First clinical evaluation of the safety and efficacy of tarumase for the debridement of venous leg ulcers

We report the first clinical evaluation of a new enzymatic wound debridement product containing tarumase in venous leg ulcer patients. As a first-in-human study, this was a prospective, open-label, multi-centre, dose escalation study across five dose cohorts and involving a total of 43 patients treated three times weekly for up to 4 weeks (12 applications). The primary and secondary endpoints of the study were to assess the systemic safety, local tolerability, and early proof of concept both for wound debridement and healing. Results indicated that the tarumase enzyme was well tolerated when applied topically to wounds, with no indications of systemic absorption, no evidence of antibody generation, and no systemic effects on coagulation pathways. Locally, there was no evidence of pain on application, no local itching, no increases in erythema, oedema, exudate or bleeding and only a few treatment emergent adverse events were reported. As the concentration of tarumase was escalated, trends towards faster and improved effectiveness of wound debridement were observed, especially in patients with significant slough at baseline. Trends towards faster rates of healing were also noted based on observations of increased granulation tissue, increased linear healing and reduction in surface area over the 4-week treatment period.

How Should Clinical Wound Care and Management Translate to Effective Engineering Standard Testing Requirements from Foam Dressings? Mapping the Existing Gaps and Needs

Significance: Wounds of all types remain one of the most important, expensive, and common medical problems, for example, up to approximately two-thirds of the work time of community nurses is spent on wound management. Many wounds are treated by means of dressings. The materials used in a dressing, their microarchitecture, and how they are composed and constructed form the basis for the laboratory and clinical performances of any advanced dressing. Recent Advances: The established structure/function principle in material science is reviewed and analyzed in this article in the context of wound dressings. This principle states that the microstructure determines the physical, mechanical, and fluid transport and handling properties, all of which are critically important for, and relevant to the, adequate performances of wound dressings. Critical Issues: According to the above principle, once the clinical requirements for wound care and management are defined for a given wound type and etiology, it should be theoretically possible to translate clinically relevant characteristics of dressings into physical test designs resulting specific metrics of materials, mechanical, and fluid transport and handling properties, all of which should be determined to meet the clinical objectives and be measurable through standardized bench testing. Future Directions: This multidisciplinary review article, written by an International Wound Dressing Technology Expert Panel, discusses the translation of clinical wound care and management into effective, basic engineering standard testing requirements from wound dressings with respect to material types, microarchitecture, and properties, to achieve the desirable performance in supporting healing and improving the quality of life of patients.

Development of a Tissue Oxygenation Flow-Based Index Toward Discerning the Healing Status in Diabetic Foot Ulcers

Objective: The objective of this study is to characterize breath-hold (BH)-induced oxygenation changes in diabetic foot ulcers (DFUs) and develop an oxygenation flow index (OFI) to discern nonhealing from healing DFUs. Approach: The imaging approach utilizes an innovative BH stimulus that induces vasoconstriction and measures for altering oxygenation flow in and around the tissues of DFUs and controls. The modified Beer-Lambert law was utilized to calculate hemoglobin-based spatiotemporal oxygenation maps in terms of oxygen saturation. Results: We found controls had synchronous BH-induced oxygenation changes across the dorsal (OFI: 29.0%) and plantar (OFI: 57.6%) aspects of the foot. Nonhealing DFUs, however, had less synchronous BH-induced oxygenation changes (OFI <28%). In addition, two complicated healing DFU cases, or cases with underlying issues or poor long-term healing outcomes, were observed to have OFIs <28%. Innovation: An OFI was developed to differentiate nonhealing DFUs from healing DFUs using a single, noncontact, near-infrared optical scanner for spatiotemporal oxygenation monitoring. The OFI has potential to provide immediate feedback on the microcirculation in DFUs, through hemoglobin-based oxygenation parameters. Conclusion: A preliminary threshold (OFI <28%) could differentiate nonhealing and complicated DFUs from healing DFUs. The overall oxygenation flow pattern was less synchronous (or the OFI value reduced) in the nonwound areas of the feet that were nonhealing. In other words, the reduced OFI value (<28%) in the entire foot, excluding the wound region is a possible indicator that the wound may not heal.

