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Gao JL, Streed CG, Thompson J, Dommasch ED, Peebles JK. Androgenetic alopecia in transgender and gender diverse populations: A review of therapeutics. J Am Acad Dermatol 2023; 89:774-783. [PMID: 34756934 DOI: 10.1016/j.jaad.2021.08.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/14/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
Androgenetic alopecia (AGA) management is a significant clinical and therapeutic challenge for transgender and gender-diverse (TGD) patients. Although gender-affirming hormone therapies affect hair growth, there is little research about AGA in TGD populations. After reviewing the literature on approved treatments, off-label medication usages, and procedures for treating AGA, we present treatment options for AGA in TGD patients. The first-line treatments for any TGD patient include topical minoxidil 5% applied to the scalp once or twice daily, finasteride 1 mg oral daily, and/or low-level laser light therapy. Spironolactone 200 mg daily is also first-line for transfeminine patients. Second-line options include daily oral minoxidil dosed at 1.25 or 2.5 mg for transfeminine and transmasculine patients, respectively. Topical finasteride 0.25% monotherapy or in combination with minoxidil 2% solution are second-line options for transmasculine and transfeminine patients, respectively. Other second-line treatments for any TGD patient include oral dutasteride 0.5 mg daily, platelet-rich plasma, or hair restoration procedures. After 6-12 months of treatment, AGA severity and treatment progress should be assessed via scales not based on sex; eg, the Basic and Specific Classification or the Bouhanna scales. Dermatologists should coordinate care with the patient's primary gender-affirming clinician(s) so that shared knowledge of all medications exists across the care team.
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Affiliation(s)
- Julia L Gao
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; George Washington University School of Medicine & Health Sciences, Washington, District of Columbia.
| | - Carl G Streed
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts; Center for Transgender Medicine and Surgery, Boston Medical Center, Boston, Massachusetts
| | | | - Erica D Dommasch
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jon Klinton Peebles
- Department of Dermatology, Kaiser-Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland
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2
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Gao JL, Sanz J, Tan N, King DS, Modest AM, Dommasch ED. Androgenetic alopecia incidence in transgender and gender diverse populations: A retrospective comparative cohort study. J Am Acad Dermatol 2023; 89:504-510. [PMID: 36780950 DOI: 10.1016/j.jaad.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/30/2022] [Accepted: 01/23/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Androgenetic alopecia (AGA) is a significant challenge for many transgender and gender diverse (TGD) patients, but the rate of AGA among TGD patients receiving gender-affirming hormone therapy (GAHT) compared to cisgender patients has not yet been studied on a large scale. OBJECTIVE We examined the incidence of AGA among TGD patients receiving GAHT compared to cisgender patients. METHODS Retrospective cohort study using electronic health records from 37,826 patients seen at Fenway Health between August 1, 2014, and August 1, 2020. Crude and adjusted incidence rate ratios (aIRR) for AGA were calculated using Poisson regression. RESULTS TGD patients receiving masculinizing GAHT had aIRR 2.50, 95% CI 1.71-3.65 and 1.30, 95% CI 0.91-1.86 compared to cisgender women and cisgender men, respectively. The rate of AGA for TGD patients receiving feminizing GAHT was not significantly different compared to cisgender men but was significantly increased compared to cisgender women (aIRR 1.91, 95% CI 1.25-2.92). LIMITATIONS Inability to determine causation and limited generalizability. CONCLUSION TGD patients receiving masculinizing GAHT have 2.5 times the rate of AGA compared to cisgender women, whereas TGD patients on feminizing GAHT did not have a significantly increased rate of AGA compared to cisgender men.
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Affiliation(s)
- Julia L Gao
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Dartmouth Health, Lebanon, New Hampshire; George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Jessika Sanz
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; New York Institute College of Osteopathic Medicine, Jonesboro, Arkansas
| | - Nicholas Tan
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Case Western University School of Medicine, Cleveland, Ohio
| | - Dana S King
- Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Erica D Dommasch
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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3
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Sanz J, Gao JL, King DS, Modest AM, Dommasch ED. Prevalence of rosacea in transgender and gender-diverse populations: a retrospective cohort study. Br J Dermatol 2023; 188:304-306. [PMID: 36763873 DOI: 10.1093/bjd/ljac041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 09/26/2022] [Accepted: 10/24/2022] [Indexed: 01/22/2023]
Abstract
Hormones have been shown to affect the pathophysiology of rosacea, however, the prevalence of rosacea in transgender and gender diverse (TGD) patients on gender affirming hormone therapy (GAHT) has never been studied. Our retrospective cohort study showed a significantly decreased prevalence TGD patients on feminizing GAHT compared to cisgender men, women, and TGD not on GAHT. Our results suggest that estrogen and/or anti-androgenetic agents may play a protective role in the development or course of rosacea.
