Tables in dermatology updates 2025.pdf

Tables in dermatology

Is unique book display only tables in different chapters highly classified ,containing more than 15 thousand tables
Very special book for special dermatologist

This is sample from book
More publications at

https://app.mediafire.com/folder/43vl37mk5dgfo


Hany salah soliman
Dermatology specialist -Egypt

1. +18 THOUSANDS TABLES

Whatsapp [phone]

“HK

2. Dermatology
ú

4 La

TREASURES OF
TABLES Bad UNUSUAL

4. a

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oe Summary et leon ping ep fon pone

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lisa ova rm en |

ar Pas wi Et a nan o ta LU HER obama mE
Pepe opt mjor Dean
Merle fan nt pet meritos Seca Em ote
Jeb Tha wi cube aed ten To

Bear D ani TL. cam et mme pate US nga te
paja mince [omer et

porn Anda NE nev font Ta en ans | DA copar TS nay Pet
Sm Gene ne dame ne prenne eps mgt ees rg
Tu men ms dom stele Fnac Al
“ent a fa sanar dyed
se mad end neo mr Jn

Fogar? carpet retos yes ro nm ts sde [Fst tee ied Bal
Sy Ben de ae do sa mare pour een ot
EDS semen |e

Tomas? ows names Bal retina umi | dyin

‘ona Bais mre D pa ep Lie
romano fia cg clear so sr Bü paie nd
Fe de

a TB

net day cm ere apr chan ve
Retceat urna a ae matin demi a
nage an ded agree pren Etat
pr a pr ra

Banana apena mine
beste repent recon
ieee bcp ae

Bazar Nor deed een faye pra PEUT
A |A imac te armen
Eu éme coins te
lation get OF eut semen | rl naar
nl [gr
cts

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rene

EXI picts compared to LL controls. Adétionalb.
increased genetic expresion of Clq components was nated
in ENL patents peripheral blood and skin Dips, wich
nomalse afer teatment. suggesting Clq as a potential
‘ingostic marker nd reainent response indicate for ENL-

‘An immunchistochemical study aso found signifient
increased expresion of ejelocg/genaie 2 and vascular
‘endothelial growth actor in dema macrophages and

vascular entabla in TIRs, olowed by T2Rs, compared
to con

Pentrain-3 (PPX), a imma marker, i higher in
MB patents before and during acute EXI, and decreases
within seven days of thalidomide therapy. A novel study
sed RNA expression analysis 1090 hole bod samples
Lo profe 103 target gens for imate and adaptive iarune

Inden ul Dem ogy Lipsy oan sun gt 205

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be Meer dpt medi win pie rl ro tins
peu ange Spe ween | eats Rok miro rains
ro
A Te
mone {ean main ug pa
Sj din gta
TRUE wp claw aaa
Dares nn má mc a med occ. [erro ma miel
ES a cen ame
reponse os
arc — | perio ane ua reg Demi may mate
Br ‘Sige im más percata ctancanat of” [oprimir hare
[arabes sald nte mena arse | scene man me
for eco second conos
any ts my abe ago 202 nement
Beso [PO wii | ast ray ad te rte reins [ype na ae DE
lero” A e A Iron
hose
bot ART
Ed
Say (MR SLR ana rn yaaa dape dm [armoires
sar erent be
co imc tweet porcion ratas
TT
mi
earn A TEN
sme apa anime
repeat
Buse [putero [Atanas patie ona irerirasion cman |Cattpndammeninsnes
‘inno etnies CUL COCA SALAD) we oe lo oes
Sees te hd acral pn hee

‘RA day ney shi ion AO UD pa rn AOL he
PE LE Conlara q OS Cro u pm a gon HUE rc
ca hue ag ES Nc eo A Mr Rens) Po ee

a a ES ac

responses: A uansriptomic sigatre ve genes (CCL2,
(CDRA. 112, ILIS, MARCO) was iene, predicting
[RRs leat two weeks before oe © Other potential ENT.
dignes beats include 1.6, IL, COLIN lla
acid coro and CD-64 No single marker or at of
‘markers has shown to reliably and effectively prognosticate
the occurence lepra teats

‘The Special System fer Evaluation of Risk of Occurrence
‘of Reastina tates in Leprosy (SEPARE is an online ool
that preditsleproey reaction with up to 877% accuracy
using soco-demraphie details, Kaniy history, lineal,
Inbertory and genetic data

‘Treatment
“ype reacios

‘The objective of tretment for TIR. i centro of neural
inflammation and prevention of further inmune metil

damage FormilTIR.noseroidalani-iammatny ds
‘may suc, bu severe reaction, especial wih net,
requires medical andor surgical reument. Curr evidence
“suggest at ea corticosteroids ae the mainstay for severe
"IR: and should be srl a done of 05-1 mg ay and
raul tapered to zero over a span of 20 weeks (Fie
A) A randomised wil (Treatment of Bay Newpathy in
Leprosy or TENLEP) compared ol crtiosterois fr 20
and 32 wecks in patents with rec onset nerve fonction
impainnet (less thn six mes drat) inling TIR ©
No dira m cial cutcomes was noted been the
rep atthe end of the dy period.

‘ter immmosuppresive agents that have been used
success fer ie management of TI include yeloparine
fandmthotrexat A recent review and tete analysis
has Highlight the role of mahowerate in type 1 and 2

nn a of Del Vem Loy hanes yt 5 os

6. anetoderma folder

Folder: anetoderma

7. (1). png

8. 0(10),pn9

1 may be depressed,
the subeuranovun
‘with alana

a was reported by
smanvwith depressed
Shave an atopic,
Singer and Buzz
like tumors that
Ins were located on

are inthe word
Herma favors young
more Regent in
snctoderama ct

Table 99.2 Classification of anetoderma.

the presence or absence of clinical inflammation at the onset of the

9. 0(11).png

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ined in Tle
Inthe lial

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10. ea

OK 1452 Morphologie abnormalities described with aretoderma

Eye abnormalities

+ ane

+ Kestoconos

+ Comes opacities

+ Optic atopy secondary to
bony change)

Osteoarıkular abnormalities

+ Abnormal calor:

+ Kyphoscoloss

+ Shorering of amb,

+ Congental fusion of cena!
verbe

+ Spina da

+ Oteopaoss

+ Methyl plas

+ Hp dia

Cardiovascular abnormalities

+ Mival vate proa
+ Aortic insulideray
+ WoteParnson-iNte

Miscellaneous

+ Emphysema

+ Potion of est

+ Pyramidal syndome

+ Myotonc dystrophy

+ Dieron of meccesophag.s

+ Begiod-Hanthosen smdrome

+ lanetodema, osteogeness
importe

11. 0(3).pn9

145. Difeental dagnoss of anetodemic lions

12. 0 (4). png

Box 94.1 Selected acquired forms of cutaneous
atrophy

+ Generalised cutaneous thinning:
+ Ageing (se earlierin this chapter)
+ Rheumatoid disease (Chapter 155)
+ Glucocorticoids exogenous or endogenous)
+ Acquited poikiloderma
striae
+ Atrophie sears
+ Stellatepseudoscare
“Spontaneous atrophic scarring ofthe checks
‘+ Acrodermatitis chronic atrophicans (Lyme borreliosis)
+ Atrophodermas:
+ Follicular atrophoderma
+ Linear atrophoderma (Moulin)
+ Atrophoderma of Pas and Pieri
rematoma ofthe finger (Achenbach syndrome)