Upregulation of Caveolae-Associated Proteins in Lesional Samples of Hidradenitis Suppurativa: A Case Series Study

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition. HS disease management has proven difficult owing to an insufficient understanding of the immunological processes that drive its pathogenesis. We have demonstrated that misregulation of caveolae perturbs inflammatory responses, inhibits cutaneous wound healing, and contributes to immune privilege collapse in other hair follicle-related diseases. However, nothing is known about its role or the role of structural components of caveolae (caveolin [Cav1] 1, Cav2, and Cavin-1) in the pathophysiology of HS. We aimed to identify whether Cav1, Cav2, and Cavin-1 may serve as immunohistochemical markers of HS. Lesional and perilesional HS skin samples from patients (n = 7, mean age = 35.7 years, range = 20-57 years) with active HS and normal skin from control participants (n = 4, mean age = 36.7 years, range = 23-49 years) were used to assess Cav1, Cav2, and Cavin-1 expression and localization by immunofluorescence staining. HS samples demonstrated increased levels of Cav1 compared with normal skin, whereas Cav1, Cav2, and Cavin-1 were all elevated in hair follicles of lesional versus perilesional HS samples, suggesting a potentially novel therapeutic target and highlighting caveolae as potential biomarkers of HS.

Anti-Tumor Necrosis Factor Alpha Therapeutic Drug Monitoring in Inflammatory Disease: A Systematic Review

BACKGROUND

Monoclonal antibodies encompass an increasingly important treatment for a variety of dermatologic conditions including hidradenitis suppurativa (HS). The high failure rate and cost of anti-tumor necrosis alpha (TNF-&alpha;) agents and emergence of biologic treatments critically warrant treatment strategies that identify treatment failures early and optimize therapy. This review&rsquo;s primary objective is to understand the current literature on biologic therapeutic drug monitoring (TDM) used in chronic inflammatory diseases and apply this knowledge to future dermatologic studies and treatment.

METHODS

Randomized controlled trials (RCTs) or high-quality retrospective analyses of RCTs investigating the outcomes of biologic TDM were identified between January 1979 and January 2020 within the PubMed/MEDLINE database using keywords: "biologic," "therapeutic drug monitoring," and "randomized controlled trial," combined with common medical conditions for which biologics are prescribed: "rheumatoid arthritis," "inflammatory bowel disease," "psoriasis," "Crohn&rsquo;s," "ulcerative colitis," "vasculitis," and "hidradenitis suppurativa." The methods and findings of each study were compared.

RESULTS

Three RCTs were included all examining TDM of TNF-&alpha; inhibitors in inflammatory bowel disease (IBD). Two studied TDM of infliximab, and one adalimumab. An additional high-quality retrospective analysis of an infliximab RCT captured in our search was also included. Two of the three RCTs (TAXIT and PAILOT) found proactive TDM superior to clinically based dosing and reactive TDM, respectively. The third RCT (TAILORX) found no significant difference between proactive and reactive TDM.

CONCLUSION

TDM of anti-TNF-&alpha; biologics in IBD has demonstrated success through RCTs. Knowledge gained from these studies applies to dermatologic treatment. J Drugs Dermatol. 2023;22(5): doi:10.36849/JDD.6671.

The development of a core outcome set for clinical effectiveness studies of bordered foam dressings in the treatment of complex wounds

AIM

The aim of this project was to develop a core outcome set (COS) for clinical effectiveness studies of bordered foam dressings in the treatment of complex wounds.

METHODS

The research project followed the Core Outcome Measures in Effectiveness Trials (COMET) initiative and consisted of two phases. The first phase prepared the background and process, while the second phase had three steps: outcome list generation via systematic review and qualitative study, Delphi consensus study, and consensus meeting. The study has been registered in the Core Outcome Measures in Effectiveness Trials database.

RESULTS

The systematic review resulted in 82 outcomes and 20 additional outcomes were obtained during the interviews. After refinement, 111 panellists from 23 countries rated a list of 51 outcomes. In the following consensus meeting, six outcomes were prioritized to be included in the core outcome set. After the consensus meeting, a patient-reported outcome was added to the core outcome set.

