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Murrell DF, Patsatsi A, Stavropoulos P, Baum S, Zeeli T, Kern JS, Sinclair R, Neale A, Arora P, Sugerman PB, Shi G, Werth VP, Caux F, Joly P. Phase 2 BELIEVE study part B: Efficacy and safety of rilzabrutinib for patients with pemphigus vulgaris. J Eur Acad Dermatol Venereol 2022; 36. [PMID: 35686647 DOI: 10.1111/jdv.18318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- D F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales Faculty of Medicine, Sydney, Australia
| | - A Patsatsi
- 2nd Dermatology Department, Aristotle University Faculty of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - P Stavropoulos
- 1st Department of Dermatology, National and Kapodistrian University, School of Medicine, Athens, Greece
| | - S Baum
- Department of Dermatology, Sheba Medical Center, Ramat Gan, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T Zeeli
- Department of Dermatology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J S Kern
- Dermatology Department, The Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria, Australia
| | - R Sinclair
- University of Melbourne and Sinclair Dermatology, Victoria, Australia
| | - A Neale
- Principia Biopharma Inc, a Sanofi Company, South San Francisco, California, United States
| | - P Arora
- Principia Biopharma Inc, a Sanofi Company, South San Francisco, California, United States
| | - P B Sugerman
- Global Medical Affairs, Sanofi Genzyme, Cambridge, Massachusetts, United States
| | - G Shi
- Biostatistics, Sanofi US Services Inc., Bridgewater, New Jersey, United States
| | - V P Werth
- University of Pennsylvania Perelman School of Medicine and Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, United States
| | - F Caux
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-, HP, Bobigny, France
| | - P Joly
- Department of Dermatology, Rouen University Hospital, Centre de Référence des Maladies Bulleuses Autoimmunes, and INSERM U1234, Normandie University, Rouen, France
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Aggarwal R, Lundberg IE, Song YW, Shaibani A, Werth VP, Maldonado MA. POS0839 RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL TO EVALUATE EFFICACY AND SAFETY OF SC ABATACEPT IN ADULTS WITH ACTIVE IDIOPATHIC INFLAMMATORY MYOPATHY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundLimited therapies are available for patients with idiopathic inflammatory myopathy (IIM), a heterogenous group of chronic, systemic, autoimmune inflammatory diseases characterized by progressive muscle weakness and/or distinct skin rashes.1 Abatacept, a selective co-stimulation modulator, may be a useful treatment option.2ObjectivesTo evaluate efficacy, safety, and tolerability of abatacept + standard of care (SOC) in patients with IIM compared with SOC alone (placebo).MethodsA 24-week, randomized, double-blind, placebo-controlled phase 3 trial of SC abatacept (125 mg weekly) + SOC (corticosteroids and immunosuppressants alone or combined; NCT02971683) in patients with active, treatment-refractory IIM (Manual Muscle Testing-8 [MMT-8] ≤ 135) was performed. Primary endpoint was proportion of patients meeting International Myositis Assessment and Clinical Studies definition of improvement (IMACS DOI) at week 24. Change from baseline in myositis Functional Index-2 (FI-2), HAQ-DI, Myositis Disease Activity Assessment Tool (MDAAT), and Myositis Response Criteria (MRC) were secondary endpoints with safety. Post hoc analyses by disease subtype were performed.ResultsOverall, 148 patients were randomized (75 abatacept; 73 placebo); IIM subtypes were dermatomyositis (DM; 53.3% vs 57.5%), polymyositis (PM; 25.3% vs 34.2%), and autoimmune necrotizing myopathy (ANM; 21.3% vs 8.2%). Mean baseline MMT-8 and HAQ-DI scores were 112.7 and 1.5, respectively. Approximately 90% of patients completed week 24. Week 24 IMACS DOI rates were abatacept 56.0% vs placebo 42.5% (adjusted odds ratio, 1.8 [95% CI, 0.9–3.5]; P = 0.083). Pre-specified IMACS DOI analysis showed no differences for patients with DM but notable benefit for those with non-DM subtypes, PM and ANM (Table 1). Secondary endpoints showed similar differences (Table 1). MRC at day 169 by category is shown in Figure 1. Proportion of AEs (69.3% and 75.3%) and serious AEs (5.3% and 5.5%) were similar in the abatacept and placebo arms.Table 1.Primary and secondary (mean change from baseline at week 24) endpointsOutcomeIIMAbataceptPlaceboNominal P value (abatacept vs placebo) or adjusted mean difference from placebo (95% CI)IMACS DOI,a n/N (%)All42/75 (56.0)31/73 (42.5)P = 0.083DM22/40 (55.0)21/42 (50.0)P = 0.679Non-DM20/35 (57.1)10/31 (32.3)P = 0.040FI-2All4.1 (1.3)1.2 (1.4)2.9 (0 to 5.8)DM2.3 (1.6)0.3 (1.4)1.9 (−2.3 to 6.2)Non-DM3.2 (1.4)−0.6 (1.5)3.7 (−0.3 to 7.8)HAQ-DIAll−0.31 (0.07)0.20 (0.07)−0.12 (−0.28 to 0.04)DM−0.31 (0.08)−0.19 (0.07)−0.11 (−0.32 to 0.10)Non-DM−0.25 (0.09)−0.07 (0.09)−0.18 (−0.44 to 0.07)MDAAT, Extramuscular Global Activity, (95% CI)bAll−1.56 (−1.96 to −1.16)−1.40 (−1.81 to −0.99)−0.16 (−0.63 to 0.30)DM−1.90 (−2.43 to −1.37)−1.85 (−2.35 to 1.36)−0.05 (−0.77 to 0.68)Non-DM−1.09 (−1.46 to −0.72)−0.85 (−1.27 to −0.43)−0.24 (−0.80 to 0.32)MMT-8All12.9 (1.9)11.0 (2.0)1.8 (−2.7 to 6.4)DM14.4 (2.2)14.0 (2.2)0.4 (−5.7 to 6.4)Non-DM12.1 (2.5)7.8 (2.7)4.3 (−3.0 to 11.7)Physician Global AssessmentbAll−2.89 (0.30)−2.69 (0.30)−0.20 (−0.92 to 0.52)DM−2.78 (0.29)−2.43 (0.28)−0.35 (−1.15 to 0.46)Non-DM−2.35 (0.43)−2.21 (0.48)−0.14 (−1.43 to 1.15)Patient Global AssessmentbAll−1.4 (0.31)−0.98 (0.32)−0.38 (−1.11 to 0.35)DM−1.4 (0.33)−1.4 (0.31)−0.00 (−0.91 to 0.90)Non-DM−1.2 (0.41)−0.3 (0.44)−0.93 (−2.14 to 0.29)Data are adjusted mean change from baseline score (SE) unless stated.aDefined as improvement of ≥ 20% in 3 IMACS core measures, worsening by ≥ 25% in ≤ 2 IMACS core measure scores, and a reduction of < 25% in MMT-8; b100 mm visual analog scale.ConclusionIn this double-blind trial of SC abatacept vs placebo, abatacept failed to meet primary or secondary endpoints. Post hoc analyses suggest a treatment benefit in patients with PM and ANM (not DM) when treated with abatacept. Abatacept use was well tolerated.References[1]Dalakas MC, Hohlfeld R. Lancet 2003;362:971–82.[2]Tjärnlund A, et al. Ann Rheum Dis 2018;77:55–62.AcknowledgementsThis study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance were provided by Fiona Boswell, PhD, of Caudex and were funded by Bristol Myers Squibb. Study execution was by Sandra Overfield and Robin Scully.Disclosure of InterestsRohit Aggarwal Consultant of: AbbVie, Alexion, Argenx, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Corbus, CSL Behring, EMD Serono, Janssen, Jubilant, Kezar, Kyverna, Mallinckrodt, Octapharma, Orphazyme, Pfizer, Q32, Roivant (personal fees), Grant/research support from: Bristol Myers Squibb, EMD Serono, Genentech, Mallinckrodt, Pfizer, Q32, Ingrid E. Lundberg Shareholder of: Novartis, Roche, Consultant of: Argenx, AstraZeneca, Corbus, EMD Serono, Janssen, Kezar, Octapharma, Orphazyme (personal fees), Grant/research support from: Bristol Myers Squibb, Yeong Wook Song: None declared, Aziz Shaibani: None declared, Victoria P Werth Consultant of: AbbVie, Akari, Amgen, Argenx, AstraZeneca, Bayer, Beacon Bioscience, Biogen, Bristol Myers Squibb, Celgene, Corcept, Crisalis, CSL Behring, Cugene, EMD Serono, Genentech, Gilead, GlaxoSmithKline, Horizon, Idera, Incyte, Janssen, Kezar, Kwoya Kirin, Lilly, Medimmune, Medscape, Merck, Nektar, Octapharma, Pfizer, Principia, Regeneron, Resolve, Rome Pharmaceuticals, Sanofi, UCB, Viela Bio, Grant/research support from: Amgen, Argenx, AstraZeneca, Biogen, Bristol Myers Squibb, Celgene, Corbus Pharmaceuticals, CSL Behring, Genentech, Gilead, Janssen, Pfizer, q32 Bio, Regeneron, Syntimmune, Ventus, Viela, Michael A Maldonado Employee of: Bristol Myers Squibb