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Affiliation(s)
- Jessika Sanz
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- New York Institute College of Osteopathic Medicine, Jonesboro, AR, USA
| | - Julia L Gao
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Dana S King
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA and
- Harvard Medical School, Boston, MA, USA
| | - Erica D Dommasch
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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4
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Gao JL, King DS, Modest AM, Dommasch ED. Acne risk in transgender and gender diverse populations: A retrospective, comparative cohort study. J Am Acad Dermatol 2022; 87:1198-1200. [PMID: 35283245 DOI: 10.1016/j.jaad.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/03/2022] [Accepted: 03/03/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Julia L Gao
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; George Washington University School of Medicine & Health Sciences, Washington, District of Columbia.
| | - Dana S King
- Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Erica D Dommasch
- Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Thoreson N, Grasso C, Potter J, King DS, Peebles JK, Dommasch ED. Incidence and Factors Associated With Androgenetic Alopecia Among Transgender and Gender-Diverse Patients Treated With Masculinizing Hormone Therapy. JAMA Dermatol 2021; 157:348-349. [PMID: 33566078 DOI: 10.1001/jamadermatol.2020.5475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nick Thoreson
- Boston University School of Medicine, Boston, Massachusetts.,The Fenway Institute, Fenway Health, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Dermatology, Boston, Massachusetts
| | - Chris Grasso
- The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Jennifer Potter
- The Fenway Institute, Fenway Health, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Dana S King
- The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - J Klint Peebles
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Department of Dermatology, Rockville, Maryland
| | - Erica D Dommasch
- The Fenway Institute, Fenway Health, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Dermatology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Thoreson N, Park JA, Grasso C, Potter J, King DS, Marc LG, Shen C, Peebles JK, Dommasch ED. Incidence and Factors Associated With Acne Among Transgender Patients Receiving Masculinizing Hormone Therapy. JAMA Dermatol 2021; 157:290-295. [PMID: 33471082 DOI: 10.1001/jamadermatol.2020.5347] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Acne is a common condition among transgender patients receiving masculinizing hormone therapy (MHT), but the incident risk and predictors of developing acne in this population have not yet been studied on a large scale. Objective To assess risk of acne among a large population of transgender patients receiving MHT and clinical risk factors for acne diagnosis. Design, Setting, and Participants A retrospective cohort study that included 988 patients who started MHT between January 1, 2014, and December 31, 2017, with at least 1 year of follow-up was performed. Data analysis was conducted from September 1 to 15, 2019. Data were obtained using electronic health records from a community health center serving the sexual and gender minority community. The population included every patient who began receiving MHT during the study period who was aged 18 years or older at the time of MHT initiation and whose assigned sex at birth was female. Main Outcomes and Measures The main outcome was acne defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes for acne. Overall prevalence and incidence proportions over 2 years after initiation of MHT were calculated. Baseline demographic and clinical characteristics were collected at the time of MHT initiation. A series of univariate analyses for all factors was calculated to test for an association with acne diagnosis, followed by multivariate analyses to test for independent predictors. Results For 988 patients (median age, 25.8 years; interquartile range, 20.8-28.2 years), there was an overall acne prevalence of 31.1% (n = 307). The 1-year post-MHT acne incidence proportion was 19.0% and the 2-year incidence proportion was 25.1%. A younger age at MHT initiation was associated with a higher likelihood of developing acne, with a median of 22.4 years (interquartile range, 19.7-25.6 years) among patients who developed acne vs 24.7 years (interquartile range, 21.3-29.4 years) among patients who did not (P = .002). Conclusions and Relevance Acne is a common condition among transgender patients on MHT, with a prevalence increasing from 6.3% to 31.1% following MHT initiation. Patients aged 18 to 21 years appear to be the most likely to develop acne after MHT initiation.