CONCLUSION

The COS for evaluating the effectiveness of bordered foam dressings in treating complex wounds includes 7 outcomes: "ability to stay in place", "leakage", "pain", "dressing related periwound skin changes", "change in wound size over time", and "overall satisfaction". These identified outcomes are correlated with contemporary bioengineering testing and evaluation methods for dressing performance, which underpins the need for a close multidisciplinary collaboration to advance the field of wound dressings. The outcome 'overall satisfaction' reflects the impact of complex wounds and their treatment on a patient's daily life. The use of these outcomes is recommended to improve data synthesis and promote evidence-based practice. Future developments in COS development involve creating measurement instruments and relevant endpoints for these outcomes.

Hidradenitis Suppurativa: Surgery, Lasers, and Emerging Techniques

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder that is characterized by painful nodules, abscesses and tunnels in skin folds. Current management of HS often requires a multidisciplinary approach, including medical, procedural, surgical, and psychosocial intervention. Here we review surgical techniques for the treatment of HS. While many surgical options are available for patients with HS, it is imperative that surgical planning focuses on medical optimization, patient risk factors, disease severity, and patient preferences to achieve the best outcomes.

Chronic wound microenvironment mediates selection of biofilm-forming multi drug resistant Staphylococcus epidermidis with capability to impair healing

Venous leg ulcers (VLU) are the most common chronic wounds characterized by bacterial biofilms and perturbed microbiome. Staphylococcus epidermidis is primarily known as skin commensal beneficial for the host, however, some strains can form biofilms and cause infections. By employing shotgun metagenomic sequencing we show that genetic signatures of antimicrobial resistance, adhesion and biofilm formation in VLU isolates correlate with in vitro bacterial traits. We demonstrate that the capability of chronic wound isolates to form biofilms and elicit IL-8 and IL-1β expression in human ex vivo wounds, correlates with the non-healing outcomes in patients with VLU. In contrast, commensal strains were incapable of surviving in the human ex vivo wounds. We show that major fitness traits of S. epidermis from VLU involve genes for resistance to methicillin and mupirocin, while the biofilm formation relied on the minimal number of genetic elements responsible for bacterial binding to fibronectin and fibrinogen. This underscores the importance of the emergence of treatment resistant virulent lineages in patients with non-healing wounds.

Mechanical and contact characteristics of foam materials within wound dressings: Theoretical and practical considerations in treatment

In the treatment of acute and chronic wounds, the clinical performance of a given foam-based dressing, and, ultimately, the wound healing and cost of care outcomes are strongly influenced by the mechanical performance of the foam material/s within that dressing. Most aspects of the mechanical performance of foam materials, for example, their stiffness, frictional properties, conformability, swelling characteristics and durability, and the overall mechanical protection provided by a foam-based dressing to a wound strongly depend on the microstructure of the foam components, particularly on their microtopography, density and porosity. This article, therefore, provides, for the first time, a comprehensive, self-inclusive compilation of clinically relevant theoretical and practical considerations, based on published analytical and experimental research as well as clinical experience related to the mechanical performance of foams in foam-based wound dressings. The current bioengineering information is useful for establishing understanding of the importance of mechanical properties of foams in foam-based dressings among clinicians and researchers in industry and academia, and other potential stakeholders in the wound care field, for example, regulators and buyers. This information is also particularly important for the development of standardised test methods for the evaluation of foam-based wound dressings and resulting standard mechanical performance metrics for these dressings.

Innate immunity and microbial dysbiosis in hidradenitis suppurativa – vicious cycle of chronic inflammation

Hidradenitis Suppurativa (HS) is a chronic multifactorial inflammatory skin disease with incompletely understood mechanisms of disease pathology. HS is characterized by aberrant activation of the innate immune system, resulting in activation of pathways that aim to protect against pathogenic microorganisms, and also contribute to failure to resolve inflammation. Imbalance in innate immunity is evident in deregulation of host antimicrobial peptides (AMPs) and the complement system associated with the microbiome dysbiosis. The pathology is further complicated by ability of pathogens associated with HS to overcome host immune response. Potential roles of major AMPs, cathelicidin, defensins, dermcidin, S100 proteins, RNAse 7 and complement proteins are discussed. Dysregulated expression pattern of innate immunity components in conjunction with bacterial component of the disease warrants consideration of novel treatment approaches targeting both host immunity and pathogenic microbiome in HS.

