A Look at Complex Cases

Joseph F. Merola, MD, MMSc, and Mital Patel-Cohen, MD, cochairs of Spring Dermatology Week 2023, discussed the latest therapeutic advances in the management of conditions affecting the skin, hair, and nails in their session, “Complex Medical Dermatology Cases.”

Dr Merola is the vice chair of clinical trials and innovation at Brigham and Women’s Hospital in Boston, MA, and Dr Patel-Cohen is the director of complex dermatology at Summit Medical Group in New Jersey. Their learning objectives included understanding the real-world infection risks associated with biologic therapy in psoriatic disease, improving strategies to balance the risk of immunosuppression in cutaneous disease, evaluating and formulating a management strategy for patients with palmoplantar pustulosis, and evaluating and implementing treatment for pityriasis rubra pilaris.

Dr Patel-Cohen started with a case study of palmoplantar pustulosis, discussing brachytherapy as an effective treatment. During brachytherapy, a radiation source, administered through flexible catheters that are secured with fully customized molds, is placed in contact with the target lesion. This delivers superficial, highly conformal radiation therapy to complex targets with fewer treatments needed and less toxicity. She also referenced a study of 7 patients with hyperkeratotic palmoplantar psoriasis refractory to systemic therapy who were successfully treated with the Janus kinase inhibitor tofacitinib. Dr Merola added, “I am very hopeful for this. It is an off-label use at present.” Dr Patel-Cohen remarked, “The more data we have, the more comfortable we will be using it and, hopefully, being able to get it for our patients through insurance.”

Dr Merola then shared a case of a 38-year-old man, wheelchair bound, with a history of multiple sclerosis (MS), nephropathy requiring chronic hemodialysis, numerous medical problems, and polypharmacy who presented with psoriasis on more than 60% of his body surface area (BSA), severe itch, and recurrent monoarthritis in his right knee with psoriatic arthritis. He could not stand in a phototherapy booth and topical therapy was inadequate. There were infection risks and immunosuppression concerns with his MS medications. After extensive review with the care team and the patient’s understanding of the risks, the IL-23 inhibitor guselkumab was administered. The patient achieved nearly clear skin (less than 1% BSA), with marked improvement in quality of life, resolved itch, and minimal joint pain.

They continued to review cases of pityriasis rubra pilaris with a discussion of ixekizumab as a possible treatment, sarcoidosis effectively treated with ruxolitinib 1.5% cream, and hidradenitis suppurativa (HS) with spondyloarthritis successfully managed with adalimumab.

Dr Merola asked Dr Patel-Cohen, “How do you operationalize asking patients, especially HS patients, about arthritis and other comorbidities? What are practical tips on how to approach that?”

“I feel like it is hard to do all in one visit in a very busy practice setting. The first visit I go over the many different treatment options and highlight them because for many of these patients, they have either been on treatment that has not worked or been told there is not treatment. I think there is a good initial buy in if you can explain to them, we have a lot of treatment options and we are going to work with you to pick the best option for you,” she answered.

Dr Patel-Cohen continued, “They probably are not going to tell you if they have a substance abuse issue or depressive issue. Many of them do not have a primary care doctor and some of them are young and have not even heard about the idea of metabolic syndrome or being tested.”

She concluded, “I think the easiest way if you are in a very busy clinic would be to just make sure you are following these patients more regularly. I will schedule them 4 weeks for ILK and then, when they come in for the injections, we chat a little bit about different things based on each individual patient.”

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Reference

Merola JF, Patel-Cohen M. Complex medical dermatology cases. Presented at: Dermatology Week; May 3–6; Virtual.