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Affiliation(s)
- Nick Thoreson
- Medical student, Boston University School of Medicine, Boston, Massachusetts.,The Fenway Institute, Fenway Health, Boston, Massachusetts.,Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jason A Park
- Medical student, Boston University School of Medicine, Boston, Massachusetts.,The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Chris Grasso
- The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Jennifer Potter
- The Fenway Institute, Fenway Health, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Dana S King
- The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Linda G Marc
- The Fenway Institute, Fenway Health, Boston, Massachusetts.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Changyu Shen
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - J Klint Peebles
- Department of Dermatology, Kaiser-Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland
| | - Erica D Dommasch
- The Fenway Institute, Fenway Health, Boston, Massachusetts.,Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Gelfand JM, Armstrong AW, Bell S, Anesi GL, Blauvelt A, Calabrese C, Dommasch ED, Feldman SR, Gladman D, Kircik L, Lebwohl M, Lo Re V, Martin G, Merola JF, Scher JU, Schwartzman S, Treat JR, Van Voorhees AS, Ellebrecht CT, Fenner J, Ocon A, Syed MN, Weinstein EJ, Gondo G, Heydon S, Koons S, Ritchlin CT. National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: Version 2-Advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments. J Am Acad Dermatol 2021; 84:1254-1268. [PMID: 33422626 PMCID: PMC7788316 DOI: 10.1016/j.jaad.2020.12.058] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To update guidance regarding the management of psoriatic disease during the COVID-19 pandemic. STUDY DESIGN The task force (TF) includes 18 physician voting members with expertise in dermatology, rheumatology, epidemiology, infectious diseases, and critical care. The TF was supplemented by nonvoting members, which included fellows and National Psoriasis Foundation staff. Clinical questions relevant to the psoriatic disease community were informed by inquiries received by the National Psoriasis Foundation. A Delphi process was conducted. RESULTS The TF updated evidence for the original 22 statements and added 5 new recommendations. The average of the votes was within the category of agreement for all statements, 13 with high consensus and 14 with moderate consensus. LIMITATIONS The evidence behind many guidance statements is variable in quality and/or quantity. CONCLUSIONS These statements provide guidance for the treatment of patients with psoriatic disease on topics including how the disease and its treatments affect COVID-19 risk, how medical care can be optimized during the pandemic, what patients should do to lower their risk of getting infected with severe acute respiratory syndrome coronavirus 2 (including novel vaccination), and what they should do if they develop COVID-19. The guidance is a living document that is continuously updated by the TF as data emerge.
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Affiliation(s)
- Joel M Gelfand
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics and Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - April W Armstrong
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Stacie Bell
- National Psoriasis Foundation, Portland, Oregon
| | - George L Anesi
- Department of Biostatistics, Epidemiology and Informatics and Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Cassandra Calabrese
- Department of Rheumatology and Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Erica D Dommasch
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Steven R Feldman
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dafna Gladman
- Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada; University of Toronto, Psoriatic Arthritis Program, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Leon Kircik
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York; Indiana University Medical Center, Indianapolis, Indiana
| | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology and Informatics and Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Joseph F Merola
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jose U Scher
- Department of Medicine, Division of Rheumatology, New York University Grossman School of Medicine and New York University Langone Orthopedic Hospital, New York, New York
| | - Sergio Schwartzman
- Department of Rheumatology, Hospital for Special Surgery, New York, New York
| | - James R Treat
- Department of Pediatric Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Abby S Van Voorhees
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Christoph T Ellebrecht
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Justine Fenner