Fish Skin Grafts with Omega-3 for Treatment of Chronic Wounds: Exploring the Role of Omega-3 Fatty Acids in Wound Healing and A Review of Clinical Healing Outcomes

Chronic, non-healing wounds, such as diabetic foot ulcers and venous leg ulcers, have a significant economic impact on healthcare and are associated with elevated patient morbidity. Among the toolset of treatment options available to clinicians, skin grafts from other species (xenografts) are often used to promote wound closure. While porcine xenografts have been the most used skin xenograft over the years, acellular fish skin grafts from Atlantic cod (Gadus morhua) have steadily gained traction in usage. Unlike other skin grafts, acellular fish skin grafts have a substantial lipid profile primarily composed of omega-3 fatty acids, notably eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Fish oil supplementation has been shown to result in faster rates of wound epithelialization, and omega 3 fatty acids provide barrier protection against bacteria and alter the inflammatory profile of wounds. EPA and DHA have been shown to have modulatory effects on the progression of wound healing. These characteristic omega-3 fatty acids and their metabolites alter skin physiology at a cellular and molecular level. Clinically, fish skin grafts continually demonstrate increased efficacy in treatment of wounds. When applied to non-responsive diabetic foot ulcers, acellular fish skin grafts have resulted in accelerated healing rates and significantly more fully healed wounds when compared to standard options. Here, we explore the role of omega-3 fatty acids in wound regeneration and repair, with particular focus on EPA and DHA. Then, we review clinical research outcomes to address notable clinical research studies and highlight the therapeutic potential of fish skin grafts with omega-3 as a treatment for chronic, non-healing wounds.

Dichotomous role of miR193b-3p in diabetic foot ulcers maintains inhibition of healing and suppression of tumor formation

Despite the hyperproliferative environment marked by activation of β-catenin and overexpression of c-myc, the epidermis surrounding chronic diabetic foot ulcers (DFUs) is clinically hypertrophic and nonmigratory yet does not undergo malignant transformation. We identified miR193b-3p as a master regulator that contributes to this unique cellular phenotype. We determined that induction of tumor suppressor miR193b-3p is a unique feature of DFUs that is not found in venous leg ulcers, acute wounds, or cutaneous squamous cell carcinoma (SCC). Genomic analyses of DFUs identified suppression of the miR193b-3p target gene network that orchestrates cell motility. Inhibition of migration and wound closure was further confirmed by overexpression of miR193b-3p in human organotypic and murine in vivo wound models, whereas miR193b-3p knockdown accelerated wound reepithelialization in human ex vivo and diabetic murine wounds in vivo. The dominant negative effect of miR193b-3p on keratinocyte migration was maintained in the presence of promigratory miR31-5p and miR15b-5p, which were also overexpressed in DFUs. miR193b-3p mediated antimigratory activity by disrupting stress fiber formation and by decreasing activity of GTPase RhoA. Conversely, miR193b-3p targets that typically participate in malignant transformation were found to be differentially regulated between DFUs and SCC, including the proto-oncogenes KRAS (Kirsten rat sarcoma viral proto-oncogene) and KIT (KIT proto-oncogene). Although miR193b-3p acts as a tumor suppressor contributing to low tumor incidence in DFUs, it also acts as a master inhibitor of cellular migration and epithelialization in DFUs. Thus, miR193b-3p may represent a target for wound healing induction, cancer therapeutics, and diagnostics.

