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Creadore A, Desai S, Alloo A, Dewan AK, Bakhtiar M, Cruz-Diaz C, Femia A, Fox L, Katz KL, Micheletti R, Nelson CA, Ortega-Loayza AG, Patrinely JR, Plovanich M, Rosenbach M, Shaigany S, Shields BE, Saleh JZ, Sharif-Sidi Z, Shinkai K, Smith J, Su C, Wanat KA, Wieser JK, Wright S, Noe MH, Mostaghimi A. Clinical Characteristics, Disease Course, and Outcomes of Patients With Acute Generalized Exanthematous Pustulosis in the US. JAMA Dermatol 2022; 158:176-183. [PMID: 34985493 PMCID: PMC8733866 DOI: 10.1001/jamadermatol.2021.5390] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Acute generalized exanthematous pustulosis (AGEP) is a rare, severe cutaneous adverse reaction associated with systemic complications. Currently available data are largely limited to small retrospective case series. Objective To describe the clinical characteristics, disease course, and outcomes of a heterogeneous group of patients with AGEP across the US. Design, Setting, and Participants A retrospective review of a case series of patients was conducted from January 1, 2000, through July 31, 2020. All 340 included cases throughout 10 academic health systems in the US were scored retrospectively using the EuroSCAR scoring system, and patients with a score corresponding to probable or definite AGEP and aged 18 years or older were included. Main Outcomes and Measures Patient demographic characteristics, clinical course, suspected causative agent, treatment, and short- and long-term outcomes. Results Most of the 340 included patients were women (214 [62.9%]), White (206 [60.6%]), and non-Hispanic (239 [70.3%]); mean (SD) age was 57.8 (17.4) years. A total of 154 of 310 patients (49.7%) had a temperature greater than or equal to 38.0 °C that lasted for a median of 2 (IQR, 1-4) days. Of 309 patients, 263 (85.1%) developed absolute neutrophilia and 161 patients (52.1%) developed either absolute or relative eosinophilia. Suspected causes of AGEP were medications (291 [85.6%]), intravenous contrast agents (7 [2.1%]), infection (3 [0.9%]), or unknown (39 [11.5%]). In 151 cases in which a single medication was identified, 63 (41.7%) were β-lactam antimicrobials, 51 (33.8%) were non-β-lactam antimicrobials, 9 (6.0%) were anticonvulsants, and 5 (3.3%) were calcium channel blockers. The median time from medication initiation to AGEP start date was 3 (IQR, 1-9) days. Twenty-five of 298 patients (8.4%) had an acute elevation of aspartate aminotransferase and alanine aminotransferase levels, with a peak at 6 (IQR, 3-9) days. Twenty-five of 319 patients (7.8%) experienced acute kidney insufficiency, with the median time to peak creatinine level being 4 (IQR, 2-5) days after the AGEP start date. Treatments included topical corticosteroids (277 [81.5%], either alone or in combination), systemic corticosteroids (109 [32.1%]), cyclosporine (10 [2.9%]), or supportive care only (36 [10.6%]). All-cause mortality within 30 days was 3.5% (n = 12), none of which was suspected to be due to AGEP. Conclusions and Relevance This retrospective case series evaluation of 340 patients, the largest known study cohort to date, suggests that AGEP onset is acute, is usually triggered by recent exposure to an antimicrobial, may be associated with liver or kidney complications in a minority of patients, and that discontinuation of the triggering treatment may lead to improvement or resolution.