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Morand E, Pike M, Merrill JT, Van Vollenhoven R, Werth VP, Hobar C, Delev N, Shah V, Sharkey B, Wegman T, Catlett I, Banerjee S, Singhal S. LB0004 EFFICACY AND SAFETY OF DEUCRAVACITINIB, AN ORAL, SELECTIVE, ALLOSTERIC TYK2 INHIBITOR, IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: A PHASE 2, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.5020a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundTyrosine kinase 2 (TYK2) mediates signaling of Type I interferons, IL-23, and IL-12, key cytokines involved in lupus pathogenesis. Deucravacitinib (DEUC) is an oral, selective, allosteric TYK2 inhibitor with a unique mechanism of action, distinct from Janus kinase (JAK) 1/2/3 inhibitors, and has shown efficacy in psoriasis and psoriatic arthritis.ObjectivesAssess efficacy and safety of DEUC in patients with active systemic lupus erythematosus (SLE).MethodsThis was a 48-week (wk), randomized, double-blind, placebo (PBO)-controlled, phase 2 trial (NCT03252587). Eligible patients met SLICC criteria, were seropositive (ANA/anti-dsDNA/anti-Sm), and had a SLEDAI-2K score ≥6 and ≥1 BILAG index A or >2 BILAG B manifestations from the musculoskeletal or mucocutaneous domain. Patients on standard background medications were randomized 1:1:1:1 to PBO or DEUC (3 mg BID, 6 mg BID, 12 mg QD). Oral corticosteroid tapering to 7.5 mg/day was required from wks 8-20; further tapering was optional from wks 32-40. The primary endpoint was the proportion of patients achieving SRI(4) at wk 32. Key secondary endpoints at wk 48 included SRI(4), BICLA, LLDAS, CLASI-50, and change from baseline in active (tender and swollen) joint count.ResultsA total of 363 patients were randomized, with baseline demographic and disease characteristics similar across treatment groups. Of randomized patients, 275 (76%) completed 48 wks of treatment. The primary endpoint at wk 32 was met, with significantly greater proportion of patients in DEUC 3 mg BID and 6 mg BID groups vs PBO achieving SRI(4) responses (PBO: 34.4%; DEUC 3 mg BID: 58.2%, P=0.0006; DEUC 6 mg BID: 49.5%, P=0.021; DEUC 12 mg QD: 44.9%, P=0.078). SRI(4) response was sustained across all DEUC groups up to 48 wks (Figure 1). At wk 48, the DEUC 3 mg BID group demonstrated statistical significance in BICLA, LLDAS, CLASI-50, and active joint count, and the two other DEUC groups demonstrated clinically meaningful differences vs PBO (Figure 1). Rates of adverse events (AEs), serious AEs, and AEs of interest were similar between DEUC and PBO groups (Table 1). Most common AEs (≥10%) with DEUC were upper respiratory tract infection, nasopharyngitis, headache, and urinary tract infection. No deaths, major cardiac events, thrombotic events, systemic opportunistic infections, or active tuberculosis occurred. Malignancies were rare with similar rates across all groups. No meaningful abnormalities in mean levels of hematology and chemistry laboratory parameters were observed.Table 1.Summary of Adverse Events Through Week 48AE, na(%)Placebo n = 90DEUC 3 mg BID n = 91DEUC 6 mg BID n = 93DEUC 12 mg QD n = 89AE79 (87.8)85 (93.4)81 (87.1)75 (84.3)SAE11 (12.2)7 (7.7)8 (8.6)7 (7.9)AEs leading to treatment discontinuation3 (3.3)8 (8.8)6 (6.5)11 (12.4)Skin-related AEsb12 (13.3)15 (16.5)32 (34.4)30 (33.7)Overall infections/infestations48 (53.3)60 (65.9)60 (64.5)45 (50.6)Serious infections/infestations1 (1.1)1 (1.1)2 (2.2)1 (1.1)Infections of interest Tuberculosis0000 Herpes zosterc4 (4.4)3 (3.3)3 (3.2)2 (2.2) Influenza1 (1.1)3 (3.3)1 (1.1)3 (3.4) COVID-193 (3.3)3 (3.3)5 (5.4)3 (3.4)Malignancy events1 (1.1)d1 (1.1)e01 (1.1)fMACE0000Thrombotic events0000an is the number of patients who experienced an event. bIncludes (≤8.6% in any arm) acne, rash, dermatitis acneiform, pruritus, skin lesion, urticaria. cIncludes herpes zoster, herpes ophthalmic, genital herpes zoster. dBasal cell carcinoma. eBreast carcinoma. fVaginal squamous cell carcinoma.AE, adverse event; COVID-19, coronavirus disease 2019; DEUC, deucravacitinib; MACE, major adverse cardiac events; SAE, serious adverse event.ConclusionIn patients with active SLE, DEUC showed statistically significant and sustained clinical efficacy in SRI(4), improvement across multiple composite and organ-specific measures up to 48 wks, and was well tolerated. DEUC shows promise as a novel therapy for SLE and warrants further investigation in phase 3 trials.AcknowledgementsThis study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Julianne Hatfield, PhD at Peloton Advantage, LLC, an OPEN Health company, Parsippany, NJ, USA, and funded by Bristol Myers Squibb. The authors acknowledge Christina Crater, MD, who was employed by Bristol Myers Squibb at the time the study was conducted, for contributions to study conduct.Disclosure of InterestsEric Morand Consultant of: AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Servier, and Novartis , Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Janssen, and UCB , Marilyn Pike Consultant of: AstraZeneca, Bristol Myers Squibb, and Pfizer, Joan T. Merrill Consultant of: UCB, GlaxoSmithKline, AbbVie, EMD Serono, Remegen, Celgene/Bristol Myers Squibb, AstraZeneca, Amgen, Janssen, Lilly, Genentech, Aurinia, Astellas, Alexion, Sanofi, Zenas, and Provention , Grant/research support from: GlaxoSmithKline and AstraZeneca , Ronald van Vollenhoven Consultant of: UCB, Pfizer, AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Galapagos, Gilead, Janssen, Servier, Paid instructor for: Roche, Pfizer, Speakers bureau: UCB, Pfizer, AbbVie, Galapagos, Janssen, Grant/research support from: Bristol Myers Squibb, GlaxoSmithKline, Eli Lilly, UCB, , Victoria P. Werth Consultant of: Celgene, Medimmune, Resolve, Genentech, Idera, Janssen, Lilly, Biogen, Bristol Myers Squibb, Gilead, Amgen, Medscape, Nektar, Incyte, EMD Serono, CSL Behring, Principia, Crisalis, Viela Bio, Argenx, Kirin, AstraZeneca, AbbVie, GSK, AstraZeneca, Cugene, UCB, Corcept, Beacon Bioscience , Grant/research support from: Celgene, Janssen, Biogen, Gilead, AstraZeneca, Viela, Amgen, Lupus Research Alliance/BMS , Coburn Hobar Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Nikolay Delev Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vaishali Shah Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Brian Sharkey Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Thomas Wegman Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Ian Catlett Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shalabh Singhal Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb
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Ezeh N, Ardalan K, Buhr KA, Nguyen C, Al Ahmed O, Ardoin SP, Barton V, Bell S, Brandling-Bennett H, Castelo-Soccio L, Chiu YE, Chong BF, Lara-Corrales I, Cintosun A, Curran ML, Diaz LZ, Elman SA, Faith EF, Garcia-Romero MT, Grossman-Kranseler J, Hogeling M, Hudson AD, Hunt RD, Ibler EM, Marques MC, Monir RL, Oza V, Paller AS, Putterman E, Rodriguez-Salgado P, Schoch JJ, Truong A, Wang J, Lee LW, Vleugels RA, Klein-Gitelman MS, von Scheven E, Werth VP, Arkin LM. Cross-Sectional Characteristics of Pediatric-Onset Discoid Lupus Erythematosus: Results of a Multicenter, Retrospective Cohort Study. J Am Acad Dermatol 2022; 87:559-566. [PMID: 35487332 PMCID: PMC10082546 DOI: 10.1016/j.jaad.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/15/2022]
Abstract
• Discoid lupus may be associated with SLE. In this study, most children with discoid lupus did not have systemic disease. Concurrent SLE was highest in female adolescents (>10 years of age) with generalized discoid lupus, who had clinically aggressive disease. • Discoid lupus in adolescence should prompt thorough evaluation for SLE.
