyositis (6 of 36 [17% ]) (P = .27). Eighteen of 71 patients with dermatomyositis (25%; 95% CI, 15%-36%) (7 of 35 [20%] with skin-predominant dermatomyositis; 11 of 36 [31%] with classic dermatomyositis; P = .41) had a low DLCO in the absence of CT findings showing ILD. The prevalence of malignant disease was higher in patients with classic dermatomyositis than in those with skin-predominant dermatomyositis (P = .02), and no patients with skin-predominant dermatomyositis had internal malignant disease. CONCLUSIONS Radiologic ILD and isolated DLCO reductions, which may signify early ILD or pulmonary hypertension, are common in dermatology outpatients with both classic and skin-predominant dermatomyositis. Because DLCO testing is both inexpensive and sensitive for pulmonary disease, it may be appropriate to screen all patients with dermatomyositis with serial DLCO measurements and base further testing on DLCO results.
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Yassaee M, Fiorentino D, Okawa J, Taylor L, Coley C, Troxel AB, Werth VP. Modification of the cutaneous dermatomyositis disease area and severity index, an outcome instrument. Br J Dermatol 2009; 162:669-73. [PMID: 19863510 DOI: 10.1111/j.1365-2133.2009.09521.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Validated outcome measures in dermatology help standardize and improve patient care. A scoring system of skin disease severity in dermatomyositis known as the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) has been developed. OBJECTIVES To simplify and improve the tool for clinical research and care, we modified the CDASI and validated the new version, v2. METHODS The original CDASI has four activity and two damage measures. The modified CDASI has three activity and two damage measures. The skin disease of 20 patients with dermatomyositis was evaluated by the same dermatologist using both the original and the modified CDASI. Global validation measures were implemented to assess overall skin disease state, skin disease activity and skin damage. Spearman's rho (r(sp)), adjusted for multiple observations on subjects, was used to determine the relationship between the two versions of the CDASI and their correlation with the physician global measures (PGMs). RESULTS The total score and activity and damage subscores of the original and the modified CDASI correlated perfectly with each other (r(sp) = 0.99, 1.00, 1.00). The PGM-overall skin scale correlated with the total scores (r(sp) = 0.72, r(sp) = 0.76) and activity subscores (r(sp) = 0.68, r(sp) = 0.63) but not with the damage subscores (r(sp) = 0.14, r(sp) = 0.15) of the original and the modified CDASI, respectively. However, the PGM-activity and PGM-damage scales correlated with the activity (r(sp) = 0.76, r(sp) = 0.75) and damage subscores (r(sp) = 0.90, r(sp) = 0.90), respectively, of the original and the modified CDASI. CONCLUSIONS The modified CDASI is perfectly correlated with the original CDASI. It has equally good concurrent validity with the PGM-overall skin and PGM-activity scales. The CDASI subscores have equally good concurrent validity with the PGM-activity and PGM-damage scales. We suggest that PGMs of skin disease activity and damage should be assessed separately for greater specificity. The modified CDASI is a refined and equally as useful outcome measure.
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Moghadam-Kia S, Chilek K, Gaines E, Costner M, Rose ME, Okawa J, Werth VP. Cross-sectional analysis of a collaborative Web-based database for lupus erythematosus-associated skin lesions: prospective enrollment of 114 patients. ACTA ACUST UNITED AC 2009; 145:255-60. [PMID: 19289753 DOI: 10.1001/archdermatol.2008.594] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To assess disease severity in subsets of patients with cutaneous lupus erythematosus (CLE) by using outcome and quality-of-life measures, and to determine treatment responsiveness by establishing a Web-based database of patients with skin manifestations of lupus. DESIGN Prospective, cross-sectional study. SETTING University hospital cutaneous autoimmunity outpatient clinic. PATIENTS One hundred fourteen patients who presented from January 15, 2007, to November 8, 2007, and met the criteria for having CLE or lupus-nonspecific skin disease. MAIN OUTCOME MEASURES Scores on the CLE Disease Activity and Severity Index and the modified Skindex-29 (a quality-of-life measure) completed at each visit. RESULTS Seven patients (6.1%) presented with acute CLE, 21 (18.4%) with subacute CLE, 77 (67.5%) with chronic CLE, 7 (6.1%) with systemic lupus erythematosus and LE-nonspecific skin lesions, and 1 (0.9%) with LE-nonspecific skin disease only. The mean baseline CLE Disease Activity and Severity Index activity/damage scores in patients with acute, subacute, and chronic CLE were 6.4/5.1, 11.1/1.6, and 7.5/10.2, respectively. The mean baseline modified Skindex-29 scores were 76.3, 79.4, and 82.7, respectively (P = .80). The disease in 11 of the patients (9.6%) was considered refractory to conventional therapies. Significantly more patients in the refractory group than the nonrefractory group were current smokers (P = .006). CONCLUSION This Web-based database should allow collection of data related to disease activity, quality of life, and response to therapy at multiple centers.
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Shah A, Albrecht J, Bonilla-Martinez Z, Okawa J, Rose M, Rosenbach M, Werth VP. Lenalidomide for the treatment of resistant discoid lupus erythematosus. ACTA ACUST UNITED AC 2009; 145:303-6. [PMID: 19289762 DOI: 10.1001/archdermatol.2009.30] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Discoid lupus erythematosus (DLE) is a chronic, disfiguring disease that is characterized by scaly, erythematous, disk-shaped patches and plaques followed by atrophy, scarring, and dyspigmentation. It is refractory to standard therapies in a small population of patients. We investigated the use of lenalidomide, a thalidomide analogue, as a novel alternative therapy in 2 cases of refractory DLE and report our results. OBSERVATIONS Two patients with chronic, severe DLE were treated with low-dose lenalidomide. Improvement was noted within 1 month at a dosage of 5 mg/d in one case and was maintained for 10 months before the dosage was doubled to 10 mg/d for 12 months because of a slight worsening of symptoms. Clinical improvement was demonstrated by a sustained reduction in the Cutaneous Lupus Erythematosus Disease Area and Severity Index activity score, with no change in the Cutaneous Lupus Erythematosus Disease Area and Severity Index damage score. Within 5 months, oral prednisone therapy (60 mg/d) was tapered and discontinued; it was restarted at a low dosage (5 mg/d), however, to manage the symptoms of systemic LE. Of note, the patient experienced mild neutropenia after taking 10 mg/d of lenalidomide, which carries a black box warning regarding neutropenia; therefore, the complete blood cell count should be monitored weekly for the first 2 months and then monthly thereafter. The second case failed to show clinical improvement, and lenalidomide therapy was discontinued after 6 months. CONCLUSIONS Lenalidomide therapy is a potential alternative or adjunctive treatment for patients with severe, chronic DLE that is refractory to standard therapies. A larger study is needed to clarify its role in the treatment of DLE and other forms of cutaneous LE.
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