+ Local panatrophy
+ Facial hemiatrophy

fa

Pat

Ste

13. Pa

ana sonne ne nen ese o ap soy
from
Box 114.2 Causes of atrophic lesions in neonates Dift
+ Maria Dit
> Atophiedermatofsarcoma profuberans prot
+ Cats mao langle comporta neu
+ plan eu congents ie
> Anetoderma of premaurly bee]
PP wit mila | Ca
as
+ Mali ike derma dency hamartoma tia
> Congenital incon (HSV and V2 may be ester)
2 Focal dermal hypoplacia of Cole The
+ Neonatal lupus erythematosis tra
SV herpes simplex virus: VZV, varicella ose ius

14. 0(6).pn9

ve acetonide
uma) cream,

in an open
kin atrophy
ice weekly

ic daily has
¿ntrleional

+ Das ang

Risk Fact
Atrophy

Systemic Effects

Aly from the
he AE and

ary-Adrenal
‘taco in,
Eso those of
Aas tro

infames and

eukocytex!** Normal and pao
du voluntcers applying more than 50 g of

paralleled increases

15. QUE

ogy demonstrates focal degeneration of
elastic fibers and normal collagen. There

ananas ahnar.

ara nn associated nvtra-

16. 0 (8)prg

also has hoon described in prematuro infants. posi

17. 0(9).png

ectopic mature lipocytes located in the dermis, woe

18. ‘pen seperated emt Bl ee

se
gn en shen ene Dre

of the anctodenna lion showed homogenous whit and
yellow sen wih distended skin markings (Fie de] The
Piet was started on ral preinisclone (075 make ta),
‘which was tapered over 12 Weeks,

Clinical, anctodermas manifest as clusters of circular
‘or orl pink macules or plaques, typically ranging fom
05 em to 1 em in diameter Over ine, these skin esis
gradual fade and flatten fom the comer cutward,
Teaving behind trophic macues that me deprssble
under pressure" The various causes of anelodema are
‘mentioned in Table 1.54

I leprosy patents, the amangemen of els Aber may
become regula semaines gested, and locally
fgaregated There ae limited reports of epramataus
Ieprosy ending to secondary aetodema #9 In leprosy,
inlammatery cells instigate changes in the demi,
replacing the normal dane matrix wi à Jouer ene nee
«conduce to ongoing inflammation. This tranommatico
primarily involves neocllgenesis. collgnolyi
latolas, and proeogyeam degradation Macrophages
within the lesions of lepomatos leprosy may produce
laos cymes, while neath recited ing
era reactions can cata t sos

Elasolyis in leprosy, particularly prevalent in expose
areas, can clica resemble anular lastly giant
sel grnuloma® Generalized anctotema has bom
‘observed in an HiVegostive man coinfeced wah
Aro and tuberculosis Once clastic tise i To, it
came be fully regenerated during the reeovay proces,
‘making andodemnn resulta fom elasolsis à longe
complication of leprosy

Diagnosis prima relies on clinical examination, and ean
‘be confines true skin biopsy. Special taining mods,

Table
+ odas Pelz pe
2 SémmimerBuzi ype
Secon modem
ufone

+ ase verter

+ st

2 Ml cocon
timer demo:
+ acuerde

+ Saco

+ usa pianos

Erin
Anime ons

+ Syanieipunaytantons

+ Semen pudre

+ Adrien

+ Autoption
Gates <a mp

+ Cxteus Tampa

Adie tee

+ Myroftroarcom

Depot ir

+ Notarios

+ Poses vec

+ menton cre mme net
+ Anodes of rent

2 Faia anton

‘ch as Von Giesan or crei taining. ae nec)
16 identify elastic Abs, clatlysis, and chatons in
ve a cron couse, and ae
hy resis to weaiment. À combination af à 398 nm
puede laser with 21580 nm non-blative fractionated
Taser may offer clinical improvement by stimulating
astogenesis and reducina Aber fragmentation ®

Inden Demi Ona Jour Vom 16 ai ut 2025 on

19. demodex mites folder

20. (png

Jindal and Devaraj Clinicoderme

+ Benzyl benzoate
elphur

+ UK ermectin
+ Combination therapies

‘Table 3: Common therapeutic modalities for demodicosi.
‘Topical treatment (6-8 weeks) Systemic treatment

+ Metronidazole 2% + Metronidazole 250 mg
+ Permethrin 5% efor 2 weeks

2 Crotamiton| + Ivermectin 200 mg/kg.
"Gamma benzene hexachloride 2 doses a week apart

+ Doxyeyetine
‘Isotretinoin

neurotoxic effects on Demodex mites, continues to be one of

21. 0(157)p09

az is gi Doo tt

m

a. png ed

rene

ee

En

See
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om
Ben

22. ea

Table 12.1. Primary human demodicosis: proposed clas-
Station and nomenclature
Te [Proposed Definition and clinical
ta nomenclature “manifestations
ze Spinulate demodicosis Disereie fine, whitish o
yellowish, spiky changes
involving sebaceous hair
follicles, with or without faint
erythema and file

©

inflammation
Papulopustular Papulopustules mostly
demodicoss, perioral involving the face (predilection

© demodicosis, or perioral, periorbital, and
periorbital periauricula regions). in
demodicoss, patients without (primary
periauricular form) or with preexisting
demodicosis inflammatory dermatoses

æ (secondary form)

Te Nodulocystic/ Intense immune reaction with

mm conglobate massive folicular and

is demodicosis perifollicular inflammatory

infiltrates caused by Demodex
ÿ proliferation, pus
te accumulation, and suppurative

succulent changes.
Adapted from Chen et al. [16]

23. 0(3).pn9

[tote 277 dorso:

Own
engin x with”

engin th)
Protonymen
angine wc)

Nymph
engin woth)

D. FOLLICULORUM D. BREVIS

105 42

23 «34

365 «96

902 «42

0x94
wor
ax
15x41
108,
17-46
208
19-50

134
Sebaceous la

Then
lowest
host, re
repone
withar
285 ye.
lou seb
Demos
Inst
During
skin sur
of adul
abdome
with a
in the
repone

DEMO

24. LIE

25. 0 (png

Table 2: When o suspect primary and secondary demodicosi

Primary demodicosis Secondary demodicosis
Late onset, >40 years ‘Can occur carl in life

Facial involvement (perioral, Can have truncal involvement
periocular,periauricular) aso

Asymmetric distribution, | More diffuse and symmetrical,

grouped in an irregulr shape involvement
th satelite lesions within one

atfected area

Follicle centric

Asymptomaticimilly prurtic More extensive inflammation
hence symptoms

Lack of classical manifestations Past history and features of

fresca ke erythema, underlying discase such as

flushing or telangiectasia perioral dermatitis and rosacea
are evident

26. 0(58).pn9

27. QUE

Ghopphags (cheese mie) Grocer’ hen

‘Dermatephagides (us mie) Mery
Trombi (tiger mie) Sont typhus
Domo sp Follett, poss rosacea

28. png

Io mie ing. Der,
ee)

Memento

= [ating rt o tin
= see min

Drum I

Ou mue

29. mite (1).png

‘Table 85.5 Mite families.

30. | Mount ve or soho mites rst Moyers medium
ites sions Men me ce

um A 5 nates a, on 2050) 209 eo
‘Nome tatty Or D sen

“Table 857 Preparation of collected mies for microscope examination.
‘tes are old ono ters inde à varuum cleaner te fer samples are
{Tete wit potassium prod (HOH) and then ste in concert
Siar sotto to oc the mites

rickettsial disease, and serologic testing can be helpful. As with ick
‘borne rickettsial diseases, biopsy ofthe eschar can be sent for immu
nohischemical staiingor PCR to distinguish yphus group organes

31. Demansie Be det ms
CR
moins rows
pp ngs sab ms
Promote Gran mes sta mt
Sci Seabee mt
Temeviese Cage arts
Error
res OF MEDICAL MPORTANCE
pS anime ty, un mao at
ita ee Waking amant on pet
reyna maccoe ast mate
Mat warehouse oh ar
oma. aout par onsen phat,

made mange nde and eats

Bienen sun. Foti chr we ah.