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anthony Ocon
- Division of Allergy, Immunology, and Rheumatology Division, University of Rochester Medical Center, Rochester, New York
| | - Maha N Syed
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Erica J Weinstein
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Sue Heydon
- National Psoriasis Foundation, Portland, Oregon
| | | | - Christopher T Ritchlin
- Division of Allergy, Immunology, and Rheumatology Division, University of Rochester Medical Center, Rochester, New York
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Gelfand JM, Dommasch ED, Mehta NN. Association Between Early Severe Cardiovascular Events and Ustekinumab Treatment? JAMA Dermatol 2021; 157:123. [PMID: 33201213 DOI: 10.1001/jamadermatol.2020.4456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joel M Gelfand
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Erica D Dommasch
- Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nehal N Mehta
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung and Blood Institute, Bethesda, Maryland
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9
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Gao JL, Thoreson N, Dommasch ED. Navigating iPLEDGE enrollment for transgender and gender-diverse patients: A guide for providing culturally competent care. J Am Acad Dermatol 2021; 85:790-791. [PMID: 33482255 DOI: 10.1016/j.jaad.2021.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Julia L Gao
- The Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
| | - Nick Thoreson
- The Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Boston University School of Medicine, Boston, Massachusetts
| | - Erica D Dommasch
- The Fenway Institute, Fenway Health, Boston, Massachusetts; Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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10
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Dommasch ED, Kim SC, Lee MP, Gagne JJ. Risk of Serious Infection in Patients Receiving Systemic Medications for the Treatment of Psoriasis. JAMA Dermatol 2019; 155:1142-1152. [PMID: 31075163 DOI: 10.1001/jamadermatol.2019.1121] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance There is a need for better understanding of the comparative safety of systemic medications used in the treatment of psoriasis. Objective To compare the risk of serious infection associated with biologic and nonbiologic systemic medications in patients with psoriasis. Design, Setting, and Participants An observational cohort study was conducted using medical and outpatient pharmacy claims from 2 large US health insurance claims databases from January 1, 2003, through September 30, 2015. We included patients with a diagnosis of psoriasis who were new users of systemic medications for psoriasis. Exposures Prescription claims for acitretin, adalimumab, apremilast, etanercept, infliximab, methotrexate, or ustekinumab. Main Outcomes and Measures The primary outcome was serious infection, defined by inpatient discharge diagnosis International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Cox proportional hazards regression was used to compare rates of serious infection for each exposure (acitretin, adalimumab, apremilast, etanercept, infliximab, and ustekinumab) with the referent group (methotrexate). We used pairwise 1:1 propensity score (PS) matching to adjust for potential confounders, which were assessed during a 180-day baseline period prior to study drug initiation. Results from the 2 databases were pooled via fixed-effects analysis. Results The databases included 31 595 patients in the Optum Clinformatics Data Mart and 76 112 patients in Truven MarketScan who were new users of acitretin, adalimumab, apremilast, etanercept, infliximab, methotrexate, and ustekinumab. Users of acitretin, apremilast, infliximab, and methotrexate were older and had higher baseline comorbidity scores than subcutaneous biologic users (adalimumab, etanercept, and ustekinumab). The pooled PS-matched analysis yielded a decreased rate of overall serious infection in users of apremilast (hazard ratio [HR], 0.50; 95% CI, 0.26-0.94), etanercept (HR, 0.75; 95% CI, 0.61-0.93), and ustekinumab (HR, 0.65; 95% CI, 0.47-0.89) compared with methotrexate. We did not find a different rate of overall serious infection among users of acitretin, adalimumab, and infliximab compared with methotrexate. Subanalysis by type of serious infection showed a significantly increased risk of cellulitis among users of acitretin compared with methotrexate (PS-adjusted HR, 1.76; 95% CI, 1.11-2.80). Conclusions and Relevance Among patients with psoriasis treated with systemic medications in 2 large US claims databases, new users of apremilast, etanercept, and ustekinumab had a decreased rate of serious infection compared with methotrexate.