Development of Chancre-Variant Cutaneous Tuberculosis After BCG Vaccine Administration in a Patient With Migraines

In countries other than the United States, the BCG vaccine is typically used as a method for preventing childhood tuberculosis; in the United States, the BCG vaccine has gained popularity as a speculated therapy for autoimmune and inflammatory disorders. Research suggests that the vaccine can train the innate immune response, thereby improving symptoms of disorders such as diabetes and fibromyalgia. However, the potential side effects associated with the use of this vaccine are not totally innocuous. Although 95% of recipients should expect common skin complications after administration of the BCG vaccine, other more serious cutaneous sequelae may occur. Potential cutaneous side effects associated with vaccine use can include fistulation, abscess formation, and even ulceration. This brief report highlights a patient in whom cutaneous tuberculosis developed, specifically tuberculous chancre, secondary to receiving the BCG vaccine as a possible treatment for fibromyalgia. After undergoing surgical debulking of the tumor, the patient subsequently received the standard of care to the wound base and was started on 6 months of isoniazid monotherapy. Cutaneous tuberculosis is exceedingly rare, and the chancre variant accounts for only about 1% of diagnosed cases. Although common in pediatric populations, the chancre variant of cutaneous tuberculosis is not typically seen in adult populations, most likely because the BCG vaccine is often administered to children to prevent childhood tuberculosis. As use of the BCG vaccine in adults becomes more prevalent to potentially treat or mitigate certain disorders, it is imperative that health care providers recognize the potentially severe side effects associated with its use.

Intracellular Staphylococcus aureus triggers pyroptosis and contributes to inhibition of healing due to Perforin-2 suppression

Impaired wound healing associated with recurrent Staphylococcus aureus infection and unresolved inflammation are hallmarks of non-healing diabetic foot ulcers (DFU). Perforin-2, an innate immunity molecule against intracellular bacteria, limits cutaneous infection and dissemination of S. aureus in mice. Here we report the intracellular accumulation of S. aureus in the epidermis of DFU with no clinical signs of infection due to marked suppression of Perforin-2. S. aureus residing within the epidermis of DFU triggers AIM2-inflammasome activation and pyroptosis. These findings were corroborated in mice lacking Perforin-2. The effects of pyroptosis on DFU clinical outcomes were further elucidated in a 4-week longitudinal clinical study in DFU patients undergoing standard of care. Increased AIM2-inflammasome and ASC-pyroptosome coupled with induction of IL-1β were found in non-healing when compared to healing DFU. Our findings reveal novel mechanism that includes Perforin-2 suppression, intracellular S. aureus accumulation and associated induction of pyroptosis that contribute to healing inhibition and prolonged inflammation in patients with DFU.

Wounds and Skin and Soft Tissue Infections in People Who Inject Drugs and the Utility of Syringe Service Programs in Their Management

Significance: Opioid use disorder and transition to injection drug use (IDU) are an urgent, nationwide public health crisis. Wounds and skin and soft tissue infections (SSTIs) are common complications of IDU that disproportionately affect people who inject drugs (PWID) and are a major source of morbidity and mortality for this population. Critical Issues: Injections in a nonsterile environment and reusing or sharing needles facilitates bacterial inoculation, with subsequent risk of serious complications such as sepsis, gangrene, amputation, and death. PWID are susceptible to infections with a wide spectrum of organisms beyond common culprits of SSTI, including Clostridium and Bacillus spp., as well as Candida. Recent Advances: Syringe services programs (SSPs) are cost-effective and successful in reducing harms associated with IDU. SSPs provide new equipment to PWID and aid in discarding used equipment. SSPs aim to reduce the risks of unhygienic injecting practices, which are associated with transmission of infections and blood-borne pathogens. Future Directions: Concurrently run SSPs and wound care clinics are uniquely positioned to facilitate care to PWID. Providing new, sterile equipment as well as early wound care intervention can reduce morbidity and mortality as well as health care expenditures by reducing the number of SSTI and injection-related wounds that require hospital admission. Establishment of wound care clinics as part of an SSP represents an untapped potential to reduce harm.

Psychosocial impact of hidradenitis suppurativa: a practical guide for clinicians

INTRODUCTION

Hidradenitis suppurativa (HS) is a debilitating skin disease with significant and often underappreciated effects on quality of life; available treatments fail to achieve consistent rates of remission. Targeting the psychosocial impact of HS has great potential to improve care for these patients. Although the literature on this topic is broad, there is a lack of specific tools that guide clinicians in this domain.