Domonugoaen Dust o tray ust Dann,

fame. D lomas mates pompa Sed on

rap mans Dt aa stay, romain th
th st mien

Ayora domes Chetan, bam mi, pour mie
‘own, ges fy moses

ricos oo.

‘Sinope sr.

pig detector Dust mt, hay mt

Upon tano mao me

a eS

ci ans as ir Caco

One nai me

(Dinard nt ope bw

A 71 el

O

=. 2

en

u
ze

Table 5 tes of mes Importe Seti namen conan nam
nd scada 1 bir tea Min sapo dl ease od
maca me bie pyle pure perp unan

Fi: Avian
bette
Sor pei
foul ef ch
En au

PREPARATION OF COLLECTED TES FOR MICROSCOPIO

Sei ir car ger a oo on)
Metin Hers megan

api motos

Moet or aes a mite day Hoyer un

“hot mo mts Port tis dl mess bro)
trey ar Sam AS ited ae ena 20 tt
‘noo edt 29am a ra ee

Thole 857 Preparation ect es for oxo amination 7
Its recede ens vaca xe he a arse oe
‘resent ptm eros HON and he ost meet
ato tw coc emt.

ice disease, and slope esting can he hepa As with ck
are reketeal den, Dopy ofthe exhar cn be en br im
‘ohsechemicalstaiingor PCR Lg plus ports
from the pred fever sou.

Differential diagnosis
Ait induced dermatoses at often misdiagnosed Bullous sions are
special common and fale pot det immune Rar
Risse Hite etre emba hose fan inc bee
may sus the are dignos, s may cin ater ol skin
Jesons componsing e as of exposure, However, connophsich
Pendel ble secur bork as ines und balls pm.
cid soa carta yi cecil

induced demas an be asocia with pt, den, rw
eine bd ess, gain, and even nina ee ENE + 6 Ann
te derma may als be acia wth pet ees, sch a ri,
Fes should de ern by à Devis enuf, als:
ine este up snpping or psy may eel the mato où the
hima, arm ios can alto te cd wi rs cl mies
ÉD A0 Anto hell eh lt pay aes andra or
{rion pet ith macaco) ago rende y eterna
Kine td om sion then tae t ove the sale
ras, wich placed ins scaled bg When an Is aed the
Bi Sees ad ha il ink, whereas mites wi at

Treatment

Some peo ite inflict “in andr inary, wile ober remain
Stachel for a prolonged mel Supine ape sping or ra
tering wih sup and vr ate al eae in remain or line

Cr ej

1927

32. Grape + Biesandsing | 53

Insect repellents containing diechyltoluamide (DEET) offer the most
effective protection against mosquitoes, fies, leas, mites, and ticks. Edhyl hex-
ancdiol, dimethyl phthalate, and dimethyl carbate butopyronoxyl provide a
narrower spectrum of prevention compared with DEET. Use of a combina-
tion ofthese repellats improves effectiveness. Repelants form a barrier against
penetration that extends <4 cm away from the skin, DEET also blocks the
‘mosquitoes ability to track human carbon dioxide vapor trail. Repellants do
not mask other insect stimuli such as sweat, moisture, and warmth, DEET pro-
tection lasts about 10 to 12 hours at room temperature, but can be shortened.
by clothing fiction, water, sweat, wind, or heat. Repellants may lst several
days on fabrics. Mosquito ness and clothing should also be used in areas where
‘mosquitoes serve as vectors for disease,

MITES

1. BACKGROUND | Mitesate a form of arachnid that parastize humans and
feed on organic matter. Depending on the type of mite, a range of dermatologic
manifestations are seen.

IL. CLINICAL PRESENTATION Mie infestations manifest as papulo-
squamous, urécarl, inflammatory, or even bullous dermatoses. They are also
responsible for wansmiting infectious diseases. Clinical manifestations and

cific mites

pra Ss
icc news

‘Symptomatic reliefs
oan on
re

«Permethrin spray
+ Fipronil spray
- Topical amitraz
‘Symptomatic reliefs

Demodex Rosacea Topical sulfur (initial
treatment)
Other topicals:
= Permethrin 5%
= Salicylic acid

(Continved)

(c) 2015 Wolters Kluwer. All Rights Reserved.

33. 84 | MANUAL OF DERMATOLOGIC THERAPEUTICS

TABLE

- Metronidazole

- Crotamiton

= Lindane

- Retinoids
Oral ivermectin
Oral retinoids

Dermanyssus Equine encephalitis Removal of infested birds and
{fou mite) nests
Omithonyssus fowl — Westem equine House cleaning and fumigation
mie) ‘encephalitis Symptomatic relief
Topical acaricides
- Gamma benzene
hexachloride 1%

- Crotamiton

- Permethrin

- Malathion.

Dermatophagoides Allergie reactions Humidity < 50%
(dust mite) ‘Atopic dermattis Mattress and pilow protective
coverings
Wash bedding once weekly in
hot water
Symptomatic relief

Ghcyphagus Grocer itch Pest control
(cheese mite) Symptomatic relie

Sarcoptes scabei Pruttic dermattis Wash clothes and bedding in
(scabies mite) hot water

Pest control

Topical permethrin

Oral ivermectin

Trombicula Dermatitis and scrub Symptomatic rele,
(chigger mite) typhus additionally:
= Antiprurtics: camphor,
menthol
- Topical anesthetics with
pramoxine
- Potent topical corticoste-
roids under occlusion
- Ice application
- Excision of refractory
lesions.

“Symptomatic ret for mie-associted dermis includes topicalcoticstercis and oral
anthistamines. *Antbioics may shorten the duraton of symptoms. Second-ine antibitics
Include enttromycn, teracycine, and chloramphenicol

(c) 2015 Wolters Kluwer. All Rights Reserved.

34. “able 49: Non-Venerel Treponema Infections

Yas Treponema palidum Primary: one o few erythematous papules at inocu
rames (pes pert) ao ie moler Jan} wall on Tower leg of
‘Transmission: direct contact wih | SM Enlaes. uleertes and disappears with
Infos lesions = Seconda: smaller daughter yams’ lesions spend

metal over boy

Tentary: sin and skeletal changes (no CNS oe car
dorer problems) gummata, Kkertodenma,
mia destin, bon} inflammation and dam:
‘ge nodal lesions,

Oo, cl ans arr coon an

Pita Treponema craeum ~ Fria smooth pape at neon ite
i) Tennis: det comas with | Secmdan small Prise sevi brown
a ons pole | Pape amd pages ni,
it) Talay” depigmened lol leon ovr
fs ris char aren
Endemic syphilis Treponema plum (pois | Primary ski sonra
os Ho Secor mucwal lion including. mocos
Transmission diet kin contact pacs, conylonaa la, an Iympbadenoaty,

ont, peros, bony damage, gummata (CNS
and caniovasclar problems very rat)

“Treatment or venereal and non-venerealreponemateses: 24 milion units of benzathine PCN
neta. e pe name dog for eee pis

Syphilis Lues, Venereal Syphilis) (igure 417, 1.0
‘Chronic systeme infection caused by Treponema pallidum (bsp
pallidum), iovolving pipe organs including skin, cardia, neurologie
fd skeletal system