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Affiliation(s)
- Erica D Dommasch
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Seoyoung C Kim
- Harvard Medical School, Boston, Massachusetts.,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Moa P Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Joshua J Gagne
- Harvard Medical School, Boston, Massachusetts.,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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11
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Wan MT, Alvarez J, Shin DB, Dommasch ED, Wu JJ, Gelfand JM. Head-to-head trials of systemic psoriasis therapies: a systematic review of study design and maximum acceptable treatment differences. J Eur Acad Dermatol Venereol 2018; 33:42-55. [PMID: 29989662 DOI: 10.1111/jdv.15174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/28/2018] [Indexed: 11/26/2022]
Abstract
There is increasing use of head-to-head clinical trials in dermatology when establishing the efficacy of a new treatment. Active comparator trials (ACTs) can be classified into three distinct study trial designs: non-inferiority, equivalence and superiority. A better understanding of the statistical parameters, such as acceptable treatment differences (also known as the margin or delta), is necessary to properly design and interpret findings of active comparator trials (ACTs) in the field of dermatology. Therefore, the objective of this study was to summarize the maximum acceptable treatment differences in clinical trials that examine the efficacy of an oral or biologic psoriasis therapy with an active comparator. We conducted a systematic search using MEDLINE, Scopus, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Web of Science and ClinicalTrials.gov from inception to 31 August 2017. All ACTs with adult participants that had a primary outcome of the Psoriasis Area and Severity Index score were included. Bibliographies of articles were further reviewed. Two investigators independently assessed for article inclusion and separately completed data extraction of predefined data points. When there was a disagreement, a third investigator was consulted. Of the 49 ACTs included, there were 13 superiority, eight non-inferiority and seven equivalence trials. Another 21 studies had inadequate information for classification. All of the non-inferiority trials reported the margin, one of the superiority and six of the equivalence trials stated the treatment difference explicitly. For superiority trials, acceptable treatment differences ranged from 14% to 20%. The non-inferiority studies reported lower bound margins ranging from -20% to -10%. The equivalence trials reported upper and lower bound margins ranging from ±12.5% to ±18%. The results demonstrate the need for harmonization in the conduct of dermatological clinical trials and in the approaches of reporting research parameters.
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Affiliation(s)
- M T Wan
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - J Alvarez
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - D B Shin
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - E D Dommasch
- Department of Dermatology and Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - J J Wu
- Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - J M Gelfand
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Thomas C, Dommasch ED. Reticular rash on the lower extremities. JAAD Case Rep 2018; 4:509-511. [PMID: 30023413 PMCID: PMC6047215 DOI: 10.1016/j.jdcr.2017.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Importance The effect of vaccination on emergency department (ED) utilization for herpes zoster (HZ) has not been examined to date. Objective To determine trends in US ED utilization and costs associated with HZ. Design, Setting, and Participants The Nationwide Emergency Department Sample data set was examined for temporal trends in the number of visits and costs for treatment of HZ in EDs in the United States from January 1, 2006, through December 31, 2013. Cases of HZ were identified using validated International Classification of Diseases, Ninth Revision-Clinical Modification diagnosis codes. Patients were stratified by age: less than 20 years (varicella vaccine recommended), 20 to 59 years (no vaccine recommended), and 60 years or older (HZ vaccine recommended). Population-based rates were estimated using sampling weights. Main Outcomes and Measures Population-based incidence rates of HZ-related ED visits, charge for ED services, and total charges. Results A total of 1 350 957 ED visits for HZ were identified between 2006 and 2013, representing 0.13% of all US ED visits. Of these patients, 563 200 (51.7%) were male; mean (SE) age was 54.0 (0.1) years. Between 2006 and 2013, the percentage of HZ-related ED visits increased from 0.13% to 0.14% (8.3%). This growth was driven by patients aged 20 to 59 years (increase of 22.8% [from 0.12% to 0.14% of ED visits]) while the proportion of ED HZ visits decreased for patients aged less than 20 years and 60 years or older, from 0.03% to 0.02% (-39.6%) and from 0.28% to 0.25% (-10.9%), respectively. For all age groups, there was an increase from 2006 to 2013 in overall adjusted total (from $92.83 to $202.47 million) and mean charges (from $763 to $1262) for HZ-related ED visits. Conclusions and Relevance The number of ED visits and total cost associated with HZ increased between 2006 and 2013. Greater use was driven by an increased number of visits by patients aged 20 to 59 years, but populations recommended for vaccination (<20 and ≥60 years) demonstrated decreased ED utilization. Per-visit and total costs increased across all age groups. Vaccination may be associated with a reduction of ED utilization. Further research is required to confirm these results and examine the drivers of increased ED costs.