METHODS

The authors surveyed the literature to find the aspects of psychosocial functioning that most significantly impact Health-Related Quality of Life (HRQOL) for HS patients, and which may be assessed in a simple and efficient manner.

RESULTS AND DISCUSSION

Depression and anxiety, sexuality and body image, and financial strain were identified as the most significant drivers of poor HRQOL with the greatest potential to be screened for and addressed succinctly and effectively. A practical psychosocial management guide for clinicians is presented. The guide includes a list of preexisting validated screening questions, clear guidelines for interpretation, and a suggested management algorithm all geared toward a 'real-life' medical practice.

CONCLUSION

Such an approach holds a great potential for improving the care of patients with HS. Validation of this approach via controlled trials is a logical next step.

Sonographic Evaluation of Hidradenitis Suppurativa with Smartphone-Linked Portable Ultrasound

BACKGROUND

Clinical staging systems for hidradenitis suppurativa (HS) have poor interrater reliability and may underestimate disease activity. Sonographic staging systems may overcome these challenges, but conventional ultrasound (US) machines are expensive and bulky. Portable (p)US may facilitate the integration of sonography into routine practice.

OBJECTIVES

To assess the ability of a novel smartphone-linked pUS device to identify key sonographic lesions of HS.

METHODS

The charts of 16 patients with HS who were assessed with pUS at the outpatient Dermatology and Wound Care Clinics of a university hospital center were retrospectively reviewed. Clinical and sonographic images of the affected areas were examined. The main outcome measures were the number of patients with identifiable sonographic lesions and the number of patients with subclinical lesions detected by pUS.

RESULTS

All 3 key sonographic lesions of HS were identifiable with pUS. Sonographic lesions were identified in 10 patients (62.5%). Subclinical lesions were identified in 2 patients (12.5%); in both cases, this affected management decisions.

CONCLUSIONS

We demonstrate the ability of pUS to identify the key sonographic lesions of HS. pUS is a simple and affordable way to integrate HSUS into clinical and research settings, with clear potential benefits to patients.

Correlates of injection-related wounds and skin infections amongst persons who inject drugs and use a syringe service programme: A single center study

Risk factors associated with wounds and skin infections amongst persons who inject drugs may have changed in the era of fentanyl and now stimulant coinjection. We assessed the number of injection site wounds and skin infections and associated factors amongst 675 persons who inject drugs in a syringe services programme. Of this sample, 173 participants reported a total of 307 wounds and skin infections. Significant factors associated with increased number of wounds and skin infections were age 30 or older, female gender, ever experiencing homelessness, cocaine injection, and injecting between 5 and 10 years. Wounds and skin infections were common amongst syringe services programme clients and are associated with certain risk factors that may help to design effective interventions. Given the high prevalence of wounds in syringe services programme clients, wound care clinicians can make a significant difference and improve outcomes. We also shed light on correlates of wounds and skin infections in persons who inject drugs in order to spur further research to devise efficacious interventions for this underserved group.

The therapeutic potential of cannabinoids for integumentary wound management

The increasing legalization of Cannabis for recreational and medicinal purposes in the United States has spurred renewed interest in the therapeutic potential of cannabinoids (CBs) for human disease. The skin has its own endocannabinoid system (eCS) which is a key regulator of various homeostatic processes, including those necessary for normal physiologic wound healing. Data on the use of CBs for wound healing are scarce. Compelling pre-clinical evidence supporting the therapeutic potential of CBs to improve wound healing by modulating key molecular pathways is herein reviewed. These findings merit further exploration in basic science, translational and clinical studies.

Thymol-Induced Chemical Leukoderma Successfully Treated with 308-Nanometer Excimer Laser

Introduction

Chemical leukoderma (CL) is an acquired depigmenting disorder caused by repeated exposure to chemical compounds. Thymol is a phenol derivative used as a preservative or antiseptic in many commercially available products. Here, we present the second reported case of CL caused by a thymol-containing compound.