+ Transmision canbe sexual (ont with infectious Iso), wansplaent
«from blood products (are)
+ Clinical stages divided as follows
+ Primary stage
‘Chance cali infections inoculation site prose a highly
Infectious, indurated pans eosion or ulceration: spontaneous
resol within 12 monts epional ymph node enlargement

ER
(Canes of Pal Ge)

35. bidradentis folder

Folder: hidradenitis

36. (1). png

37. 0(10),pn9

u u oo
Fina Sc ey

38. 0(11).pnq

BIE 5.1 Hurley staging system

Stage Abscesses Sinus tracts _Cicatrization
1 Single or multiple — =
Recurrent + (separated) +
(separated)
no Multiple, +
interconnected
idradenitis Suppurativa: À Diagnostic Alas, ist Edition. Giuseppe Mica

© 2017 John Wiley & Sons Ld,

iblshed 2017 by John Wiley & Sons Lid

39. 0(12).pn9

Table 5.2 HS-PGA scale

Stage Descr

1
2

Clear, no inflammatory or non-inflammatory nodules

Minimal, only the presence of non-inflammatory
nodules

Mild, less than five inflammatory nodules or one
abscess or draining fistula and no inflammatory
nodules

Moderate, less than five inflammatory nodules or one
abscess or draining fistula and one or more inflamma-
tory nodules or two to five abscesses or draining
fistulas and less than ten inflammatory nodules
Severe, two to five abscesses or draining fistulas and
ten or more inflammatory nodules

Very severe, more than five abscesses or draining fistulas

and fistulas) within seven anatomical regions (left axila, right

villa left orain richt ornin loft

‚Mack socia right hutack

40. 0(13).pn9

A eran arte any Coane Rabu eco et

ep sy era Im ra
De

po rc nie at
Pate tacto Sesame spa ine

41. 0 (14),png

PAE IPS
13 Arr nd at td eon oe
Junco WS tng ao Pi

42. 0(15).pn9

(eat Senna nay ara py the a Ane lic €.

Dom Ea
Sun rien
ed A
extortion dint bly po ponme

EE Se Rtas rb ey ETS

43. 0 (18).pn9

MS De sc et

om =
Beeren tee oa egg na ale lord
den ut ue nono rat dara ao pn coma oe

e am ote maar comes

44. 0(17).pn9

45. 0 (18).pn9

ree yb mal pe tt
tte wun nue So hrc de

‘Sera bp mae gan Sve

46. 0(19).pn9

Table 36.1. Hurley stage classification for HS patients

Stage 1 | Abscess formation, single or multiple, without sinus
tracts or scarring
Stage I} | Recurrent abscesses with sinus tract formation or scarring

| Single or multiple, widely separated lesions

Stage II | Diffuse or near-diffuse involvement or multiple
interconnected sinus tracts and abscesses across entire
anatomic region

Modified from: Hurley H. Axillary hyperhidrosis, apocrine bromhidre

sis. hidradenitis suppurativa, and familial benign pemphigus. In

Roenigk RK and Roenigk HH Jr, editors. Dermatologic Surgery:

Principles and Practice. New York: Marcel Dekker; 1989. pg. 631-643

Asa result, patients” improvement from their “basel
ense activity assessed at the time o

dis-

initiation of an investi

47. 02).PNG

HS Phenotypes

mr ema em nu ernennen
nana nn

lauren) T =
nee

48. 0 (20).pn9

| wanvAt oF DERMATOLOGIC THERAPEUTICS

| Stage | ‘Stage It ‘Stage u
1 Longterm ietacyeine 1. Artists
pt tr 2 Conoterds
marne eh ret

2 Gamer» Hamon fr fre ardt
modo ace
Amir connate Momo de 3 Sa

ea 3 hirer
remain meri

A. Lee Modifications

49. 0 (21)png

HURIEY ST merry

Primary ‘Topical antbiones
‘indamein 18 sation MID
Benzoyl peroside 10%. lation oF wash BD
Gene 4% solution BD

Secondary Topics antibiotics +
Semi abia
Bosa 50-100 mg HD or mnocycine
Too me BD
Amen 360 500 mg BD
‘Sismethonazokwimeshopsiny DS BD
Gindamscin 300 my BD
Aniandrugen (Females PR
Sproneisctons $0 200 my QD

Tertiary Topical antibiotics + atomic antibitin
Other therapies
Dapsone inastride, ottetisoi
Immenomedulrere
Semi weroke iniimab, etanersept,xiospora
Antandiogen PRN

Independent ofseveriy Adjunctive therapy (weight ls. smoking cent
‘St bath, warm compresses, tale OR roids)
management (nowterolssl antinori
‘opiates
surgi exc

MA 7 no» MO

50. 0 (22)png

42 _Hardeniis Suppurativa

Table 42.1. Sovery clasifiction of hidradenissuppu- + Crohn’s dis
ava according to Hurley staging

HS has to
Suge Abscess formation, single or multiple. case of sole

‘without sinus tracts and cicatrisation ot La

II. Recurrent abscesses with tract formation and

Brenn HS. Tere.

separated lesions ane.
Stage Diflue or near-ifse involvement or + Acne vulgar
MI maple interconnected tracts and abscesses ‘edones anc

aaa lesions,
Diagnosis and Differential General Prir
Diagnosis

Management 0

51. 0 (23).pn9

52. 0 (28).pn9

262 o oa

53. 0(25).pn9

Bon IM shows ale of leant investigations.

natty
afc le fie co

it toma dan
“amt ah qui rn
‘Sau no conte
‘eae

TEE
Aree oler coms,
‘ine a

act kg Cham ero
a

55. 0(7).pn9

aa Note ES
A e re
grecs a o | tow
FH = + Mma as
© een crate | ect, am dose
| 5-5 mg one injection | evaporation, dinage of acces

Cindumycn + Riampicin» 10k’ | Preinhone 40-60 mp day
for 34 dys then taper
OR

Cyclosporine 3-5 mp day

Local procedure fr sins

À Adsimumab » 12 whe! E

+ Dapsone 13-290 m da
Ace (0.5 mi day
= + Wide chien fr ager

seat aes
Radical wide con.
Champ 01019 0 > Rain 10 mp 80 ay. "Dolo ln vac at xin STEEP egy,

‘ton oun oran tee oun am weet 16m Con ROMEO Aare
orgs weet

for HS salient agents are detailed below. Here must be noted that the cardinal feature of HS

Lépine of Ex

56. 0 (28).pn9

a ee

57. 0 (29).pn9

Box 90.1 Essential criteria for a diagnosis of
hidradenitis suppurativa to be made

1 Typical lesions | Deep-sated painful nodules, abscesses,
‘draining tunnel, bridged scars and paired or
‘multiheaded open pseudocomedones
2 Typical Axillae, grin, perineal and perianal region,
topography buttocks, infra and intermammary folds
3Chroniity and Recurrent lates of painful lesions over time in
recurrence of the same or differing skin sites (at least two
lesions flares in a 6 month period)

58. 0 (8)png

Table 5.1 Diseases with an association with HS
Cb isene

Table bowel syndrome
Down's syndrome
Abrió

Graves disease
Hashimoto thyroiditis
Sjogren's syndrome
Hyperundrogenisn
Herpes simplex
Acanto niga

TableS.2 Apocrinegland arcas ofthe bay prone to HS
Inguinal olds

Inframarary ess

Perineal aras

Buttocks

Scrotum

Mons pubis

Abdominal folds

59. 0 (30),pn

able 90.1 Denton ofthe thee Hare stages m iras supuratra

ES

Lure 90.13) Recurent nlamematry din lesion without in turns an
sang

figure 9014) Recumentinfommatory skin lesions with widely separated sin
une and cam

1 Figure 90.15) Multiple interconnected inilaneraory less, shin turrets and
sang fuse Imola an entre sin region

60. 0(31).png

2 May seventy stages,

ER

‘Stage | Stary or mute abcess occuring hou formation fus ac
org

Stage! Racuent abscesses wih snus ack formation and scaring occuring
hen an anatomical region but separated by areas mama sk

Stage Confentvoament ofan ant anatomeal region wth mate
conne absesss, nodules, rus CS and searing

capi om I

61. 0 (32).pn9

tration of
> without
activation

apport to
essarily a
ind in all
Rough its

Ile 135.1 Dasrbution of Langetans cl hist in 170 chicken with singe
tem Langehons cl his50Q fs treated nthe DAL HX tue.