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Affiliation(s)
- Erica D Dommasch
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Cara J Joyce
- Department of Public Health Sciences, Loyola University, Chicago, Illinois
| | - Arash Mostaghimi
- Harvard Medical School, Boston, Massachusetts.,Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
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Dommasch ED, Li T, Okereke OI, Li Y, Qureshi AA, Cho E. Risk of depression in women with psoriasis: a cohort study. Br J Dermatol 2015; 173:975-80. [PMID: 26186277 DOI: 10.1111/bjd.14032] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Psoriasis is a common, chronic and inflammatory disease of the skin, which has been associated with depression in cross-sectional studies with limited adjustment for confounders. OBJECTIVES In this prospective cohort study, we investigated the risk of incident depression among individuals with psoriasis and psoriatic arthritis (PsA). METHODS We included 50 750 US female nurses from the Nurses' Health Study who were free of depression at baseline in 2000. Those participants who had ever self-reported clinician-diagnosed depression or regular use of antidepressants, or had a Mental Health Inventory score of ≤ 52 were excluded. In 2008, we retrospectively asked participants if they had ever received a physician's diagnosis of psoriasis or PsA. We defined depression as self-report of clinician-diagnosed depression or regular use of antidepressant medication. Time-dependent Cox proportional hazard models were used to estimate age and multivariate-adjusted relative risks (RRs) of clinical depression. RESULTS After adjusting for covariates including body mass index, physical activity, smoking and the presence of major chronic conditions, the multivariate-adjusted RRs of clinical depression were 1·29 [95% confidence interval (CI) 1·10-1·52] for women with psoriasis and 1·52 (95% CI 1·06-2·19) for women with psoriasis and concomitant PsA, compared with women without psoriasis. CONCLUSIONS We found an increased risk of depression in US women with psoriasis compared with those without psoriasis. This risk was higher in those who reported concomitant PsA. Future studies are needed to confirm these findings in other populations and to identify pathophysiological mechanisms linking psoriasis to depression.
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Affiliation(s)
- E D Dommasch
- Department of Dermatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, U.S.A
| | - T Li
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - O I Okereke
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A.,Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Y Li
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A
| | - A A Qureshi
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A.,Department of Epidemiology, Brown School of Public Health, Providence, RI, U.S.A.,Department of Dermatology, Warren Alpert Medical School, Brown University, Providence, RI, U.S.A
| | - E Cho
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A.,Department of Epidemiology, Brown School of Public Health, Providence, RI, U.S.A.,Department of Dermatology, Warren Alpert Medical School, Brown University, Providence, RI, U.S.A
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Dommasch ED, Troxel AB, Gelfand JM. Counterpoint: A tale of two meta-analyses revisited. J Am Acad Dermatol 2014; 70:381-3. [PMID: 24438955 DOI: 10.1016/j.jaad.2013.10.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/21/2013] [Indexed: 01/12/2023]
Affiliation(s)
| | - Andrea B Troxel
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel M Gelfand
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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Dommasch ED, Troxel AB, Gelfand JM. Major cardiovascular events associated with anti-IL 12/23 agents: a tale of two meta-analyses. J Am Acad Dermatol 2013; 68:863-5. [PMID: 23602173 DOI: 10.1016/j.jaad.2013.01.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 01/14/2013] [Accepted: 01/17/2013] [Indexed: 01/14/2023]
Affiliation(s)
- Erica D Dommasch
- Department of Dermatology, Boston University, Boston, Massachusetts, USA.
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Dommasch ED, Abuabara K, Shin DB, Nguyen J, Troxel AB, Gelfand JM. The risk of infection and malignancy with tumor necrosis factor antagonists in adults with psoriatic disease: a systematic review and meta-analysis of randomized controlled trials. J Am Acad Dermatol 2011; 64:1035-50. [PMID: 21315483 DOI: 10.1016/j.jaad.2010.09.734] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 09/19/2010] [Accepted: 09/21/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is a need to better understand the safety of tumor necrosis factor (TNF) inhibitors in patients with psoriatic disease in whom TNF inhibitors are frequently used as monotherapy. OBJECTIVE We sought to examine the risks of infection and malignancy with the use of TNF antagonists in adult patients with psoriatic disease. METHODS We conducted a systematic search for trials of TNF antagonists for adults with plaque psoriasis and psoriatic arthritis. We included randomized, placebo-controlled trials of etanercept, infliximab, adalimumab, golimumab, and certolizumab for the treatment of plaque psoriasis and psoriatic arthritis. Twenty of 820 identified studies with a total of 6810 patients were included. Results were calculated using fixed effects models and reported as pooled odds ratios. RESULTS Odds ratios for overall infection and serious infection over a mean of 17.8 weeks were 1.18 (95% confidence interval [CI] 1.05-1.33) and 0.70 (95% CI 0.40-1.21), respectively. When adjusting for patient-years, the incidence rate ratio for overall infection was 1.01 (95% CI 0.92-1.11). The odds ratio for malignancy was 1.48 (95% CI 0.71-3.09) and 1.26 (95% CI 0.39-4.15) when nonmelanoma skin cancer was excluded. LIMITATIONS Short duration of follow-up and rarity of malignancies and serious infections are limitations. CONCLUSIONS There is a small increased risk of overall infection with the short-term use of TNF antagonists for psoriasis that may be attributable to differences in follow-up time between treatment and placebo groups. There was no evidence of an increased risk of serious infection and a statistically significant increased risk in cancer was not observed with short-term use of TNF inhibitors.