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Affiliation(s)
- N Ezeh
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - K Ardalan
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, Departments of Pediatrics and Medical Social Sciences, Northwestern University Feinberg School of Medicine/Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - K A Buhr
- Department of Biostatistics & Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - C Nguyen
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - O Al Ahmed
- Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus OH
| | - S P Ardoin
- Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus OH
| | - V Barton
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, SC
| | - S Bell
- Department of Pediatrics, Division of Rheumatology, University of California at San Francisco, San Francisco, CA
| | - H Brandling-Bennett
- Division of Dermatology; Department of Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, WA
| | - L Castelo-Soccio
- Children's Hospital of Philadelphia, Department of Pediatrics, Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Y E Chiu
- Departments of Dermatology (Section of Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - B F Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Pediatrics, Division of Allergy/Immunology/Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - I Lara-Corrales
- Department of Pediatrics, Section of Dermatology, The Hospital for Sick Children/University of Toronto, Toronto, ON
| | - A Cintosun
- Department of Pediatrics, Section of Dermatology, The Hospital for Sick Children/University of Toronto, Toronto, ON
| | - M L Curran
- Department of Pediatrics, Section of Rheumatology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO
| | - L Z Diaz
- Department of Pediatrics, Division of Dermatology, Dell Medical School/Dell Children's Hospital, Austin, TX
| | - S A Elman
- Department of Dermatology, Boston's Children Hospital/Harvard Medical School, Boston, MA
| | - E Fernandez Faith
- Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus OH
| | - M T Garcia-Romero
- Department of Dermatology, National Institute for Pediatrics, Mexico City, MX
| | - J Grossman-Kranseler
- Division of Dermatology; Department of Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, WA
| | - M Hogeling
- Department of Dermatology, University of California at Los Angeles, Los Angeles, CA
| | - A D Hudson
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX
| | - R D Hunt
- Department of Dermatology and Pediatrics, Texas Children's Hospital, Houston, TX
| | - E M Ibler
- Departments of Dermatology (Section of Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - M C Marques
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | - R L Monir
- Department of Dermatology, University of Florida School of Medicine, Gainesville, FL
| | - V Oza
- Departments of Pediatrics and Dermatology, New York University Grossman School of Medicine, New York, NY
| | - A S Paller
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine/Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - E Putterman
- Children's Hospital of Philadelphia, Department of Pediatrics, Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - P Rodriguez-Salgado
- Department of Dermatology, National Institute for Pediatrics, Mexico City, MX
| | - J J Schoch
- Department of Dermatology, University of Florida School of Medicine, Gainesville, FL
| | - A Truong
- Department of Dermatology, University of California at Los Angeles, Los Angeles, CA
| | - J Wang
- Departments of Pediatrics and Dermatology, New York University Grossman School of Medicine, New York, NY
| | - L Wine Lee
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, SC
| | - R A Vleugels
- Department of Dermatology, Boston's Children Hospital/Harvard Medical School, Boston, MA
| | - M S Klein-Gitelman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine/Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - E von Scheven
- Department of Pediatrics, Division of Rheumatology, University of California at San Francisco, San Francisco, CA
| | - V P Werth
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania and Corporal Michael J. Crescenz VAMC, Philadelphia, PA
| | - L M Arkin
- Departments of Dermatology and Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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Concha JSS, Afarideh M, Werth VP. Postinflammatory hyperpigmentation and erythema: new insights into the pathogenesis. Br J Dermatol 2021; 186:390-391. [PMID: 34961919 DOI: 10.1111/bjd.20938] [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: 11/28/2022]
Affiliation(s)
- J S S Concha
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Afarideh
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - V P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Vazquez T, Feng R, Williams KJ, Werth VP. Immunological and clinical heterogeneity in cutaneous lupus erythematosus. Br J Dermatol 2021; 185:480-481. [PMID: 33966286 DOI: 10.1111/bjd.20085] [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: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
- T Vazquez
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - R Feng
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - K J Williams
- Department of Physiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, University of Pennsylvania, Philadelphia, PA, USA
| | - V P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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Murrell DF, Patsatsi A, Stavropoulos P, Baum S, Zeeli T, Kern JS, Roussaki-Schulze AV, Sinclair R, Bassukas ID, Thomas D, Neale A, Arora P, Caux F, Werth VP, Gourlay SG, Joly P. Proof of concept for the clinical effects of oral rilzabrutinib, the first Bruton tyrosine kinase inhibitor for pemphigus vulgaris: the phase II BELIEVE study. Br J Dermatol 2021; 185:745-755. [PMID: 33942286 PMCID: PMC8518737 DOI: 10.1111/bjd.20431] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 01/01/2023]
Abstract
Background Bruton tyrosine kinase (BTK) inhibition targets B‐cell and other non‐T‐cell immune cells implicated in the pathophysiology of pemphigus, an autoimmune disease driven by anti‐desmoglein autoantibodies. Rilzabrutinib is a new reversible, covalent BTK inhibitor demonstrating preclinical efficacy as monotherapy in canine pemphigus foliaceus. Objectives To evaluate the efficacy and safety of oral rilzabrutinib in patients with pemphigus vulgaris in a multicentre, proof‐of‐concept, phase II trial. Methods Patients with Pemphigus Disease Area Index severity scores 8–45 received 12 weeks of oral rilzabrutinib 400–600 mg twice daily and 12 weeks of follow‐up. Patients initially received between 0 and ≤ 0·5 mg kg−1 prednisone‐equivalent corticosteroid (CS; i.e. ‘low dose’), tapered after control of disease activity (CDA; no new lesions, existing lesions healing). The primary endpoints were CDA within 4 weeks on zero‐to‐low‐dose CS and safety. Results In total, 27 patients with pemphigus vulgaris were included: nine newly diagnosed (33%) and 18 relapsing (67%); 11 had moderate disease (41%) and 16 moderate to severe (59%). The primary endpoint, CDA, was achieved in 14 patients (52%, 95% confidence interval 32–71): 11 using low‐dose CS and three using no CS. Over 12 weeks of treatment, mean CS doses reduced from 20·0 to 11·8 mg per day for newly diagnosed patients and from 10·3 to 7·8 mg per day for relapsing patients. Six patients (22%) achieved complete response by week 24, including four (15%) by week 12. Treatment‐related adverse events were mostly mild (grade 1 or 2); one patient experienced grade 3 cellulitis. Conclusions Rilzabrutinib alone, or with much lower CS doses than usual, was safe, with rapid clinical activity in pemphigus vulgaris. These data suggest that BTK inhibition may be a promising treatment strategy and support further investigation of rilzabrutinib for the treatment of pemphigus. What is already known about this topic?Standard pemphigus treatment relies on systemic high‐dose corticosteroids (CS), rituximab and/or immunosuppressives, which are limited by delayed onset of action and potential toxicities. Immune‐mediated mechanisms that are fast acting on both the innate and adaptive immune systems, are steroid sparing, and have safety profiles well suited for chronic administration are greatly needed for patients with pemphigus.
What does this study add?Rilzabrutinib is an oral Bruton tyrosine kinase (BTK) inhibitor targeting B‐cell and other non‐T‐cell immune cells implicated in pemphigus pathophysiology. Treatment with rilzabrutinib (with or without low‐dose CS) demonstrated rapid disease control and a well‐tolerated safety profile in patients with newly diagnosed and relapsing pemphigus vulgaris. BELIEVE provides evidence for a promising treatment strategy via BTK inhibition, supporting further investigation of rilzabrutinib in other immune‐mediated diseases.
Linked Comment: A.M. Drucker and N.H. Shear. Br J Dermatol 2021; 185:691–692. Plain language summary available online
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Affiliation(s)
- D F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales Faculty of Medicine, Sydney, NSW, Australia
| | - A Patsatsi
- 2nd Dermatology Department, Aristotle University Faculty of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - P Stavropoulos
- 1st Department of Dermatology, National and Kapodistrian University, School of Medicine, Athens, Greece
| | - S Baum
- Department of Dermatology, Sheba Medical Center, Ramat Gan, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T Zeeli
- Department of Dermatology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J S Kern
- Dermatology Department, The Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, the University of Melbourne, Melbourne, VIC, Australia
| | - A-V Roussaki-Schulze
- Department of Dermatology, University General Hospital of Larissa, Larissa, Greece
| | - R Sinclair
- University of Melbourne and Sinclair Dermatology, Melbourne, VIC, Australia
| | - I D Bassukas
- Department of Skin and Venereal Diseases, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - D Thomas
- Principia Biopharma Inc., a Sanofi Company, South San Francisco, CA, USA
| | - A Neale
- Principia Biopharma Inc., a Sanofi Company, South San Francisco, CA, USA
| | - P Arora
- Principia Biopharma Inc., a Sanofi Company, South San Francisco, CA, USA
| | - F Caux
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP, Bobigny, France
| | - V P Werth
- University of Pennsylvania and Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
| | - S G Gourlay
- Principia Biopharma Inc., a Sanofi Company, South San Francisco, CA, USA
| | - P Joly
- Department of Dermatology, Rouen University Hospital, Centre de Référence des Maladies Bulleuses Autoimmunes, and INSERM U1234, Normandie University, Rouen, France
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Krain RL, Bax CE, Chakka S, Ahmed S, Feng R, Payne AS, Werth VP. Establishing cut-off values for mild, moderate and severe disease in patients with pemphigus using the Pemphigus Disease Area Index. Br J Dermatol 2020; 184:975-977. [PMID: 33314027 DOI: 10.1111/bjd.19718] [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: 04/26/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- R L Krain
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - C E Bax
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - S Chakka
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - S Ahmed
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - R Feng
- Department of, Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - A S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - V P Werth
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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9
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Vazquez T, Concha JSS, Werth VP. Patient-oriented outcomes for atopic dermatitis. Br J Dermatol 2020; 184:794-795. [PMID: 33161565 DOI: 10.1111/bjd.19614] [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: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
- T Vazquez
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J S S Concha
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - V P Werth
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Bax CE, Ravishankar A, Yan D, Concha J, Kushner CJ, Zamalin D, Feng R, Payne AS, Werth VP. Identifying the required degree of disease clearance to improve quality of life in pemphigus vulgaris. Br J Dermatol 2020; 184:573-575. [PMID: 33090460 DOI: 10.1111/bjd.19625] [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: 09/13/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- C E Bax
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - A Ravishankar
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - D Yan
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - J Concha
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - C J Kushner
- Department of Dermatology, New York University, New York City, NY, USA
| | - D Zamalin
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - R Feng
- Department of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - A S Payne
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - V P Werth
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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11
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Werth VP, Merrill JT. A double-blind, randomized, placebo-controlled, phase II trial of baricitinib for systemic lupus erythematosus: how to optimize lupus trials to examine effects on cutaneous lupus erythematosus. Br J Dermatol 2020; 180:964-965. [PMID: 31025748 DOI: 10.1111/bjd.17344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- V P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, PA, U.S.A
| | - J T Merrill
- Oklahoma Medical Research Foundation, Oklahoma City, OK, U.S.A
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12
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Affiliation(s)
- C E Bax
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - V P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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13
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Concha JSS, Pena S, Gaffney RG, Patel B, Tarazi M, Kushner CJ, Merola JF, Fiorentino D, Dutz JP, Goodfield M, Nyberg F, Volc-Platzer B, Fujimoto M, Ang CC, Werth VP. Developing classification criteria for skin-predominant dermatomyositis: the Delphi process. Br J Dermatol 2019; 182:410-417. [PMID: 31049930 DOI: 10.1111/bjd.18096] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The European League Against Rheumatism/American College of Rheumatology classification criteria for inflammatory myopathies are able to classify patients with skin-predominant dermatomyositis (DM). However, approximately 25% of patients with skin-predominant DM do not meet two of the three hallmark skin signs and fail to meet the criteria. OBJECTIVES To develop a set of skin-focused classification criteria that will distinguish cutaneous DM from mimickers and allow a more inclusive definition of skin-predominant disease. METHODS An extensive literature review was done to generate items for the Delphi process. Items were grouped into categories of distribution, morphology, symptoms, antibodies, histology and contextual factors. Using REDCap™, participants rated these items in terms of appropriateness and distinguishing ability from mimickers. The relevance score ranged from 1 to 100, and the median score determined a rank-ordered list. A prespecified median score cut-off was decided by the steering committee and the participants. There was a pre-Delphi and two rounds of actual Delphi. RESULTS There were 50 participating dermatologists and rheumatologists from North America, South America, Europe and Asia. After a cut-off score of 70 during the first round, 37 of the initial 54 items were retained and carried over to the next round. The cut-off was raised to 80 during round two and a list of 25 items was generated. CONCLUSIONS This project is a key step in the development of prospectively validated classification criteria that will create a more inclusive population of patients with DM for clinical research. What's already known about this topic? Proper classification of patients with skin-predominant dermatomyositis (DM) is indispensable in the appropriate conduct of clinical/translational research in the field. The only validated European League Against Rheumatism/American College of Rheumatology criteria for idiopathic inflammatory myopathies are able to classify skin-predominant DM. However, a quarter of amyopathic patients still fail the criteria and does not meet the disease classification. What does this study add? A list of 25 potential criteria divided into categories of distribution, morphology, symptomatology, pathology and contextual factors has been generated after several rounds of consensus exercise among experts in the field of DM. This Delphi project is a prerequisite to the development of a validated classification criteria set for skin-predominant DM.