[ss Patents OH)
Untocatene Fr
Mata one 5
pres "
kts mon ode 2

Reproduce tor Trgemeyer et al 2001 [23] wth permision of John Wiley Sans

PART 12: NEOH

62. 0 (83)png

ans. Clinical Findinas

63. LIE

MM “Ayia eto ses may be ect at st par mu
beim

64. 0 (35).png
syst however ae generally Zonsidered too cum a"
rome for cine Price bt remain usa in O5
Be =
fur

un

the

65. 0 (36).pn9

Sages yas runny a opens a we

= review. Am Acad Dermatol, 2009014) 539-561, with permission. Copy

ts
ie
xe
it
Eur
plugging
oe

66. 0(37).pn9

ae Teen oppo sect FO peo

“en a ae "Sane a corso
‘Seng si rn

Tann nos

Poot emai, sere

rst cn Seperate ya

es ‘te va?
A

CERTES

PE bs
Lan og ty

67. 0 (38) png

be ni en cts we Ns urn a ang nen

= Can O a tn ge aci

68. 0 (39).pn9

= i O

69. 0 (png

Tables Levon ype sed ein

Br ine
AO Rael en an ST
Aid Seine ciment
rn | gs nt
Compe ae

tee ay Seiten
Noam a SH am Lipset $) id

70. 0 (40)png

Table 2- Hurleystoging”

‘eget Nico lion, sr o i wih tne

‘ego ren cay oman ond
AAN

Segen. Du one ine aumen se lo
cd oct ond cai so ee a.

heropeui einig 1,2 end 3 iste pie coses
‘FHS poten wih Murty 110 3 diente, spacer Re

‘any, 9 vers rarien af Huey sloping war proposed

71. 0(41),pn9

= u een
ee =>
SS ==
> — a
>= ==

72. 0 (42).pn9

Table 4- Physician Globel Assessment

Clear Ne mono o ner tomarán
en en
‘Ting tar reat ng od en
‘edna nn na
odas <5 rarer mode. abo
SS ain ion mue
‘Shenae or rong fies ns “10 denen

Save 25 sp © done Be 10
rt ml

D st babies
3.4. Hidden Suppurctvo Cinica Response (ISC

The MSCR sores dnd © = 0% edoción he
‘umber ol rre late lesions Gum ol abscess

73. 0 (43).pn9

A aporta At

E Fon scone ra atra
Lors

E aS =:
| Ss

A Bomar Team SI

— SR nos: Absorbent drsings. on the other Dan,

74. 0 (44).pn9

sue samples from a patient

Table 18.1 Hurley sages 1-3

Sage F Single or multiple abscesses wi no searing
“Stage 2: Recuten abscesses wih sins wast
Formation

Stage $ Diffuse involvement wih interconnected
Sinus tracts and multiple abscesos

m
‘mato, Updates in Clinical

75. 0(5).pn9

Table 2.3 HS-PGA sae
Stage | Deseription

Clear [No inflammatory or non-inflammatory
nodules

Minimal | Only the presence of non-inflammatory
nodules

Mild Fewer than five inflammatory nodules or

‘one abscess or draining fistula and no
inflammatory nodules

Moderate | Fewer than 5 inflammatory nodules or 1
abscess or draining fistula and 1 or more
inflammatory nodules or 2-5 abscesses or
‘draining fistulas and fewer than 10
inflammatory nodules

Severe Two to S abscesses or draining
10 or more inflammatory nodules

Very More than five abscesses or di

severe |fistulas

Kimball et al. modified [62]

clas and

are fluid collections ar two

76. ORT

Table 3.2 Clinical staging and severity scales
Seo
+ Hurley staging syst
* Modified Sartorius Score (MSS)
+ HS-Physician’s Global Assessment (HS-PGA)
+ Acne Inversa Severity Index (AISI)

+ Hidradenitis Suppurativa Severity
+ Hidradenitis Suppurativa Seven
ansa)

idradeni
MSCR)

Suppurativa Clinical Response

77. QUE

LS

ogg ee kind ar
Hoty a protein Cte de
[pt cope endo,

78. 0 (8)prg

“Ta Bs Pa CURE gee a age sw AP ea
+ Patt innen 2 po
ape D ip qi 6 mg fen
TS pn ee er gs Pe
“Neri se
LU peter” st sg ang
“Gen Sm be ee |
e pte pe se
‘eal cb ee
“Caner deen tn pos won lh oi pen, sr den
‘dtu nee ek a
one iat miei
Soie anime 2
Peer
im ger nd ow a ut

CH

abi. Top se 1% chemi ping ag, hs bse show
rodas pin. improve rab. and ponte reson of none when api
Sy inane esos nce w ce dal 132] tales! comicos are

79. 0(9).png

A Sorat Sisto Sean sas

=
sar a a men an Re

Pan Yorn pp ey

80. En

Hate tng sytem
Sp on mar aces wih fo aos tact cs tata

‘Stage it~ rp moco ons La wa acoso id aloe gan Pero eu Sang
Sans rating syst
+ Atom gora moves ata et rah ont io Nh te et ered oot ron einai: ot prog moves

“nea tres ess teh ear nas =. halon
“elope tres einen two ror laure aes an fa, ech aan: em =: S410 em +210 0020

“A on cry spate y soma sn? Inch gn = os Oo oy 1

Merpaute naco

pa ear
lobe our, wat ein,
“hotest saps
"Sacra cto

aos:

roy ag Hno 5.98958) ut at any (rojo)

papes

er to wm ecos ton
aie ga po 0150)

nc vein

ber in vom cos tan

co tee
org mpm 1019 fos Sum mes en 1 0 0m
Areca ep me.

{Rac con nd most sn wegen, ren one, an opc uan re

son miis 5m cons y iaa eons
nao

{den Sam canag win pes pun ns, ets, ross. pra pens

“ort roe tn o ens entra resto para

“Gtr bee may ons orn con mme) iiem Em, ean,

Sonore sm dao tanta urn

an Dar a. as)

{Spc montane st cg atun, tin”, ar cn

"Lite eons win scan ten nang

{NEA overtone a st 94 mony sons
Masel sera cine for Sapo a

"ay wee rp! on a men a

echo bce cren

ain

ing

12 oye 1 emg 2 a y st

‘abe 387 Hirani suppuane = racing stes and taped A cn ers we sed man he Roue mat

‘fe Sten cing aan re rns aa ee ans ena
gados Mr i

ical we ove wh scan modes rudo ao

era
‘eho St andes upp Cina opus SCA anda paca Goa Amen See hae ben las ark 3 manent
ye