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Affiliation(s)
- Andrew Creadore
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts ,Student, Boston University School of Medicine, Boston, Massachusetts
| | - Sheena Desai
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts ,Student, Tufts University School of Medicine, Boston, Massachusetts
| | - Allireza Alloo
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Anna K. Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina Bakhtiar
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Carla Cruz-Diaz
- Department of Dermatology, University of California, San Francisco,Assistant Section Editor, JAMA Dermatology
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York
| | - Lindy Fox
- Department of Dermatology, University of California, San Francisco
| | - Kimberly L. Katz
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | - Robert Micheletti
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia,Images in Dermatology Editor, JAMA Dermatology
| | - Caroline A. Nelson
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | | | - J. Randall Patrinely
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Molly Plovanich
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York
| | - Misha Rosenbach
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia,Editorial Board member, JAMA Dermatology
| | - Sheila Shaigany
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York,Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York
| | - Bridget E. Shields
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia,Assistant Section Editor, JAMA Dermatology,Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Jamal Z. Saleh
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | | | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco,Chief Editor, JAMA Dermatology
| | - Jacob Smith
- Department of Dermatology, Oregon Health and Science University, Portland
| | - Chang Su
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Karolyn A. Wanat
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | - Jill K. Wieser
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York
| | - Shari Wright
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Megan H. Noe
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts ,Associate Editor, JAMA Dermatology
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Noe MH, Wan MT, Mostaghimi A, Gelfand JM, Agnihothri R, Armstrong AW, Bhutani T, Bridges A, Brownstone N, Butt M, Duffin KPC, Carr C, Creadore A, DeNiro KL, Desai S, Dominguez AR, Duffy EK, Fairley JA, Femia A, Gudjonsson JE, Kaffenberger JA, Katz KL, Kirby JS, Le ST, Martinez E, Maverakis E, Myers B, Naik HB, Nelson CA, Ortega-Loayza AG, Plovanich ME, Rangel LK, Ravi V, Reddy VD, Saleh JZ, Sandhu JK, Shakshouk H, Shields BE, Sharif-Sidi Z, Smith J, Steahr A, Toussi A, Wanat KA, Wang B, Wei BM, Weinhammer A, Worswick SD, Yang A. Evaluation of a Case Series of Patients With Palmoplantar Pustulosis in the United States. JAMA Dermatol 2021; 158:68-72. [PMID: 34878495 DOI: 10.1001/jamadermatol.2021.4635] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Palmoplantar pustulosis (PPP) is a is a chronic, orphan disease with limited epidemiological data. Objective To describe the clinical characteristics, treatments, longitudinal disease course, and health care utilization in adults with PPP across the US. Design, Setting, and Participants This retrospective, longitudinal case series from 20 academic dermatology practices in the US included a consecutive sample of 197 adults who met the European Rare and Severe Psoriasis Expert Network consensus definition for PPP between January 1, 2007, and December 31, 2018. Data analysis was performed June 2020 to December 2020. Main Outcomes and Measures The primary outcome was to describe the patient characteristics, associated medical comorbidities, treatment patterns, complications, and PPP-specific health care utilization. Results Of 197 patients, 145 (73.6%) were female, and the mean (SD) age at presentation was 53.0 (12.6) years, with a mean (SD) follow-up time of 22.1 (28.0) months. On initial presentation, 95 (48.2%) patients reported skin pain, and 39 (19.8%) reported difficulty using hands and/or feet. Seventy patients (35.5%) were treated with systemic treatments, and use of more than 20 different systemic therapies was reported. In patients with at least 6 months of follow-up (n = 128), a median (IQR) of 3.7 (4-10) dermatology visits per year were reported; 24 (18.8%) patients had 5 or more visits during the study period. Conclusions and Relevance In this case series, PPP was associated with persistent symptoms, continued health care utilization, and a lack of consensus regarding effective treatments, emphasizing the unmet medical need in this population. Additional research is necessary to understand treatment response in these patients.