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Affiliation(s)
- J S S Concha
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - S Pena
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - B Patel
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M Tarazi
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - C J Kushner
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J F Merola
- Department of Dermatology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - D Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA, U.S.A
| | - J P Dutz
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - M Goodfield
- Department of Dermatology, Leeds General Infirmary, Leeds, U.K
| | - F Nyberg
- Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - B Volc-Platzer
- Department of Dermatology, Wiener Krankenanstaltenverbund, Vienna, Austria
| | - M Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - C C Ang
- Department of Dermatology, Changi General Hospital, Singapore
| | - V P Werth
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
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14
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Ahmed S, Chakka S, Concha J, Krain R, Feng R, Werth VP. Evaluating important change in cutaneous disease activity as an efficacy measure for clinical trials in dermatomyositis. Br J Dermatol 2019; 182:949-954. [PMID: 31206600 DOI: 10.1111/bjd.18223] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients may experience improved quality of life (QoL) without complete clearance of skin disease. The Cutaneous Dermatomyositis Disease Area and Severity Index Activity (CDASI-A) score correlates with the Symptoms and Emotions subscales of Skindex-29, a measure of QoL, down to CDASI-A scores of 7 points (for Symptoms) and 10 points (for Emotions). OBJECTIVES Our goal was to define an important change in disease activity, as measured by the CDASI-A, that results in a meaningful change in QoL in patients with dermatomyositis. METHODS In 103 patients, we assessed the percentage change and actual change in CDASI-A scores needed to achieve a meaningful improvement in QoL, using linear regression models. RESULTS We found that meaningful improvement correlates with 7·86 points (P < 0·001) in Symptoms, and 10·29 points (P < 0·001) in Emotions, after correlating Skindex-29 to an established definition of meaningful change in the Dermatology Life Quality Index (DLQI). For patients with initial CDASI-A scores > 14 points, a 40% change in CDASI-A between the first two visits suggests a meaningful change in Skindex-29. In patients with moderate initial CDASI-A (15-26 points), the changes in CDASI-A resulting in meaningful changes in Symptoms and Emotions were 6 points (P < 0·001) and 7 points (P < 0·001), respectively. For initial CDASI-A scores in the severe range (27-35 points), an improvement in CDASI-A by 11 points (P = 0·030) and 9 points (P = 0·021) leads to a meaningful change in Symptoms and Emotions, respectively. CONCLUSIONS In patients with an initial CDASI-A score > 14 points, a 40% change in the CDASI-A score can be used to indicate a meaningful change in QoL in future dermatomyositis trials. What's already known about this topic? The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) is a validated disease assessment tool used to capture the extent of cutaneous activity and damage. The Skindex-29 and Dermatology Life Quality Index are standardized and validated measures of quality of life (QoL) for clinical trials and correlate with CDASI Activity (CDASI-A) scores. What does this study add? We identified what change in Skindex-29 scores over two consecutive visits would indicate an important change (a minimal clinically important difference) in QoL. We determined which change in CDASI-A scores over two consecutive visits would lead to a meaningful change in QoL. For patients with an initial CDASI-A score > 14 points, a 40% change in the CDASI-A score over two visits is associated with a meaningful change in QoL. What are the clinical implications of this work? Clinical trials can consider using a 40% change in the CDASI-A score as an end point when assessing the clinical efficacy of drugs.
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Affiliation(s)
- S Ahmed
- Department of Dermatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - S Chakka
- Department of Dermatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J Concha
- Department of Dermatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Krain
- Department of Dermatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Feng
- Department of Statistics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
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Gandiga PC, Zhang J, Sangani S, Thomas P, Werth VP, George MD. Utilization patterns and performance of commercial myositis autoantibody panels in routine clinical practice. Br J Dermatol 2019; 181:1090-1092. [PMID: 31102270 DOI: 10.1111/bjd.18133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- P C Gandiga
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Division of Rheumatology, Emory University, Atlanta, GA, U.S.A
| | - J Zhang
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - S Sangani
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - P Thomas
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Department of Dermatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - M D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, U.S.A
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Affiliation(s)
- S Chakka
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
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Tarazi M, Gaffney RG, Feng R, Werth VP. Evaluating cutaneous lupus disease activity end points and their effects on quality of life as an outcome measure for clinical trials. Br J Dermatol 2019; 181:841-842. [PMID: 30920654 DOI: 10.1111/bjd.17926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M Tarazi
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Feng
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, U.S.A
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Concha JSS, Tarazi M, Kushner CJ, Gaffney RG, Werth VP. The diagnosis and classification of amyopathic dermatomyositis: a historical review and assessment of existing criteria. Br J Dermatol 2019; 180:1001-1008. [PMID: 30561064 DOI: 10.1111/bjd.17536] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Diagnostic criteria are used to identify a patient having a disease in a clinical setting, whereas classification criteria create a well-defined population for research purposes. The diagnosis and classification of amyopathic dermatomyositis (ADM) have not been recognized by most existing criteria for idiopathic inflammatory myopathies (IIMs). To address this, several criteria were proposed to define ADM either as a distinct disease entity or as a subset of the spectrum of IIMs. OBJECTIVES To discuss the diagnosis and classification of ADM and to assesses the available criteria in identifying cases of ADM and/or distinguishing it from dermatological mimickers such as lupus erythematosus. METHODS We conducted an extensive literature search using the PubMed database from June 2016 to August 2018, using the search terms 'amyopathic dermatomyositis', 'diagnosis' and 'classification'. RESULTS The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) criteria, which are the only validated classification criteria for adult and juvenile IIM and their major subgroups, include three cutaneous items (Göttron sign, Göttron papules, heliotrope rash) to be able to classify ADM. This international and multispecialty effort is a huge step forward in the classification of skin-predominant disease in dermatomyositis. However, about 25% of the population with ADM do not meet two out of the three skin features and are misdiagnosed or classified as having a different disease entity, most commonly lupus erythematosus. CONCLUSIONS These gaps rationalize the continuous assessment and improvement of existing criteria and/or the development of validated, separate and skin-focused criteria for DM.
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Affiliation(s)
- J S S Concha
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - M Tarazi
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - C J Kushner
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
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19
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Arkin LM, Buhr K, Brandling-Bennett H, Chiu Y, Chong B, Curran M, Hunt R, Paller AS, Werth VP, Klein-Gitelman M, von Scheven E, Ardalan K. Practice-based differences in paediatric discoid lupus erythematosus. Br J Dermatol 2019; 181:805-810. [PMID: 30768778 DOI: 10.1111/bjd.17780] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Children with discoid lupus erythematosus (DLE) are at risk for disfigurement and progression to systemic lupus erythematosus (SLE). Consensus is lacking regarding optimal care for children with DLE. OBJECTIVES The aim of this study was to compare practice patterns among paediatric dermatologists/rheumatologists treating paediatric DLE. METHODS An online survey was sent to 292 paediatric rheumatologists in the Childhood Arthritis and Rheumatology Research Alliance and 200 paediatric dermatologists in the Pediatric Dermatology Research Alliance. Consensus was defined as ≥ 70% agreement. RESULTS Survey response rates were 38% (76 of 200) for dermatology and 21% (60 of 292) for rheumatology. Both specialties agreed that screening labs should include complete blood counts with differential, urinalysis, complement levels, erythrocyte sedimentation rate, antinuclear antibody and other autoantibodies, hepatic function and renal function/electrolytes. Both specialties agreed that arthritis or nephritis should prompt intensified evaluation for SLE. No other patient features achieved consensus as disease-modifying risk factors. Hydroxychloroquine was agreed upon as first-line systemic therapy, but consensus was lacking for second- or third-line treatment. CONCLUSIONS We found few areas of consensus and significant practice differences between paediatric dermatologists and rheumatologists treating DLE. Knowledge gaps include risk factors for SLE, optimal screening and treatment of refractory skin disease.
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Affiliation(s)
- L M Arkin
- Department of Dermatology and Pediatrics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, U.S.A
| | - K Buhr
- Department of Biostatistics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, U.S.A
| | - H Brandling-Bennett
- Department of Dermatology and Pediatrics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, U.S.A
| | - Y Chiu
- Department of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - B Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, U.S.A
| | - M Curran
- Department of Pediatrics, University of Colorado, Denver, CO, U.S.A
| | - R Hunt
- Department of Pediatrics and Dermatology, Baylor College of Medicine, Houston, TX, U.S.A
| | - A S Paller
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - M Klein-Gitelman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, U.S.A
| | - E von Scheven
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, U.S.A
| | - K Ardalan
- Department of Pediatrics and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, U.S.A
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20
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Tarazi M, Gaffney RG, Pearson D, Kushner CJ, Werth VP. Fatigue in systemic lupus erythematosus and other autoimmune skin diseases. Br J Dermatol 2018; 180:1468-1472. [PMID: 30269332 DOI: 10.1111/bjd.17257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fatigue is a well-established symptom in systemic lupus erythematosus (SLE), but has not been well characterized in other skin-limited autoimmune diseases such as cutaneous lupus erythematosus (CLE), amyopathic dermatomyositis (ADM) or autoimmune blistering diseases (AIBD). OBJECTIVES In this retrospective study, we compared fatigue in controls (n = 84) with that in patients enrolled in prospective longitudinal databases with SLE (n = 165), CLE (n = 226), ADM (n = 136) and AIBD (n = 79). METHODS We used the 36-Item Short Form Survey (SF-36) vitality scale to analyse median scores and the percentages of patients with clinically significant fatigue (defined as a score ≤ 35) between experimental groups and controls. RESULTS Median and interquartile range (IQR) vitality scores demonstrated greater fatigue in the experimental groups (SLE 35, IQR 20-55; CLE 50, IQR 30-70; ADM 50, IQR 30-65; AIBD 55, IQR 35-70) than in controls (73, IQR 65-85) (P < 0·05 for each experimental group vs. control). The SLE group had worse fatigue than all of the other groups (P < 0·05 SLE vs. each group), but there was no difference between the CLE, ADM or AIBD groups (all P > 0·05). In addition, the experimental groups had more clinically significant fatigue (score ≤ 35) (SLE 44·2%, CLE 25·2%, ADM 31·6%, AIBD 24·1%) than controls (2%) (P < 0·01 for each experimental group vs. control). The SLE group had more clinically significant fatigue than the CLE group (P < 0·01); however, there was no difference in clinically significant fatigue between SLE and either ADM (P = 0·17) or AIBD (P = 0·055). CONCLUSIONS These findings demonstrate that patients with skin-limited autoimmune disease experience more fatigue than controls. Fatigue is an important symptom that negatively affects quality of life for patients. It should be addressed by clinicians and measured in future clinical trials.