‘emo Stag stem much Saget de a te AAC

TRICHOSTASIS SPINULOSA

“Those sino i coman, hu oc undcrdiagose, li.
Li ander of unkoo clog Asmpromat comedo ke eins
that contain ean and mu ves hats rc sen, par on
thetic, xp mid ower central porton e fable 363)
Anl he mnt oe dis segona
es fllelr ies un wile ef ais ob
‘erate seat wana ite ar all Pan ook ee
Because of de comet appeatance, bat pus ar ted the ite
incide emi deploy opal ecm ad sr (ee kg
pass anand, shor pulsed dame pued ide Thee
Tess por of feet hom prod applies ofa hence abe
‘ive yd are") nd a emmendation shoe sure mes
Indus wh more dy gmemed skin so sw ede the Fk
‘ot hypemmenttion

VIRAL-ASSOCIATED TRICHODYSPLASIA

Sony =Vaalssscte ios sinus «vea
routed cholo aire Tamara.
‘inden: Opern lear yop

Vial social vichy war fit decried in 1995 in the
contest diugnducedimmunosipesion ir amant ci
ee re acc oo Tute ne
sul wicht sima asc polyoma Sk
hd co pal leer papas and bee pn Enr be cn
face ice Fg. 150.8 and hey muy be accompanied y oso he ee
Brow and eelasbs, extafcllesons with asocia aloe may
to develop. Histalogealy enlarged and tended anager pe ll
‘ss hve à igh number of inner rot hen sl dh sone
Spun of haine rans, The spe en be dene by
tie mung oie conc Ile pall es str
none therapy cannot be reused tonal lr o cr
tene olor onl vaganceon (900 mg on orice daly) may be we

‘Acknowledgment
The rs would ke wach the lt A Ral Key, MD.
por hs conti to the pros edo 0] hs caper

O)
re

81. Opa

art An amer ec ogame nc nent

Tal. Sonnige ng de armee nents

(ai) ee if ne” =
mes nme | mem a
mes mm = wma, = (a
He
mes [as | Banpiceeyiwes ji
mar fes | mate |
ur [menta |= Imprentas [as
CRC" HE Donges [a
uv m = E Pre)
CONC E Mongsecermet |= [80
7 [sti | B Wongmzne | [00
un [ons |- Papas ee (a
E Peas Mongiennenovaeins |=
ee
E tac O
E tc mucama a
“ha FÉES
a fa |: ry Wongsconingaay |= [one
éromanaireeonéone
Dose)
mn
ar fes |= recipe ih [gates CL
CC - eee mm

nn mb a

82. Opa

Chapter 20 + Hidradeniis Suppuratia | 175

TABLE 20-1

Stage | Abscess formation, single or multiple without sinus tracts and scar

Stage ll Recurrent abscesses with tract formation and scar formation,
single or multiple widely separated lesions

Stage Il. Diffuse or near-dífuse involvement, or mutiple interconnecting,
tracts and abscesses across entire area

TABLE 20-2

Follicular tetrad-—folicular occlusive disease
+ Acne vulgaris/conglobata

+ Dissecting cellultis

+ Pionidal cysts/sinuses

Rheumatologic diseases

Arthritis

+ Synoviis acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome
Miscellaneous

+ Crohn disease

‘Pyoderma gangrenosum

+ Dowling-Degos and Kitamura disease

TABLE 20-3

Infections + Carbuncles, furuncies, and abscesses (including tuberculous)
+ Deep fungal infection
+ Sexually transmitted infections (granuloma inguinale, y mpho-
‘granuloma venereum, and noduloulcerative syphilis)
Tumors + Cysts (epidermoid, Bartholin, and pilonidal)

Other + Crohn disease
+ Anal or vulvovaginal fistulae

IV. TREATMENT HS is very difcult ro teat, and there is often only partial
response to therapy: Few randomized, controlled ral exist regarding HS tre
ments, Consequently, most teatment options are based upon case reports or
‘ase series. One strategy isto select the treatment appropriate for the severity
based on Hurley stages (Table 20-4)

(c) 2015 Wolters Kluwer. All Rights Reserved.

83. Opa

armpit brest inguinolemoral,
perianal, perineal

Typesof lesions

Total area involved by lesions

+ Recordlongescstancebemeen
‘wolesonsineachatlected region
on

+ record thesia of helesionfonty
‘one eson presenta region

‘reall lesions clearly separated
by normal skin?

Total Score

DIAGNOSTIC WoRKUP - 31

(e ofindividvalstesinvolved =

3)
#offstuas x 4 ._—
#ofnodulesx2 =
‘of abscesses x =
rotar zu
# of other lits, pustules) =
x05

(e of regions with <Sem maz

distance between lesions) 2

(@ofregionswithS-10em =
distance between? lesions) x4

(a ofregions with 10m
distance between 2lesions) x8

ves=0 —
No=6 =

Table 4.2 Modified Midadenits Suppuratva Score,

ar

Minimal

mis

Moderate

severe
Verysevere

Zero bscesss taining fst, Infammatory nodules andnen-
Inlammatory nodules

Zero abscesses dining Fst, infammatory nodules andnon-
Inflammatory nodules

Zero abcess and ann fats
1-4infammaterynodules

or

1 abscess or draining sua and Oinfammatorynodules

Zero abscesses ining fists, and 2Sieflammaton nodules
on

1 abscess or drining fistula and =1 infammatory nodule

or

25 absceses or daining islas and <10infommatory nodules
25 abscssesor chaining fstulasand =10infammatory nodules
>Sabscestes or daining filas

‘Table4.3HidradenitisPhyscian Global Assessment Scale

84. Opa

_— AA

Pradera Dissecting comu
suppurative ‘here congotata __ Pionkaleye ofthe sap
SE ey intaesiona bene Ivleinal bene Une tbe Invasions benef
invasion Gunngecutefres duiogacutofaros beneficial Ging cute ares
(Amboëes (ora M Benefialduing Benofcniduing acute May be benefeial Beneficial ing acte
‘epi cite ares far ang cut ares fares
and postoperatively
Non-serial ant: Oapsone hasbeen Dapaonehasbeen Notarseted Dapsone hasbeen
infammatary agents suggestedas an suggested as an suggested as an
(systemic topic) alemaie therapy aerate Detapy ‘Sematieterapy
eon May be somewhat Frat ine therapy for Sugieainarvenien Consideredfest ne
benef ‘quali parts iskeyloteniment therapy fr moderate to
‘over Saa
Tiraminters FOAapproved Enicacicus cabal Not assnated Eficacous asbl lor
indien or forretactory esse rotactr dense
‘alum on
Cine 2019 nia
Sea banal aude
IA inner Efeackurofinbei _Efencuroflbei Notarsoted fieacousofabo for
forrokacary dasase forrotactoydosso. rotectary dense
IATimbtors Efacourolebel EFeacous label Netarcassod FEricacins ofabe for
fortotactry dasase forrafactoy ase ratactr sense
¡ugicalintrsenton Indeatedermany No assessed Indestedter at Not asenceed
patent th onensve Patent once cate
Genese ater cat lofarmatay phase
inftumerator pase bested
¡eventos
Lasertreatnent Eficacousoftabel Eien oftlabel__Notindcated Eficacousotabe for
fortetactary dsease ferretactorydsease rotectry dense

occluding clothing. An ansbiotie cleanser uch as benzoyl
peronid or chlohexidine may be Beneficial reducing
Ficroblal vigered Mares. During active ares, aniblo-
des are often fesline therapy, including topical cl

damycin or erythromycin and systemic antibiotics such
as doxyeyeline or clindamycin, For moderate o severe
fares, there is evidence for the benef of rifampin and
dapsone, though nether has been studied in a controled
‘inka ral seing, Inalesional corticosteroid therapy
is another option to teat localized lesions. For severe,
tweatment-esstant disease, adalimumab (Humir), a sub
cutaneous injected TNFa inhibitor is FDA approved
Interesting, a comparison of the outcomes achieved
‘with V-administred ifisimab versus adalimumab su