Case Presentation

A 48-year-old woman presented with a 4-month history of depigmentation of the nail folds of all ten fingers. This occurred after 1 month of twice-daily application of a thymol-containing compound intended for the removal of gel nails. No improvement was noted after the product was discontinued. There was no family history of vitiligo or other autoimmune disorders. On physical exam, depigmentation of all ten proximal and lateral nail folds was seen, with accentuation on Wood's lamp exam. Partial re-pigmentation was achieved after 32 treatments with 308-nm excimer laser.

Discussion

A thorough history and physical exam are instrumental in differentiating CL from other causes of depigmentation. Avoidance of the offending agent is an essential part of management. It is important to note that many cosmetic products are not tightly regulated by the FDA. Excimer laser is an effective treatment for CL with a favorable side-effect profile.

The use of virtual reality in non-burn dermatological care - a review of the literature

Aim: Virtual Reality (VR) is the artificial depiction of a three-dimensional (3D) environment using computer-generated technology which allows users to interact with a simulated setting. VR has been used in a variety of clinical scenarios due to its efficacy as a distraction intervention, reducing anxiety and pain associated with medical procedures. The aim of this review is to provide clinicians with an overview of VR use in clinical dermatology.Methods: A search on VR use in clinical dermatology was conducted using PubMed Medline, Embase, Cochrane, Google Scholar and ClinicalTrials.Gov in July 2019. Results related to burn care were excluded.Results: This review identifies studies that utilized VR in the management of skin diseases and discusses considerations for its future use.Conclusion: The findings of these studies indicate that VR has beneficial effects as a complementary tool in the treatment of dermatological conditions.

Examining risk factors and preventive treatments for first venous leg ulceration: A cohort study

BACKGROUND

Large studies that examine risk factors for first occurrence of venous leg ulcerations are needed to guide management.

OBJECTIVE

To investigate factors associated with development of first occurrence of venous leg ulcerations.

METHODS

A retrospective cohort study using a validated national commercial claims database of patients with venous insufficiency. Subjects were followed to determine whether they developed first occurrence of venous leg ulcerations, and risk and protective factors were analyzed.

RESULTS

Adjusted hazard ratio (AHR) for comorbidities demonstrated an increased risk in men (AHR 1.838; 95% confidence interval [CI] 1.798-1.880), older age (45-54 years: AHR 1.316, 95% CI 1.276-1.358; 55-64 years, AHR 1.596, 95% CI 1.546-1.648), history of nonvenous leg ulceration (AHR 3.923; 95% CI 3.699-4.161), anticoagulant use (AHR 1.199; 95% CI 1.152-1.249), antihypertensive use (AHR 1.067; 95% CI 1.040-1.093), and preexisting venous insufficiency including chronic venous insufficiency (AHR 1.244; 95% CI 1.193-1.298), edema (AHR 1.224; 95% CI 1.193-1.256), and chronic venous hypertension (AHR 1.671; 95% CI 1.440-1.939). Possible protective factors were having venous surgery (AHR 0.454; 95% CI 0.442-0.467), using compression stockings (AHR 0.728; 95% CI 0.705-0.753), using prescribed statin medications (AHR 0.721; 95% CI 0.700-0.743), and using pain medications (AHR 0.779; 95% CI 0.757-0.777).

LIMITATIONS

Risk of misclassification, given the use of International Classification of Diseases, Ninth Revision codes. Possible confounding factors such as body mass index could not be adequately controlled with these codes.

CONCLUSION

The new evidence presented supports a paradigm shift toward venous leg ulceration prevention.

Complementary and Alternative Medicine Therapies for Psoriasis: A Systematic Review

Importance

Up to 51% of patients with psoriasis report the use of complementary and alternative medicine (CAM) in their treatment regimen, although it is unclear which CAM therapies are effective for treatment of psoriasis.

Objective

This review compiles the evidence on the efficacy of the most studied CAM modalities for treatment of patients with plaque psoriasis and discusses those therapies with the most robust available evidence.

Evidence Review

PubMed, Embase, and ClinicalTrials.gov searches (1950-2017) were used to identify all documented CAM psoriasis interventions in the literature. The criteria were further refined to focus on those treatments identified in the first step that had the highest level of evidence for plaque psoriasis with more than 1 randomized clinical trial supporting their use. This excluded therapies lacking randomized clinical trial (RCT) data or showing consistent inefficacy.

