The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ACNE AND ROSACEA
Laboratory monitoring for isotretinoin therapy (September 2022)
Reduced monitoring of liver function and lipid tests in healthy patients receiving isotretinoin has been proposed based upon data that suggest low utility of monthly testing. A Delphi consensus study in which acne experts responded to a series of surveys found at least 70 percent consensus for checking alanine aminotransferase (ALT) and triglyceride levels within one month prior to isotretinoin therapy and after reaching the peak isotretinoin dose [1]. There was also consensus that several other laboratory tests were not necessary, such as complete blood count panels, basal metabolic panels, and select liver function and lipid tests. Although these findings align with the trend towards reduced laboratory monitoring for healthy patients taking isotretinoin, no consensus was achieved for some commonly obtained tests, and additional study is necessary to confirm the best approach to monitoring. Additionally, individual patient characteristics may warrant a different approach to laboratory testing. (See "Oral isotretinoin therapy for acne vulgaris", section on 'Evidence'.)
ATOPIC DERMATITIS AND OTHER DERMATITIS
Allergen immunotherapy for atopic dermatitis (October 2022)
Allergen immunotherapy (AIT) is a well-established treatment for allergic rhinoconjunctivitis and asthma, but studies of its utility for atopic dermatitis (AD) are mixed. In a new meta-analysis, the addition of AIT (either subcutaneous or sublingual, mostly using house dust mites as the allergen) or placebo was evaluated in 23 randomized trials that enrolled nearly 2000 children and adults with AD who were not controlled with standard therapy (either topical corticosteroids or calcineurin inhibitors) [2]. Patients receiving add-on AIT more often experienced a clinically important decrease in AD severity and improvement in quality of life. Thus, add-on AIT may be beneficial for patients who have eczema that is not controlled with conventional therapies and proven sensitization to house dust mites. AIT may be especially helpful for patients with concomitant allergic rhinoconjunctivitis or asthma. (See "Treatment of atopic dermatitis (eczema)", section on 'Allergen immunotherapy'.)
Dupilumab-induced seronegative arthritis and enthesitis (September 2022)
Dupilumab is an IL-4/IL-13 inhibitor approved for the treatment of atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyposis, and eosinophilic esophagitis. An analysis of nearly 38,000 adverse reactions to dupilumab reported to VigiBase, the World Health Organization's global pharmacovigilance database, found a 9 percent rate of musculoskeletal and connective tissue adverse effects [3]. Specifically, dupilumab was associated with diseases sharing T helper 17 (Th17) immunogenetics, including seronegative arthritis, enthesitis/enthesopathy, and iridocyclitis. Based on these data, we suggest that all patients initiating treatment with dupilumab be counseled about the risk of new-onset joint pain, which is mild in most cases and typically does not require discontinuation of treatment. (See "Treatment of atopic dermatitis (eczema)", section on 'Adverse effects'.)
AUTOIMMUNE AND SYSTEMIC DISEASES
Acute cutaneous graft-versus-host disease with Stevens-Johnson syndrome/toxic epidermal necrolysis-like features (November 2022)
For patients with acute cutaneous graft-versus-host disease (GVHD) and Stevens-Johnson syndrome/toxic epidermal necrolysis- (SJS/TEN)-like features, the prognosis is not well described. In a retrospective cohort study of 31 patients with acute cutaneous GVHD, the 16 patients with SJS/TEN-like features were more likely to have systemic complications (eg, hematologic abnormalities, hepatitis, diarrhea, renal dysfunction, and bacteremia), lower survival rates at two months, and higher risk for mortality at five years [4]. Although limitations of this study necessitate validation of the results and preclude conclusions on contributing factors, the findings provide additional insight into extracutaneous adverse events in patients with SJS/TEN-like acute GVHD. (See "Cutaneous manifestations of graft-versus-host disease (GVHD)", section on 'Diagnosis'.)
Apremilast for refractory cutaneous dermatomyositis (October 2022)
Cutaneous dermatomyositis (DM) can be challenging to treat and often requires immunosuppressive therapy. In the first study to assess efficacy of apremilast, a phosphodiesterase-4 inhibitor, for cutaneous DM, the addition of apremilast to other therapies for cutaneous DM was associated with improvement in the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) in seven of eight patients with refractory cutaneous dermatomyositis [5]. The mean reduction in CDASI was 12.9 points at three months. Apremilast was generally well tolerated. Additional study is necessary to confirm efficacy of apremilast for cutaneous DM. (See "Management of refractory cutaneous dermatomyositis in adults", section on 'Apremilast'.)
INFECTIONS AND INFESTATIONS
Updated guidance on head lice from the American Academy of Pediatrics (October 2022)
The American Academy of Pediatrics released updated guidance on the diagnosis and management of head lice (pediculosis capitis) [6]. The guidance provided continued support for topical permethrin and topical pyrethrins as the preferred first-line treatments in most patients. We agree with this approach and other key principles in the guidance report, such as the restriction of pediculicide treatment to patients with confirmed active lice infestation, the selection of a different class of topical pediculicide as the preferred next step after failure of an initial topical pediculicide, and the elimination of policies that exclude children from school because of head lice. (See "Pediculosis capitis", section on 'Locations with low pyrethroid resistance'.)