{gest that fia is more cet, but at present time,
infisimab has not received FDA clearance for this dis.
case" Patients started on TNF agents require maine
hance dosing. though ery evidence suggests these agents
do not necessarily reduce the frequency of new lesion

evelopment; however, discontinuation of he agent leads
o new ares In addition to TNFa inhibitors Les eta
lshed biologi therapes have demonstrated early prom:
ise including IL-17 inibidon va ustekinumab and Ih
Inhibition via anakina. Bok tl. reported 82% response
‘tein 17 patients treated with ustekinumab in an uncon
(old study, miroring carr resul with the same
agent" Teanetakow eta. demonstrated 67% response
rate 19 anakra versus 20% inthe placebo group in a ii
al til th 20 patents" Andandrogentetherapies may
be beneficial as maintenance therapy." Oral retinoid,
including isotretinoin and ackrein, have mixed re,
and theirus'slinited in a large population of HS patents
(Ge. females of productive ae)

These modales, ultimate, ar almed at decreasing
tive inflammation, at which pint patients are generally
good candidates for more definitive surgical excision of
the afected areas. The goal of surgical intervention Is 10
prevent recurrence of inflammation in pre-existing tracts

85. Opa

E 2owbossand Goya

ai na Dir in may ce sio
Ge aro tas monts ‘
‘ls th he tet cen pom alpina
‘Suerte onan ao hc E peal naan
Boned
Dermal cisne
Ya) Obtain era
ad pas re in
a be)
a
"slap pls lia) nas

Table 102 mem Hrn Sopra. Sri re
Sen OE

st poi) =
+ Name nancy pales mp 1
Naci mid y +
Namen une aan es ali y 4

uns pois
Sees orm pins

Table 19.3 Hatt men of HS [251

Suge Del
1 todos pray eon and gst wut sta ce
Indi pinay ton and ot wih pren

a el ey el ci beta
Sot wih ae mc

Table 19.4 Metis Esopo quines or ween
LL Active tana) dese

ue “Moderates
Tica Con sen management
Champ 1% Cnam empty

Truman cg Ati
(purine ith
Ice (mine) ease

re en
mr as
Se
=

een: Wig on nd cco inn ti in
‘mime tenet of pal

193.1 Comorbid Disorders

Obesity, diabetes, pension, metabolic syndrome. dylip-
ia depresion, and substance dependence are otenaso-
ciated with HS [O], together with increased si: for
cardiovascular disease 27] HS is lo often associated with
seve conglebut. dissecting cells, and pilonidal sinus
forming together a sol follar ccason tetrad |
Fare socios are thos wth intmmatory bowel con
ion (Cro’s disease, ukeraive colts), seronegative
artis, and spodylcanbriós [25]. Co-osewrence of HS
‘vith Crobn’s teas ben estate in 06-38% and with
‘erate cols in 18% of the css, In contras onl 05%
HS pasen also present Crohn's disease and 13% uleratve
coli PO. HS can als cooecur with pyoderma gangreno-
Sum. Manifestations of HS with ober genetic of soguirod
syndromes such she SAPHO syndrome, KID some. the
Dowling Degos disease, seaoostoma maple Sjogren
"drome sad oor rar ets have been repone OL

19.4 Management

‘The cant of HS i chlknging fr any physician since
requires long tem sry withconsecuve menunsigeher
‘wih carol montrng. Gene epee recommendations
hse been ect anduvo Europe clins pl ae
temic an sya mew. depen ont ag fhe di
se athe pati chartres CTE 19. In mid cases
tec ges ach a 1% cing, benzyl peroxide, and
15% resorcinol pel may be ace prevent rdelay pro
grsion nuca! tñamcinokn injection (2-10 mn)
incombiaon with cra an pl management act san fc
‘ive atm een in had HS nodules.

86. Opa

20 Advexal Disorders an

‘Table 22.10 Pharmacological and non-pharnaclogical weament of indes suppuraiva

* Local ep
Benzoyl peroxide wash [125]
= Topical cindamycin (129-151)
Topical sono [1321
= Inalesional conioseroids 86)
+ Systeme Therapy
Ora anne
Tewacylnes
Doxyeyline$0-100 mg BID
Minocicine 50-100 mg BID
(Clindamyein 300 mg BID and sfampin 300-600 mg BID (105,131,133)
Dapsone 0-200 mg daily
= Hormonal therapy
Ami androgen medicuons ie. cyproterone ace + estrogen, oral conacegives, oral
contmceptv + spironolactone, naseride
Target dep
Tafiximab (15, 147)
‘Adama (105, 1501
Usekinumab (153, 154]
“Anakin [155 150
Etanercepe (nt curly recommended 15
= Immunosuppresans
Systemic slcoceticois [125]
{Cyospoine 1140 11]
“Tari [157]
= Ona eos
‘Aciretia 0.6 meg daily for 9-12 months [133]
Isotretinoin 05-048 mg/Kg for at leat 4-6 months (135, 1421
= Metformin (182
= Zine suplementación [183.184]
+ Surgery
= Punch debridemen (mini unmeting)
T ncison and drainage [16S]
= Surgical unrofing
= Carbon done (003) laser excision [167]
= Wide excision [168,169]
+ Otter procedures
= 1068 nm long: pused NLYAG laser [158 1501
tense pulsed Tight 1160)
= Extemal bem adios [161]

= Photodynamic therapy [1

a

and finasteride are thought to be more effective than antibiotics alone (137-139,
144]. Oral contraceptive pills containing ethinyl estradiol or drospirenone are pre-
ferred and should be combined with spironolactone 50-100 mg if possible [145].
For severe, inflammatory HS, anti-TNF inhibitors adalimumab and infliximab
are associated with significant clinical improvement [104, 146-150]. Adalimumab
is FDA (Food and Drug Administration) approved for moderate to severe HS.
Infiximab appears to be more effective based on current evidence; however, more

87. Opa

SECTION 6: Adnexal Diseases

282

‘THERAPEUTIC OPTIONS FOR HIDRADENITIS SUPPURATIVA
Indication “Treatment
Au Patents General Measures

+ Moig reduction bee or overweight
+ Measures to reduce ton and moisturo

4. Topical aluminum choide
+ Warm compresses

+ Stop smoking

Hurloy Stage 1 Disease Modical Treatment

+ Solar or multiple isolated + Intrlesional viamcinolone (5 mg/m nections into
Fons sar infarmmator lions

No scaning or us tacts + Topical cindamyein

* Eradication ofS. aureus cantago with topical muptocin
In ose, axilas, umblicus, porana gions

+ Oral anibotes tard to resus of actoral cutres
{rom drainage discharge or abscess contents

+ Oral antbictc therapy (alone or in combination) fr its
antknlanmmatry effect (etrecjeine, doyeycine,
mnoeyeine, cindamych, rifampin + cindamycin,
Gapsone, vimethoprm-sulfametrovazol)

+ Oral ant-androgen therapy (ey Master)

Flares + Short courses of systomic OS.
Hurley Stage Disease (see Medical Treatment
GE)
+ Systemic adjuvant or maintenance therapy (may be
+ Rocurent abscesses alu in selected cases).
+ Sinus tract formations 1-Acivetn
+ Gary sea 2 tenia
sia) oe)
Surgical Treatment

+ Limita local excisions with secondary intenton healing
+ CO, laser ablation with secondary intention healing

Harley Stage I Disease Surgical Treatment

we + Early wide surgical excision of involve areas

* Difuse or broad involvement + CO, laser ablation wth secondary intention healing

vith mutipeintercomacted
oscense and sin tracts

+ More extensive scaring
Table 31.7 Therapeutic options for hidradenitis suppurativa.