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Affiliation(s)
- M Tarazi
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, U.S.A
| | - D Pearson
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A
| | - C J Kushner
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A
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21
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Kushner CJ, Tarazi M, Gaffney RG, Feng R, Ardalan K, Brandling-Bennett HA, Castelo-Soccio L, Chang JC, Chiu YE, Gmuca S, Hunt RD, Kahn PJ, Knight AM, Mehta J, Pearson DR, Treat JR, Wan J, Yeguez AC, Concha JSS, Patel B, Okawa J, Arkin LM, Werth VP. Evaluation of the reliability and validity of the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) in paediatric cutaneous lupus among paediatric dermatologists and rheumatologists. Br J Dermatol 2018; 180:165-171. [PMID: 30033560 DOI: 10.1111/bjd.17012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) is a reliable outcome measure for cutaneous lupus erythematosus (CLE) in adults used in clinical trials. However, it has not been validated in children, limiting clinical trials for paediatric CLE. OBJECTIVES This study aimed to validate the CLASI in paediatrics. METHODS Eleven paediatric patients with CLE, six dermatologists and six rheumatologists participated. The physicians were trained to use the CLASI and Physician's Global Assessment (PGA), and individually rated all patients using both tools. Each physician reassessed two randomly selected patients. Within each physician group, the intraclass correlation coefficient (ICC) was calculated to assess the reliability of each measure. RESULTS CLASI activity scores demonstrated excellent inter- and intrarater reliability (ICC > 0·90), while the PGA activity scores had good inter-rater reliability (ICC 0·73-0·77) among both specialties. PGA activity scores showed excellent (ICC 0·89) and good intrarater reliability (ICC 0·76) for dermatologists and rheumatologists, respectively. Limitations of this study include the small sample size of patients and potential recall bias during the physician rerating session. CONCLUSIONS CLASI activity measurement showed excellent inter- and intrarater reliability in paediatric CLE and superiority over the PGA. These results demonstrate that the CLASI is a reliable and valid outcome instrument for paediatric CLE.
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Affiliation(s)
- C J Kushner
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - M Tarazi
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - R Feng
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - K Ardalan
- Department of Pediatrics and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, U.S.A
| | - H A Brandling-Bennett
- Department of Pediatrics and Dermatology, University of Washington School of Medicine, Seattle, WA, U.S.A
| | - L Castelo-Soccio
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - J C Chang
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - Y E Chiu
- Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - S Gmuca
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - R D Hunt
- Departments of Dermatology and Pediatrics, Baylor College of Medicine, Houston, TX, U.S.A
| | - P J Kahn
- Department of Pediatrics, Division of Rheumatology, NYU Langone Medical Center, New York, NY, U.S.A
| | - A M Knight
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - J Mehta
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - D R Pearson
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - J R Treat
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - J Wan
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - A C Yeguez
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A
| | - J S S Concha
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - B Patel
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - J Okawa
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - L M Arkin
- Departments of Dermatology and Pediatrics, University of Wisconsin School of Medicine, Madison, WI, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
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22
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Kim HJ, Zeidi M, Bonciani D, Pena SM, Tiao J, Sahu S, Werth VP. Itch in dermatomyositis: the role of increased skin interleukin-31. Br J Dermatol 2018; 179:669-678. [PMID: 29494763 DOI: 10.1111/bjd.16498] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Interleukin (IL)-31 is implicated in pruritus associated with pruritic skin diseases like atopic dermatitis. Although pruritus is a prominent feature in dermatomyositis (DM), few studies have evaluated the pathogenesis of DM-associated itch. OBJECTIVES To establish the prevalence of itch in DM, and to investigate the role of IL-31 in DM-related itch. METHODS Pruritus and disease activity of DM were evaluated by a visual analogue scale (VAS) and the Cutaneous Disease and Activity Severity Index (CDASI), respectively. Expression of IL-31 and IL-31 receptor alpha (IL-31RA) in lesional DM, nonlesional DM and healthy control skin was evaluated by quantitative reverse-transcriptase polymerase chain reaction and immunofluorescence. Flow cytometry was performed on skin cells isolated from lesional DM skin to identify cellular sources of IL-31 in DM. RESULTS Among 191 patients with DM, 50·8% had moderate-to-severe itch, and itch was correlated with increased cutaneous severity (r = 0·34). In patients with itchy DM, gene expression of IL31 and IL31RA in lesional skin was upregulated compared with nonlesional skin and healthy control skin. IL31 mRNA expression positively correlated with VAS itch score (r = 0·67). On immunofluorescence, immunoreactivity for IL-31 and IL-31RA was stronger in lesional skin. Flow cytometry showed that lesional DM skin contained significantly more IL-31-producing cells, and CD4+ cells were the most common cell type. Lenabasum, an emerging treatment for DM, significantly downregulated IL-31 from CpG-stimulated peripheral blood mononuclear cells. CONCLUSIONS Increased skin IL-31 may play a role in DM-associated itch, and ongoing trials will evaluate the effects of systemic treatment on IL-31 and itch in DM.
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Affiliation(s)
- H J Kim
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Department of Dermatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - M Zeidi
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A
| | - D Bonciani
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Department of Surgery and Translational Medicine, Section of Dermatology, University of Florence, Florence, Italy
| | - S M Pena
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A
| | - J Tiao
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A
| | - S Sahu
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A
| | - V P Werth
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A
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23
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Presto JK, Okon LG, Feng R, Wallace DJ, Furie R, Fiorentino D, Werth VP. Computerized planimetry to assess clinical responsiveness in a phase II randomized trial of topical R333 for discoid lupus erythematosus. Br J Dermatol 2018; 178:1308-1314. [PMID: 29336019 DOI: 10.1111/bjd.16337] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND R333 is a topical janus kinase and spleen tyrosine kinase inhibitor being evaluated for discoid lupus erythematosus (DLE) treatment. There is no validated measure to assess the area of active DLE lesions. OBJECTIVES To evaluate R333 efficacy and assess a technique to measure responsiveness. METHODS Fifty-four patients with DLE were randomized in a double-blind design to R333 or placebo. Primary end point was the proportion of patients achieving ≥ 50% decrease in erythema and scale based on lesional Cutaneous Lupus Erythematosus Disease Area and Severity IndexTM for all treated lesions at week 4. Two-dimensional (2D) area measurements for each lesion were recorded at baseline and weeks 1-6. Eighty-eight photographs (44 pre- and 44 post-treatment) were obtained from the trial and change in size of active areas was analysed by computerized planimetry and physician-assessed area change (PAAC). RESULTS Thirty-six patients were randomized to R333 and 18 patients were randomized to placebo. Primary end point was not achieved. There was a strong association between lesion activity and physician global assessment (P < 0·001). Photos of 42 patients assessed by computerized planimetry demonstrated excellent inter- and intra-rater reliability. Area change by computerized planimetry showed a strong correlation with PAAC (Spearman r = 0·72). Area change by 2D measurements showed a weak correlation with PAAC (Spearman r = 0·29). CONCLUSIONS Four weeks of R333 treatment did not result in significant improvement in lesion activity. Lesion activity and area change using computerized planimetry are better determinants of responsiveness than area change using 2D measurements.