PSORIASIS AND OTHER PAPULOSQUAMOUS DISORDERS
Secukinumab for pityriasis rubra pilaris (December 2022)
Secukinumab and other biologic IL-17 inhibitors are used in the treatment of pityriasis rubra pilaris (PRP). However, prior data on secukinumab for PRP has been limited to case reports and case series. In an open-label study of 12 adults with PRP treated with secukinumab for 24 weeks, at least 75 percent improvement in the Psoriasis Area and Severity Index occurred in 6 of 11 patients (55 percent) [7]. RNA sequencing analysis also revealed improvement in gene expression patterns in lesional skin after two weeks of treatment. No patients discontinued treatment because of adverse effects. Although limitations of this small study preclude definitive conclusions on the efficacy of secukinumab, the findings suggest benefit for PRP. (See "Pityriasis rubra pilaris: Prognosis and management", section on 'IL-17 inhibitors'.)
Oral deucravacitinib for moderate to severe plaque psoriasis (October 2022)
Tyrosine kinase inhibition represents a novel approach to psoriasis treatment. Two phase 3 trials support efficacy of oral deucravacitinib, a selective tyrosine kinase 2 inhibitor, for moderate to severe plaque psoriasis [8,9]. In the POETYK PSO-1 and POETYK PSO-2 trials, adults with moderate to severe plaque psoriasis were randomly assigned to deucravacitinib, placebo, or apremilast. At week 16, patients treated with deucravacitinib were more likely to achieve at least 75 percent improvement in the Psoriasis Area and Severity Index score than patients in the placebo or apremilast groups (58, 13, and 35 percent in POETYK PSO-1 and 53, 9, and 40 percent in POETYK PSO-2, respectively). Serious adverse effects were infrequent in both trials. These findings support deucravacitinib as an effective oral treatment for psoriasis and contributed to FDA approval of deucravacitinib for moderate to severe psoriasis in adults who are candidates for systemic therapy or phototherapy. Additional study will be useful for determining long-term efficacy and safety. (See "Treatment of psoriasis in adults", section on 'Deucravacitinib'.)
Updated treatment guidelines for psoriatic arthritis (October 2022)
The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has published updated guidelines to include newer therapeutic options for patients with psoriatic arthritis (PsA) that have become available [10]. The guidelines use a domain-based approach that includes recommendations for peripheral arthritis, axial disease, enthesitis, dactylitis, skin psoriasis, and nail psoriasis. Important comorbidities and related conditions that may have a potential impact on treatment are also addressed. Our approach to the treatment of PsA is generally consistent with these guidelines. (See "Treatment of psoriatic arthritis", section on 'MTX use and efficacy'.)
URTICARIA AND ANGIOEDEMA
Review of all reported cases of aquagenic urticaria (September 2022)
Aquagenic urticaria is a rare form of physical urticaria in which patients develop 1 to 2 mm punctate hives (identical in appearance to cholinergic urticaria) and occasionally systemic symptoms upon exposure of the skin to water. A systematic review of case reports and small series identified 77 patients, which is the largest series to date [11]. The disorder can be acquired or familial, triggered by salt or fresh water and occasionally body fluids, and confirmed by placing a wet, room-temperature towel on the skin for 30 to 40 min, after which transient hives develop. Of 39 patients treated with standard doses of nonsedating H1 antihistamines, 28 experienced complete or marked control, with others responded to higher doses. This series provides support for nonsedating H1 antihistamines as the initial treatment of choice. (See "Physical (inducible) forms of urticaria", section on 'Treatment'.)
OTHER DERMATOLOGY
Topical ruxolitinib for limited nonsegmental vitiligo (October 2022)
Vitiligo is a difficult-to-treat autoimmune skin disease characterized by depigmented patches. In two recent identical randomized trials that included 674 patients with nonsegmental vitiligo involving ≤10 percent of total body surface area, more patients assigned to twice daily ruxolitinib 1.5% cream (a topical Janus kinase inhibitor) achieved a 75 percent reduction in the facial Vitiligo Area Scoring Index at 24 weeks, compared with vehicle (30 versus 7 percent [trial 1] and 31 percent versus 11 percent [trial 2]) [12]. Ruxolitinib-related adverse events included acne and pruritus at the site of application and nasopharyngitis. These studies were the basis for the US Food and Drug Administration approval for this indication. However, due to safety concerns related to systemic absorption of ruxolitinib, we continue to suggest topical corticosteroids and topical calcineurin inhibitors as initial treatments for limited vitiligo. (See "Vitiligo: Management and prognosis", section on 'Localized disease'.)
Oral baricitinib for alopecia areata (August 2022)
Effective therapies for severe alopecia areata are limited. Two phase 3 trials support the efficacy of baricitinib, an oral Janus kinase (JAK) 1 and JAK2 inhibitor [13]. In BRAVE-AA1 (n = 654) and BRAVE-AA2 (n = 546), adults with severe alopecia areata were randomly assigned to baricitinib 4 mg per day, baricitinib 2 mg per day, or placebo. After 36 weeks, patients treated with either dose of baricitinib were more likely to achieve the specified level of improvement in the alopecia severity score than patients in the placebo group. Acne, elevated levels of creatinine kinase, and elevated levels of low density lipoprotein cholesterol and high density lipoprotein cholesterol occurred more frequently in the baricitinib groups than the placebo group. These findings support baricitinib as a preferred therapy for severe alopecia areata in adults and contributed to US Food and Drug Administration approval for this indication. However, uncertainty remains about long-term efficacy and safety. (See "Alopecia areata: Management", section on 'Other Janus kinase inhibitors'.)