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Affiliation(s)
- Megan H Noe
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marilyn T Wan
- Department of Internal Medicine, Memorial Hospital West, Pembroke Pines, Florida
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joel M Gelfand
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | - Ritesh Agnihothri
- Department of Dermatology, University of Rochester, School of Medicine & Dentistry, Rochester, New York
| | - April W Armstrong
- Department of Dermatology, Keck Hospital of USC, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tina Bhutani
- Department of Dermatology, UCSF Medical Center, University of California San Francisco School of Medicine
| | - Alina Bridges
- Department of Dermatology, Mayo Clinic Graduate School of Education, Rochester, Minnesota.,Richfield Laboratory of Dermatopathology, Dermpath Diagnostics, Cincinnati, Ohio
| | - Nicholas Brownstone
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco
| | - Melissa Butt
- Department of Dermatology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Andrew Creadore
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Katherine L DeNiro
- Division of Dermatology, Department of Medicine, University of Washington, Seattle
| | - Sheena Desai
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Arturo R Dominguez
- Departments of Dermatology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Emily K Duffy
- Division of Dermatology, Department of Medicine, University of Washington, Seattle
| | - Janet A Fairley
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, NYU Langone Hospitals, New York University Grossman School of Medicine, New York, New York
| | | | | | - Kimberly L Katz
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | - Joslyn S Kirby
- Department of Dermatology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Stephanie T Le
- Department of Dermatology, University of California, Davis School of Medicine, Sacramento
| | | | - Emanual Maverakis
- Department of Dermatology, University of California, Davis School of Medicine, Sacramento
| | - Bridget Myers
- University of California San Francisco School of Medicine
| | - Haley B Naik
- Department of Dermatology, UCSF Medical Center, University of California San Francisco School of Medicine
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University School of Medicine, Portland
| | - Molly E Plovanich
- Department of Dermatology, University of Rochester, School of Medicine & Dentistry, Rochester, New York
| | - Lauren K Rangel
- Ronald O. Perelman Department of Dermatology, NYU Langone Hospitals, New York University Grossman School of Medicine, New York, New York
| | - Vignesh Ravi
- Department of Dermatology, Keck Hospital of USC, University of Southern California Keck School of Medicine, Los Angeles, California
| | | | - Jamal Z Saleh
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | - Jeena K Sandhu
- Department of Dermatology, Keck Hospital of USC, University of Southern California Keck School of Medicine, Los Angeles, California.,Division of Dermatology, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Hadir Shakshouk
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Bridget E Shields
- Department of Dermatology, School of Medicine and Public Health, University of Wisconsin, Madison
| | | | - Jacob Smith
- Oregon Health and Science University School of Medicine, Portland
| | - Amanda Steahr
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City
| | - Atrin Toussi
- Department of Dermatology, University of California, Davis School of Medicine, Sacramento
| | - Karolyn A Wanat
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | - Bo Wang
- Department of Dermatology, University of Michigan, Ann Arbor
| | - Brian M Wei
- Yale School of Medicine, New Haven, Connecticut
| | - Annika Weinhammer
- Department of Dermatology, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Scott D Worswick
- Department of Dermatology, Keck Hospital of USC, University of Southern California Keck School of Medicine, Los Angeles, California
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Abstract
Background: Psoriasis and vitiligo are 2 autoimmune conditions that can occur concurrently in patients. At present, no single systemic therapy has been identified to be effective in treating both the conditions. Observations: Recent advances in our understanding of the T helper (Th) 17 subset of Th cells suggests that interleukin (IL)-17 may play a key role in the pathogenesis of both vitiligo and psoriasis. We report a case of anatomically superimposed psoriatic plaques and vitiligo for which treatment with ixekizumab leads to resolution of psoriasis but did not improve the patient’s vitiligo. Conclusion: While IL-17 is highly effective in the treatment of psoriasis, it does not seem to be an effective treatment for vitiligo.
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Affiliation(s)
- Kimberly L. Katz
- Department of Dermatology, New York Medical College, Valhalla, NY, USA
| | - Katherine Rupley
- Department of Dermatology, New York Medical College, Valhalla, NY, USA
| | - Jacquelyn Sink
- Department of Dermatology, New York Medical College, Valhalla, NY, USA
| | - Adele Shuley
- Department of Dermatology, New York Medical College, Valhalla, NY, USA
| | - Alice B. Gottlieb
- Department of Dermatology, New York Medical College, Valhalla, NY, USA
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