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Affiliation(s)
- J K Presto
- Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A.,Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, U.S.A
| | - L G Okon
- Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A.,Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, U.S.A
| | - R Feng
- Biostatistics and Epidemiology at the Hospital of the University of Pennsylvania, Pennsylvania, PA, U.S.A
| | - D J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, U.S.A
| | - R Furie
- Division of Rheumatology, Northwell Health, Great Neck, NY, U.S.A
| | - D Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - V P Werth
- Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A.,Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, U.S.A
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24
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Caplan A, Imadojemu S, Werth VP. Importance of recognition and improved treatment for antimelanoma differentiation-associated protein 5-associated dermatomyositis. Br J Dermatol 2017; 177:1168-1169. [PMID: 29192975 DOI: 10.1111/bjd.15944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- A Caplan
- Department of Dermatology, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - S Imadojemu
- Departments of Medicine and Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A
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25
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Kim HJ, Langenhan JL, Robinson ES, Privette E, Achtman JC, Mitrani RA, Zeidi M, Sharma MR, Feng R, Nevas JL, Calianno C, Okawa J, Taylor L, Pappas-Taffer L, Werth VP. Effect of long-term treatment with tumour necrosis factor-α inhibitors on single-dose ultraviolet-induced changes in human skin. Br J Dermatol 2017; 177:1762-1764. [PMID: 28815549 DOI: 10.1111/bjd.15897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- H J Kim
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Department of Dermatology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Department of Dermatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - J L Langenhan
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - E S Robinson
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - E Privette
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J C Achtman
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R A Mitrani
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M Zeidi
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M R Sharma
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Feng
- Departments of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J L Nevas
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A
| | - C Calianno
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A
| | - J Okawa
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - L Taylor
- Departments of Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - L Pappas-Taffer
- Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Departments of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
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26
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Tiao J, Feng R, Berger EM, Brandsema JF, Coughlin CC, Khan N, Kichula EA, Lerman MA, Lvovich S, McMahon PJ, Rider LG, Rubin AI, Scalzi LV, Smith DM, Taxter AJ, Treat JR, Williams RP, Yum SW, Okawa J, Werth VP. Evaluation of the reliability of the Cutaneous Dermatomyositis Disease Area and Severity Index and the Cutaneous Assessment Tool-Binary Method in juvenile dermatomyositis among paediatric dermatologists, rheumatologists and neurologists. Br J Dermatol 2017; 177:1086-1092. [PMID: 28421601 DOI: 10.1111/bjd.15596] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) and Cutaneous Assessment Tool-Binary Method (CAT-BM) have been shown to be reliable and valid outcome measures to assess cutaneous disease in adult dermatomyositis (DM) and juvenile DM (JDM), respectively. OBJECTIVES This study compared the CDASI and CAT-BM for use by paediatric dermatologists, paediatric rheumatologists and paediatric neurologists in patients with JDM. METHODS Five paediatric dermatologists, five paediatric rheumatologists and five paediatric neurologists each evaluated 14 patients with JDM using the CDASI, CAT-BM, and skin Physician Global Assessment (PGA) scales. Inter-rater reliability, intra-rater reliability, construct validity and completion time were compared. RESULTS Inter-rater reliability for CDASI activity and damage scores was good to moderate for paediatric dermatologists and rheumatologists, but poor for paediatric neurologists. The inter-rater reliability for CAT-BM activity scores was moderate for paediatric dermatologists and rheumatologists, but poor for paediatric neurologists and poor across all specialties for damage scores. Intra-rater reliability for the CDASI and CAT-BM activity and damage scores was moderate to excellent for paediatric dermatologists, rheumatologists and neurologists. Strong associations were found between skin PGA activity and damage scores and CDASI or CAT-BM activity and damage scores, respectively (P < 0·002). The CDASI had a mean completion time of 5·4 min compared with that for the CAT-BM of 3·1 min. CONCLUSIONS Our data confirm the reliability of the CDASI activity and damage scores and the CAT-BM activity scores when used by paediatric dermatologists and rheumatologists in assessing JDM. Significant variation existed in the paediatric neurologists' scores.
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Affiliation(s)
- J Tiao
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A
| | - R Feng
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - E M Berger
- Hackensack University Medical Center, Hackensack, NJ, U.S.A
| | - J F Brandsema
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - C C Coughlin
- Division of Dermatology, Washington University School of Medicine, St Louis, MO, U.S.A
| | - N Khan
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A
| | - E A Kichula
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - M A Lerman
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - S Lvovich
- St Christopher's Hospital for Children, Philadelphia, PA, U.S.A
| | - P J McMahon
- Division of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - L G Rider
- Environmental Autoimmunity Group. Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD, U.S.A
| | - A I Rubin
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Division of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - L V Scalzi
- Penn State Children's Hospital, Hershey, PA, U.S.A
| | - D M Smith
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - A J Taxter
- Brenner Children's Hospital, Wake Forest Baptist Medical Center, Winston-Salem, NC, U.S.A
| | - J R Treat
- Division of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - R P Williams
- Minneapolis Clinic of Neurology, Maple Grove, MN, U.S.A
| | - S W Yum
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - J Okawa
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A
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27
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Anyanwu CO, Chansky PB, Feng R, Carr K, Okawa J, Werth VP. The systemic management of cutaneous dermatomyositis: Results of a stepwise strategy. Int J Womens Dermatol 2017; 3:189-194. [PMID: 29234712 PMCID: PMC5715209 DOI: 10.1016/j.ijwd.2017.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/15/2017] [Accepted: 05/08/2017] [Indexed: 12/18/2022] Open
Abstract
Treatment of dermatomyositis (DM) is often achieved with a stepwise algorithm. However, the literature lacks quality evidence to support the use of this therapeutic strategy. The result of a stepwise therapeutic strategy in the management of skin-only DM is presented to better understand the clinical outcomes and allow for future studies. A cohort of 102 patients with DM, 41 of whom had skin-only disease, were seen between July 2009 and April 2013 at a referral-based connective tissue disease clinic. The Cutaneous Dermatomyositis Disease Area and Severity Index was used to prospectively assess disease severity and the outcomes in 41 adult patients with skin-only DM were analyzed. Of the 41 patients with skin-only DM, 23 patients (56.1%) received antimalarial medications alone and 18 patients (43.9%) received second- or third-line agents. Ten patients (24.4%) remained at the first level of the treatment algorithm and received only hydroxychloroquine. Prednisone was included in the treatment regimen for 11 patients with skin-only disease (26.8%). The results show that management of cutaneous DM often requires second-line agents because antimalarial medications alone are insufficient to treat most patients with skin-only disease.
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Affiliation(s)
- C O Anyanwu
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - P B Chansky
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - R Feng
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - K Carr
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J Okawa
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - V P Werth
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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28
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Chansky PB, Mittal L, Werth VP. Dermatological evaluation in patients with skin of colour: the effect of erythema on outcome measures in atopic dermatitis. Br J Dermatol 2017; 176:853-854. [PMID: 28418145 DOI: 10.1111/bjd.15433] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- P B Chansky
- Department of Dermatology, Perelman Center for Advanced Medicine, Suite 1-330A, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, U.S.A
| | - L Mittal
- Department of Dermatology, Perelman Center for Advanced Medicine, Suite 1-330A, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, Perelman Center for Advanced Medicine, Suite 1-330A, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A
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29
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Abstract
It is currently believed that autoimmune conditions are triggered and aggravated by a variety of environmental factors such as cigarette smoking, infections, ultraviolet light or chemicals, as well as certain medications and vaccines in genetically susceptible individuals. Recent scientific data have suggested a relevant role of these factors not only in systemic lupus erythematosus, but also in cutaneous lupus erythematosus (CLE). A variety of environmental factors have been proposed as initiators and exacerbators of this disease. In this review we focused on those with the most convincing evidence, emphasizing the role of drugs in CLE. Using a combined search strategy of the MEDLINE and CINAHL databases the following trigger factors and/or exacerbators of CLE have been identified and described: drugs, smoking, neoplasms, ultraviolet radiation and radiotherapy. In order to give a practical insight we emphasized the role of drugs from various groups and classes in CLE. We also aimed to present a short clinical profile of patients with lesions induced by various drug classes.
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Affiliation(s)
- J Szczęch
- 1 Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - D Samotij
- 1 Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - V P Werth
- 2 Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center and Department of Dermatology University of Pennsylvania School of Medicine Philadelphia, PA, USA
| | - A Reich
- 1 Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
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30
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- J Tiao
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A
| | - R Feng
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - S Bird
- Department of Neurology Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J K Choi
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A
| | - J Dunham
- Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M George
- Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - T C Gonzalez-Rivera
- Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Department of Neurology, GlaxoSmithKline USA, Philadelphia, PA, U.S.A
| | - J L Kaufman
- Department of Neurology Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - N Khan
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A
| | - J J Luo
- Department of Neurology, Temple University School of Medicine, Philadelphia, PA, U.S.A
| | - R Micheletti
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - A S Payne
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Price
- Department of Neurology Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - C Quinn
- Department of Neurology Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - A I Rubin
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - A G Sreih
- Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - P Thomas
- Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J Okawa
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A
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31
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George MD, Shah R, Kreider M, Miller WT, Merkel PA, Werth VP. Pulmonary function tests, interstitial lung disease and lung function decline in outpatients with classic and clinically amyopathic dermatomyositis. Br J Dermatol 2016; 176:262-264. [PMID: 27229750 DOI: 10.1111/bjd.14771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- M D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Shah
- Division of Pulmonary & Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Division of Pulmonary, Allergy, and Critical Care Medicine, University of California, San Francisco, CA, U.S.A
| | - M Kreider
- Division of Pulmonary & Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - W T Miller
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - P A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, U.S.A
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32
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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] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C C Ang
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Department of Dermatology, Changi General Hospital, Singapore
| | - C O Anyanwu
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - E Robinson
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J Okawa
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R Feng
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Y Hamaguchi
- Department of Dermatology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - V P Werth
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
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33
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Abstract
Cutaneous lupus erythematosus (CLE) is an autoimmune skin disease occurring in association with or without systemic lupus erythematosus (SLE). Although antimalarials are widely used as the first-line systemic agent, refractory cases may benefit from additional immunomodulators, immunosuppressives, and biologics. An interest in biological therapies for CLE has emerged in recent years due to novel insight into the pathogenesis of CLE. These targets include B cells, T cells, and cytokines that are involved in immune system pathways. Currently belimumab is the only biological therapy approved for SLE and no biologic has been approved for CLE. While there is a paucity of high quality evidence with regard to biologics in CLE management, trials are currently being performed to determine their role.
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Affiliation(s)
- J K Presto
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), USA.,2 Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, USA
| | - E Z Hejazi
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), USA.,2 Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, USA
| | - V P Werth
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), USA.,2 Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, USA
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34
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Reich A, Werth VP, Furukawa F, Kuhn A, Szczęch J, Samotij D, Szepietowski JC. Treatment of cutaneous lupus erythematosus: current practice variations. Lupus 2016; 25:964-72. [PMID: 26821963 DOI: 10.1177/0961203316628997] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Indexed: 11/16/2022]
Abstract
The treatment of cutaneous lupus erythematous (CLE) remains a challenge. Most of the therapeutic options used in CLE have not been tested in randomized controlled studies and to date no agent has been approved. Therefore, CLE treatment is mostly based on personal experience. To better characterize therapeutic habits among physicians treating CLE patients, a questionnaire-based study about various aspects of topical and systemic treatment for CLE has been performed. The questionnaire was distributed among CLE experts, mostly from Japan, the USA, and Europe. A total of 82 completed questionnaires were assessed. High-potent and potent corticosteroids as well as calcineurin inhibitors were the most often recommended topical treatment for all CLE subtypes. The most relevant factors for initiation of systemic therapy were severity of skin lesions, concomitant involvement of internal organs, CLE subtype and lack of response to topical therapies. Corticosteroids and antimalarials were considered as the most suitable and effective systemic drugs for CLE patients. However, significant differences were observed between various CLE subtypes and between different countries regarding the assessment of various topical and systemic treatment options. In conclusion, great variability of obtained answers underlines the need of development of CLE treatment guidelines suitable for different disease subtypes.