Findings

Primary CAM therapy searches identified 457 articles, of which 107 articles were retrieved for closer examination. Of those articles, 54 were excluded because the CAM therapy did not have more than 1 RCT on the subject or showed consistent lack of efficacy. An additional 7 articles were found using references of the included studies, resulting in a total of 44 RCTs (17 double-blind, 13 single-blind, and 14 nonblind), 10 uncontrolled trials, 2 open-label nonrandomized controlled trials, 1 prospective controlled trial, and 3 meta-analyses. Compared with placebo, application of topical indigo naturalis, studied in 5 RCTs with 215 participants, showed significant improvements in the treatment of psoriasis. Treatment with curcumin, examined in 3 RCTs (with a total of 118 participants), 1 nonrandomized controlled study, and 1 uncontrolled study, conferred statistically and clinically significant improvements in psoriasis plaques. Fish oil treatment was evaluated in 20 studies (12 RCTs, 1 open-label nonrandomized controlled trial, and 7 uncontrolled studies); most of the RCTs showed no significant improvement in psoriasis, whereas most of the uncontrolled studies showed benefit when fish oil was used daily. Meditation and guided imagery therapies were studied in 3 single-blind RCTs (with a total of 112 patients) and showed modest efficacy in treatment of psoriasis. One meta-analysis of 13 RCTs examined the association of acupuncture with improvement in psoriasis and showed significant improvement with acupuncture compared with placebo.

Conclusions and Relevance

The CAM therapies with the most robust evidence of efficacy for treatment of psoriasis are indigo naturalis, curcumin, dietary modification, fish oil, meditation, and acupuncture. This review will aid practitioners in advising patients seeking unconventional approaches for treatment of psoriasis.

Protocol for a longitudinal cohort study: determination of risk factors for the development of first venous leg ulcer in people with chronic venous insufficiency, the VEINS (venous insufficiency in South Florida) cohort

INTRODUCTION

Chronic venous insufficiency (CVI) affects up to one-third of the adult population yet venous leg ulcers (VLU), a significant complication of CVI, only affect 1%-2% of adults in the USA. Why some develop VLU and others do not is unclear. VLU have a significant impact on quality of life and are extremely costly and difficult to treat. Moreover, VLU prevalence is increasing, doubling in the last 20 years. In order to characterise the differences between people with CVI and those who ultimately develop VLU, we aim to set up the unique venous insufficiency in South Florida cohort.

METHODS AND ANALYSIS

Subjects will be recruited from the University of Miami Hospital and Clinic's vascular laboratory database, which began in July 2011. Any adult age 18-95 who has had venous reflux detected on duplex ultrasound of the lower extremities is included. Approximately 2500 patients are already in the database that meet these criteria, with an estimated 2500 additional potential subjects to be recruited from the vascular laboratory database over the next 5 years. Subjects with a history of VLU prior to the duplex study date will be excluded. Data will be collected via review of the Doppler study report, patient phone interview and review of the electronic medical record. Subjects will be contacted for follow-up every 3 months for at least 5 years until the study endpoint, development of first VLU (fVLU), is reached. In order to estimate the time from reflux documentation to fVLU, Kaplan-Meier survival curves will be constructed. Cox proportional hazard regression models will be constructed to investigate possible risk factors.

ETHICS AND DISSEMINATION

This study is approved by the University of Miami's Institutional Review Board. We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals.

Proceeding report of the Second Symposium on Hidradenitis Suppurativa Advances (SHSA) 2017

The 2nd Annual Symposium on Hidradenitis Suppurativa Advances (SHSA) took place on 03-05 November 2017 in Detroit, Michigan, USA. This symposium was a joint meeting of the Hidradenitis Suppurativa Foundation (HSF Inc.) founded in the USA, and the Canadian Hidradenitis Suppurativa Foundation (CHSF). This was the second annual meeting of the SHSA with experts from different disciplines arriving from North America, Europe and Australia, in a joint aim to discuss most recent innovations, practical challenges and potential solutions to issues related in the management and care of Hidradenitis Suppurativa patients. The last session involved clinicians, patients and their families in an effort to educate them more about the disease.