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Affiliation(s)
- Erica D Dommasch
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Dommasch ED, Shin DB, Troxel AB, Margolis DJ, Gelfand JM. Reliability, validity and responsiveness to change of the Patient Report of Extent of Psoriasis Involvement (PREPI) for measuring body surface area affected by psoriasis. Br J Dermatol 2009; 162:835-42. [PMID: 19906216 DOI: 10.1111/j.1365-2133.2009.09589.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The development of a simple, reliable, valid and responsive method for measuring the extent of skin involvement in psoriasis is important for use in epidemiological studies. OBJECTIVES We sought to investigate the psychometric characteristics of the Patient Report of Extent of Psoriasis Involvement (PREPI), a single-question method for measuring body surface area affected by psoriasis. METHODS This was a cross-sectional study of 140 patients with psoriasis, with an exploratory prospective longitudinal cohort component. Reliability was measured via a test-retest approach and criterion validity was investigated by comparing the PREPI with an assessment of body surface area of involvement by a dermatologist. We additionally compared Skindex-29 scores with the PREPI. To demonstrate responsiveness and establish a minimally important difference in the PREPI, we created receiver operating characteristic curves for the PREPI instrument. RESULTS The test-retest reliability of the PREPI was nearly perfect [intraclass correlation coefficient (ICC) = 0.99, 95% confidence interval (CI) 0.97-0.99], and there was substantial agreement between patient and physician assessments (ICC = 0.82, 95% CI 0.75-0.87). The PREPI showed significant correlations with all Skindex-29 domains. We found the PREPI to be responsive to change and identified changes in the PREPI score that have good discrimination between patients with and without a minimally important clinical difference. CONCLUSIONS Our study suggests that the PREPI is a reliable, valid and responsive measure of body surface area affected by psoriasis that may be useful for future epidemiological research.
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Affiliation(s)
- E D Dommasch
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA 19104, USA
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Gelfand JM, Dommasch ED, Shin DB, Azfar RS, Kurd SK, Wang X, Troxel AB. The risk of stroke in patients with psoriasis. J Invest Dermatol 2009; 129:2411-8. [PMID: 19458634 DOI: 10.1038/jid.2009.112] [Citation(s) in RCA: 401] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Psoriasis is a chronic Th-1 and Th-17 inflammatory disease. Chronic inflammation has also been associated with atherosclerosis and thrombosis. The purpose of this study was to determine the risk of stroke in patients with psoriasis. We conducted a population-based cohort study of patients seen by general practitioners participating in the General Practice Research Database in the United Kingdom, 1987-2002. Mild psoriasis was defined as any patient with a diagnostic code of psoriasis, but no history of systemic therapy. Severe psoriasis was defined as any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis. The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code. When adjusting for major risk factors for stroke, both mild (hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.0-1.1) and severe (1.43, 95% CI 1.1-1.9) psoriasis were independent risk factors for stroke. The excess risk of stroke attributable to psoriasis in patients with mild and severe disease was 1 in 4,115 per year and 1 in 530 per year, respectively. Patients with psoriasis, particularly if severe, have an increased risk of stroke that is not explained by major stroke risk factors identified in routine medical care.
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Affiliation(s)
- Joel M Gelfand
- Department of Dermatology, University of Pennsylvania School of Medicine, Pennsylvania, PA 19104, USA.
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