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Affiliation(s)
- A Reich
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - V P Werth
- Philadelphia Veterans Affairs Medical Center and Department of Dermatology University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - F Furukawa
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - A Kuhn
- Interdisciplinary Center for Clinical Trials, University Medical Center, Mainz, Germany
| | - J Szczęch
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - D Samotij
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
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35
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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: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- C O Anyanwu
- Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A
| | - D F Fiorentino
- Division of Immunology and Rheumatology, Department of Dermatology and Medicine, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - L Chung
- Division of Immunology and Rheumatology, Department of Dermatology and Medicine, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - C Dzuong
- Division of Immunology and Rheumatology, Department of Dermatology and Medicine, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Y Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J Okawa
- Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A
| | - K Carr
- Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A
| | - K J Propert
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, U.S.A.,Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A
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36
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Merola JF, Nyberg F, Furukawa F, Goodfield MJ, Hasegawa M, Marinovic B, Szepietowski J, Dutz J, Werth VP. Redefining cutaneous lupus erythematosus: a proposed international consensus approach and results of a preliminary questionnaire. Lupus Sci Med 2015; 2:e000085. [PMID: 25861460 PMCID: PMC4379883 DOI: 10.1136/lupus-2015-000085] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 02/17/2015] [Accepted: 02/22/2015] [Indexed: 11/24/2022]
Abstract
There is currently no uniform definition of cutaneous lupus erythematosus (CLE) upon which to base a study population for observational and interventional trials. A preliminary questionnaire was derived from and sent to a panel of CLE experts which demonstrated consensus agreement that (1) there is a need for new definitions for CLE (2) CLE is distinct from systemic lupus erythematosus and that a CLE grouping scheme should remain apart from current systemic lupus erythematosus schema (3) current CLE grouping schemes are inadequate around communication, prognostic information and to meet the needs of researchers, clinicians, patients and payers.
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Affiliation(s)
- J F Merola
- Division of Rheumatology, Departments of Dermatology and Medicine , Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts , USA
| | - F Nyberg
- Institution for Clinical Sciences, Karolinska Institutet at Danderyd Hospital , Stockholm , Sweden
| | - F Furukawa
- Department of Dermatology , Wakayama Medical University , Wakayama , Japan
| | - M J Goodfield
- Department of Dermatology , Leeds General Infirmary , Leeds , UK
| | - M Hasegawa
- Department of Dermatology, Faculty of Medical Sciences , School of Medicine, University of Fukui , Fukui , Japan
| | - B Marinovic
- University Department of Dermatology and Venereology , Zagreb University Hospital Center and School of Medicine , Zagreb , Croatia
| | - J Szepietowski
- Department of Dermatology, Venereology and Allergology , University of Medicine , Wrocław , Poland
| | - J Dutz
- Department of Dermatology and Skin Science , University of British Columbia , Vancouver, British Columbia , Canada
| | - V P Werth
- Philadelphia Department of Veterans Affairs Medical Center , University of Pennsylvania , Philadelphia, Pennsylvania , USA ; Department of Dermatology , University of Pennsylvania , Philadelphia, Pennsylvania , USA
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37
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- R P Hall
- Department of Dermatology, Duke Hospital South, Duke University Medical Center, Room 4044, Durham, NC, 27710, U.S.A
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38
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- E S Robinson
- Veteran Affairs Medical Center, Philadelphia, PA, U.S.A.; Department of Dermatology, University of Pennsylvania, 1 Convention Avenue, Philadelphia, PA, 19104, U.S.A
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- S M Verma
- Department of Dermatology, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, U.S.A; Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A
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Orbai AM, Truedsson L, Sturfelt G, Nived O, Fang H, Alarcón GS, Gordon C, Merrill J, Fortin PR, Bruce IN, Isenberg DA, Wallace DJ, Ramsey-Goldman R, Bae SC, Hanly JG, Sanchez-Guerrero J, Clarke AE, Aranow CB, Manzi S, Urowitz MB, Gladman DD, Kalunian KC, Costner MI, Werth VP, Zoma A, Bernatsky S, Ruiz-Irastorza G, Khamashta MA, Jacobsen S, Buyon JP, Maddison P, Dooley MA, Van Vollenhoven RF, Ginzler E, Stoll T, Peschken C, Jorizzo JL, Callen JP, Lim SS, Fessler BJ, Inanc M, Kamen DL, Rahman A, Steinsson K, Franks AG, Sigler L, Hameed S, Pham N, Brey R, Weisman MH, McGwin G, Magder LS, Petri M. Anti-C1q antibodies in systemic lupus erythematosus. Lupus 2014; 24:42-9. [PMID: 25124676 DOI: 10.1177/0961203314547791] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Anti-C1q has been associated with systemic lupus erythematosus (SLE) and lupus nephritis in previous studies. We studied anti-C1q specificity for SLE (vs rheumatic disease controls) and the association with SLE manifestations in an international multicenter study. METHODS Information and blood samples were obtained in a cross-sectional study from patients with SLE (n = 308) and other rheumatologic diseases (n = 389) from 25 clinical sites (84% female, 68% Caucasian, 17% African descent, 8% Asian, 7% other). IgG anti-C1q against the collagen-like region was measured by ELISA. RESULTS Prevalence of anti-C1q was 28% (86/308) in patients with SLE and 13% (49/389) in controls (OR = 2.7, 95% CI: 1.8-4, p < 0.001). Anti-C1q was associated with proteinuria (OR = 3.0, 95% CI: 1.7-5.1, p < 0.001), red cell casts (OR = 2.6, 95% CI: 1.2-5.4, p = 0.015), anti-dsDNA (OR = 3.4, 95% CI: 1.9-6.1, p < 0.001) and anti-Smith (OR = 2.8, 95% CI: 1.5-5.0, p = 0.01). Anti-C1q was independently associated with renal involvement after adjustment for demographics, ANA, anti-dsDNA and low complement (OR = 2.3, 95% CI: 1.3-4.2, p < 0.01). Simultaneously positive anti-C1q, anti-dsDNA and low complement was strongly associated with renal involvement (OR = 14.9, 95% CI: 5.8-38.4, p < 0.01). CONCLUSIONS Anti-C1q was more common in patients with SLE and those of Asian race/ethnicity. We confirmed a significant association of anti-C1q with renal involvement, independent of demographics and other serologies. Anti-C1q in combination with anti-dsDNA and low complement was the strongest serological association with renal involvement. These data support the usefulness of anti-C1q in SLE, especially in lupus nephritis.
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Affiliation(s)
- A-M Orbai
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L Truedsson
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden
| | - G Sturfelt
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden
| | - O Nived
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden
| | - H Fang
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - C Gordon
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences University of Birmingham, Birmingham, UK
| | - Jt Merrill
- Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - P R Fortin
- Division of Rheumatology, Department of Medicine, Centre Hospitalier Universitaire (CHU) de Québec Axe Maladies Infectieuses et Immunitaires, CRCHU de Québec, Université Laval, Quebec City, Quebec, Canada
| | - I N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK
| | - D A Isenberg
- Centre for Rheumatology, Research Division of Medicine, London, UK
| | - D J Wallace
- Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - R Ramsey-Goldman
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - S-C Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - J G Hanly
- Division of Rheumatology, Departments of Medicine and Pathology Capital Health and Dalhousie University, Halifax, Nova Scotia, Canada
| | - J Sanchez-Guerrero
- Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - A E Clarke
- Divisions of Clinical Epidemiology and Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - C B Aranow
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - S Manzi
- Department of Medicine, Division of Rheumatology, Allegheny Singer Research Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - M B Urowitz
- Toronto Western Hospital Toronto, Ontario, Canada
| | - D D Gladman
- Toronto Western Hospital Toronto, Ontario, Canada
| | - K C Kalunian
- Division of Rheumatology, Allergy and Immunology, UCSD School of Medicine, La Jolla, CA, USA
| | - M I Costner
- North Dallas Dermatology Associates, Dallas, TX, USA
| | - V P Werth
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA, USA
| | - A Zoma
- Lanarkshire Centre for Rheumatology and Hairmyres Hospital, East Kilbride, UK
| | - S Bernatsky
- Divisions of Clinical Epidemiology and Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - G Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Hospital Universitario Cruces Universidad del Pais Vasco, Barakaldo, Spain
| | | | - S Jacobsen
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - J P Buyon
- New York University, New York, NY, USA
| | | | - M A Dooley
- University of North Carolina, Chapel Hill, NC, USA
| | | | - E Ginzler
- State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - T Stoll
- Kantonsspital Schaffhausen, Schaffhausen, Switzerland
| | - C Peschken
- University of Manitoba Winnipeg, Manitoba, Canada
| | - J L Jorizzo
- Wake Forest University, Winston-Salem, NC, USA
| | - J P Callen
- University of Louisville, Louisville, KY, USA
| | - S S Lim
- Emory University, Atlanta, GA, USA
| | - B J Fessler
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M Inanc
- Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - D L Kamen
- Medical University of South Carolina, Charleston, SC, USA
| | - A Rahman
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK
| | - K Steinsson
- Landspitali University Hospital, Reykjavik, Iceland
| | | | - L Sigler
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S Hameed
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - N Pham
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Brey
- University of Texas Health Science Center, San Antonio, TX, USA
| | - M H Weisman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - G McGwin
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - L S Magder
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
| | - M Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Cutaneous lupus erythematosus (CLE) encompasses a wide range of dermatologic manifestations, which may or may not be associated with the development of systemic disease. Cutaneous lupus is divided into several sub-types, including acute CLE (ACLE), sub-acute CLE (SCLE) and chronic CLE (CCLE). CCLE includes discoid lupus erythematosus (DLE), LE profundus (LEP), chilblain cutaneous lupus and lupus tumidus. The diagnosis of these diseases requires proper classification of the sub-type, through a combination of physical examination, laboratory studies, histology, antibody serology and occasionally direct immunofluorescence, while ensuring to exclude systemic disease. The treatment of cutaneous lupus consists of patient education on proper sun protection along with appropriate topical and systemic agents. Systemic agents are indicated in cases of widespread, scarring or treatment-refractory disease. In this chapter, we discuss issues in classification and diagnosis of the various sub-types of CLE, as well as provide an update on therapeutic management.
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Affiliation(s)
- L G Okon
- Department of Dermatology, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Tjärnlund A, Bottai M, Rider LG, Werth VP, Pilkington C, de Visser M, Alfredsson L, Amato AA, Barohn RJ, Liang MH, Singh JA, Miller FW, Lundberg IE. OP0035 Progress Report on the Development of New Classification Criteria for Adult and Juvenile Idiopathic Inflammatory Myopathies. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Vasquez R, Wang D, Tran QP, Adams-Huet B, Chren MM, Costner MI, Cohen JB, Werth VP, Chong BF. A multicentre, cross-sectional study on quality of life in patients with cutaneous lupus erythematosus. Br J Dermatol 2012; 168:145-53. [PMID: 22708924 DOI: 10.1111/j.1365-2133.2012.11106.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A study at the University of Pennsylvania (UPenn) Medical Center demonstrated that quality of life in patients with cutaneous lupus erythematosus (CLE) is negatively impacted. Whether patients with CLE in other geographic locations have similar quality of life is unknown. OBJECTIVES We sought to compare quality of life indicators between patients with CLE at the University of Texas Southwestern (UTSW) Medical Center at Dallas and those at UPenn. METHODS Patients with CLE (total n=248) at UTSW (n=91) and UPenn (n=157) completed the Skindex-29 +3 and Short Form-36 (SF-36) surveys related to quality of life. Additional information, including demographics, presence of systemic lupus erythematosus (SLE) and disease severity, was collected from UTSW patients with CLE. RESULTS Most Skindex-29 + 3 and SF-36 subdomain scores between UTSW and UPenn patients with CLE were similar. However, UTSW patients with CLE were significantly more affected in the functioning and lupus-specific Skindex-29 + 3 domains, and physical functioning, role-physical and general health SF-36 subscales than UPenn patients with CLE (P<0·05). Factors related to poor quality of life in UTSW patients with CLE include sex, income, education, presence of SLE, and skin disease activity. CONCLUSIONS Most quality of life indicators were similar between the two CLE populations. Differences in psychosocial behaviour, and a larger proportion of patients with SLE and females in the UTSW group likely attributed to differences in a minority of Skindex-29+3 and SF-36 subdomains. Capturing data from CLE populations in different locations provides a more thorough picture of the quality of life that patients with CLE experience on a daily basis with special attention to quality of life issues in select patients with CLE.
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Affiliation(s)
- R Vasquez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- I Braunstein
- Dermatology Section, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
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Mosca M, Tani C, Aringer M, Bombardieri S, Boumpas D, Cervera R, Doria A, Jayne D, Khamashta MA, Kuhn A, Gordon C, Petri M, Schneider M, Shoenfeld Y, Smolen JS, Talarico R, Tincani A, Ward MM, Werth VP, Carmona L. Development of quality indicators to evaluate the monitoring of SLE patients in routine clinical practice. Autoimmun Rev 2011; 10:383-8. [PMID: 21224016 DOI: 10.1016/j.autrev.2010.12.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
The assessment of systemic lupus erythematosus (SLE) patients in routine clinical practice is mainly based on the experience of the treating physician. This carries the risk of unwanted variability. Variability may have an impact on the quality of care offered to SLE patients, thereby affecting outcomes. Recommendations represent systematically developed statements to help practitioners in reducing variability. However, major difficulties arise in the application of recommendations into clinical practice. In this respect, the use of quality indicators may raise the awareness among rheumatologists regarding potential deficiencies in services and improve the quality of health care. The aim of this study was to develop a set of quality indicators (QI) for SLE by translating into QIs the recently developed EULAR Recommendations for monitoring SLE patients in routine clinical practice and observational studies. Eleven QIs have been developed referring to the use of validated activity and damage indices in routine clinical practice, general evaluation of drug toxicity, evaluation of comorbidities, eye evaluation, laboratory assessment, evaluation of the presence of chronic viral infections, documentation of vaccination and of antibody testing at baseline. A disease specific set of quality assessment tools should help physicians deliver high quality of care across populations. Routine updates will be needed.
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Affiliation(s)
- M Mosca
- Rheumatology Unit, Department of Internal Medicine, University of Pisa, Italy.
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Ruperto N, Hanrahan LM, Alarcón GS, Belmont HM, Brey RL, Brunetta P, Buyon JP, Costner MI, Cronin ME, Dooley MA, Filocamo G, Fiorentino D, Fortin PR, Franks AG, Gilkeson G, Ginzler E, Gordon C, Grossman J, Hahn B, Isenberg DA, Kalunian KC, Petri M, Sammaritano L, Sánchez-Guerrero J, Sontheimer RD, Strand V, Urowitz M, von Feldt JM, Werth VP, Merrill JT. International consensus for a definition of disease flare in lupus. Lupus 2010; 20:453-62. [PMID: 21148601 DOI: 10.1177/0961203310388445] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Lupus Foundation of America (LFA) convened an international working group to obtain a consensus definition of disease flare in lupus. With help from the Paediatric Rheumatology International Trials Organization (PRINTO), two web-based Delphi surveys of physicians were conducted. Subsequently, the LFA held a second consensus conference followed by a third Delphi survey to reach a community-wide agreement for flare definition. Sixty-nine of the 120 (57.5%) polled physicians responded to the first survey. Fifty-nine of the responses were available to draft 12 preliminary statements, which were circulated in the second survey. Eighty-seven of 118 (74%) physicians completed the second survey, with an agreement of 70% for 9/12 (75%) statements. During the second conference, three alternative flare definitions were consolidated and sent back to the international community. One hundred and sixteen of 146 (79.5%) responded, with agreement by 71/116 (61%) for the following definition: "A flare is a measurable increase in disease activity in one or more organ systems involving new or worse clinical signs and symptoms and/or laboratory measurements. It must be considered clinically significant by the assessor and usually there would be at least consideration of a change or an increase in treatment." The LFA proposes this definition for lupus flare on the basis of its high face validity.
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Affiliation(s)
- N Ruperto
- Gaslini Pediatria II, Reumatologia, PRINTO, Genova, Italy
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Mosca M, Tani C, Aringer M, Bombardieri S, Boumpas D, Brey R, Cervera R, Doria A, Jayne D, Khamashta MA, Kuhn A, Gordon C, Petri M, Rekvig OP, Schneider M, Sherer Y, Shoenfeld Y, Smolen JS, Talarico R, Tincani A, van Vollenhoven RF, Ward MM, Werth VP, Carmona L. European League Against Rheumatism recommendations for monitoring patients with systemic lupus erythematosus in clinical practice and in observational studies. Ann Rheum Dis 2009; 69:1269-74. [PMID: 19892750 DOI: 10.1136/ard.2009.117200] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To develop recommendations for monitoring patients with systemic lupus erythematosus (SLE) in clinical practice and observational studies and to develop a standardised core set of variables to monitor SLE. METHODS We followed the European League Against Rheumatism (EULAR) standardised procedures for guideline development. The following techniques were applied: nominal groups, Delphi surveys for prioritisation, small group discussion, systematic literature review and two Delphi rounds to obtain agreement. The panel included rheumatologists, internists, dermatologists, a nephrologist and an expert related to national research agencies. The level of evidence and grading of recommendations were determined according to the Levels of Evidence and Grades of Recommendations of the Oxford Centre for Evidence-Based Medicine. RESULTS A total of 10 recommendations have been developed, covering the following aspects: patient assessment, cardiovascular risk factors, other risk factors (osteoporosis, cancer), infection risk (screening, vaccination, monitoring), frequency of assessments, laboratory tests, mucocutaneous involvement, kidney monitoring, neuropsychological manifestations and ophthalmology assessment. A 'core set' of minimal variables for the assessment and monitoring of patients with SLE in clinical practice was developed that included some of the recommendations. In addition to the recommendations, indications for specific organ assessments that were viewed as part of good clinical practice were discussed and included in the flow chart. CONCLUSIONS A set of recommendations for monitoring patients with SLE in routine clinical practice has been developed. The use of a standardised core set to monitor patients with SLE should facilitate clinical practice, as well as the quality control of care for patients with SLE, and the collection and comparison of data in observational studies.
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Affiliation(s)
- M Mosca
- Correspondence to Dr Marta Mosca, University of Pisa, via Roma 67, Ospedale S. Chiara, Pisa, 56126, Italy.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- M Yassaee
- Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia, PA 19104-2676, USA
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Klein RQ, Bangert CA, Costner M, Connolly MK, Tanikawa A, Okawa J, Rose M, Fakharzadeh SS, Fiorentino D, Lee LA, Sontheimer RD, Taylor L, Troxel AB, Werth VP. Comparison of the reliability and validity of outcome instruments for cutaneous dermatomyositis. Br J Dermatol 2008; 159:887-94. [PMID: 18616782 DOI: 10.1111/j.1365-2133.2008.08711.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reliable and validated measures of skin disease severity are needed for cutaneous dermatomyositis (DM). Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI), Dermatomyositis Skin Severity Index (DSSI) and Cutaneous Assessment Tool (CAT) skin indices have been developed as outcome instruments. OBJECTIVES We sought to demonstrate reliability and validity of the CDASI, and to compare the CDASI with other potential tools for use in measuring disease severity in cutaneous dermatomyositis. PATIENTS AND METHODS CDASI has four activity and two damage measures, with scores from 0 to 148. DSSI assesses activity based on body surface area and severity on a scale of 0-72. CAT uses 21 activity and damage items, for a range of 0-175 for activity and 0-33 for damage. Ten dermatologists used the instruments to score the same 12-16 patients in one session. Global validation measures were administered to physicians and patients. RESULTS Global validation measures correlated with the three outcome instruments (P < 0.0001). CAT displayed lower inter- and intrarater reliability relative to the CDASI. All scales correlate better with physician than patient global skin measures. CONCLUSIONS It appears that the CDASI may be a useful outcome measure for studies of cutaneous DM. Further testing to compare responsiveness of all three measures is necessary.
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Affiliation(s)
- R Q Klein
- Department of Dermatology, School of Medicine, University of Pennsylvania, 3600 Spruce Street, 2 Maloney Building, Philadelphia, PA 19104, USA
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