For further information see Ch, 38, From Dermatology, Third Edition

88. Opa

1408

TABLE 84-4

A )

=
no bon pl nba o

on mt nue nt
nea

TABLE 845

Category of Evidence/Strength of Recommendation Grading Scale

cana tanning ane eager

‘cater nomma cai tec cp nc
cer

NR certe
one non none one | Cm ennemi gets

Fans e

89. Opa

su G.Genones tal

Table 1 Spectrum of conditions associated with syndrome HS

Invobod gens or chromosomal
aleron

Down syndrome “Tiisomy chromosome 21
Dowling Depos disease KRTS PORUTI, POGLUTI, and
PSENEN
‘Group? Follicularcccluson syndrome ”
Groups Pyoderma gangrenosum, ane, suppurative | MEFV, NOD2, NLRP3,ILIRN,
idradnitis PASH) PSTPIPI,PSMBS, NCSTN

Pyogenic ans, pyoderma gangrenosum, | PSTPIPI,ILIRN, MEFV

ace. suppuaivehidadeniis PAPASH)

Pari arts pyoderma gangrenosum, 1

ace. suppurative hidden PAPAS)

Pyoderma gangrenosum, ace, suppurative 77

idradnits am osing spondy ts (PASS)

Familia Mediterranean fever FME)

Synowi acne, pustulosis, hyperosions

xis (SAPHO)
Abbreviations: G/B2 Gap junction bta2 rein, ILIRN ire receptor antagonist, ARTS
rain 5 LPIN pin 2, MEFV Mediterranean fever. NCSTN nicastin, NOD? nucleate binding
‘oligomerization domi containing protein 2, NLRP'3 NOD., LRR and prin domain <omainng
protein 3. POFUTI protein O-fucosylanseras 1. POGLUTI protein O-glucsylransers 1
‘PSENEN presen enhance, PSMBS proteasome subunit beta type 8, PSTPIP? prole cine.
{troonine Phosphatase interacting protein I, PSTPI proline seine threonine phosphate ir
acing rotin 2

EV
2, NOD2, PSTPIP2, ILIRN

+ Group I: syndromic HS associated with a genetic condition and related diagnos-
tic testing ~ Dowling-Degos disease (DDD), Down syndrome (DS), keratitis:
ichthyosis-deafness syndrome (KIDS), and PAPASH

+ Group 2: syndromic HS associated with folicular keratinization disorders or
structural disorders follicular occlusion syndrome (FOS), DDD, DS, and KIDS.

+ Group 3: syndromic HS associated with autoinflammatory disease (monogenic,
ppolygenic, other) ~ familial Mediterranean fever (FMF), PASH, PAPASH,
PsaPASH, PASS, and SAPHO

Insyndromic HS, a prevalent pathogenetic factor induces the follicular occlusion
or a hyperactivation of the innate immune response, leading 10 the suppurative
inflammation of the hair follicle. The diagnosis of syndromic HS is complex and
should result from the combination of clinical evaluation (including HS-specific
diagnostic criteria) (Fig. 1), histology of skin lesions (Fig, 2), laboratory findings,
“and genetic testing.

Inthe present chapter, we aimed at providing a comprehensive description ofthe
‘main pathophysiological and clinical features of the following entities associated
with HS belonging to the Group 3 ofthe classification by Gasparic etal, which are
regarded as a paradigm of autoinflammatory syndromes: (1) PASH (pyoderma

90. Opa

m D. Bride
820 Conclusion

Hidradenitis suppurativa is a very chronic and debilitating disease. The pain, dis-
charge and chronicity havea severe psychological impact. The approach in manage
ment should consider all the factors and the molecules should be used judiciously.
‘The targeted therapies like biologicals can help to improve quality of lie and this
‘option should be discussed with patient. The different modalities should be com
bined to achieve prolonged remission and attention should be given to the lifestyle
‘modifications. Good counselling session, a sympathetic approach and appropriate
use of various treatment modalities can help the patients to lead a near-normal life
(Tables 8.1 and 8.2),
Clinical Results: (Figs. 8.7 and 88).

“Table 8.1 Treatment Algora for HS [57,58]

rey Surgical and ler
ride” __Lifewyle modiicaion | Medical management_weatnent
‘Mild- | Weight eduction, essaton Topical lindamyein 1% For bah stationary and
moderate of smoking, loose lotes. for 2 weeks revurenodules and
amisepi wash, pain IS foracuicand abscoses Excision,
management, pochological recaleivant lesions CO, evaporation,
apport drag
Dowyeycine 100 mg bd
Moderne | Same as above Oraleindamyein | Deooting of sins wets
oser 300 mem Ein of snus tacts
+ afampicio CO; lar
300 mem br | Wide local excision plus
ets second degree close
Adina for
2 weeks and evaluate
infix
‘Other oral therapies
Dapsone 25-200 mgm
aay
Actrein 02-05 men’
hy
Predaisoone
40-60 mm per day and

per
Cscloporne 3-5 mem’
aay

91. Opa

8 Hidradniis Suppraiva

‘Table 82 Medial management of HS

Mia
Mid leased widespread Moderate Severe
tlie Fist ine et ine
Topical weatment | Oral reumentTeiacyline (500 mg twice |Clindamycineifampicin
Clindamyein (1%) Teicycline daily or 12 week (GRADE combination fr 10 week
vice daly for 00m) B) (GRADE B)
12 week GRADE twice dilly of Ctindamycin (100 mp) twice
» for 12 week Doxyeyetine and daly Ritampicin 300 mg)
o (GRADEB) minocycline (50-100 mg) wie daily
Resorinol (185) |or vio dal (GRADED) TNF-iahibior
once dil: twice Doxyeyetine Second line Adalimumab for 12 week
(hil for ares as and CClindamyein + ifampicn followed by assessment
needed (GRADE | minocycline combination for 10 week |(GRADE A)
o (50-1001m8) | (GRADE) Loading doses
Second line wieda Clindamycin (300mg) twice | Week 0 (160mg
Miscellaneous (GRADED) dal Rifampcin GOO mg) subewaneous)
treatment tie daily Week 2(80 me
for individual Thiele subcutaneous)
lesions TNFaimtibior Maintenance (40 mg
suchas Adaimumab for 12weck subeuaneous)
intleional followed by assessment Weekly or
(GRADE A) Iafisimab S ms
Loading doses ravenous) on Weeks 0,2
Week 0(160 mg and Gand then every
mon subeutaneous) 8 weeks thereafter (GRADE
mea Week 2(80 mg B)
(GRADEC) subeutaneous) Second ine
Maintenance (0 mg Immunosuppression for

subeutaneous) wey or
Tafisimab (mg/L
ravenous) on weeks 0,2
and 6 and then eve
Sven hereifter (GRADE
B)

Dapsone (25-200 mp) ily
(GRADE Cor

Asien (OS mpg) daily
(GRADEC)

short eatment course
Prison (40-60 mg) daily
For 3-4 days then per
(GRADE Cor
Closporine 3-5 e/g)
day (GRADE ©)

92. 11 (48).pn9

Table 3: Hidradenitis Suppurativa Physician Global

nerapy, and genetic
lisposing factors.
rity of the diseases
than in nonsmoker
f smoking has not
+ disease.

1.2 times for every
to be more severe
. Few studies have
Ac syndrome in HS
stress occurring in
essure and friction
ing factor

een seen in more
‚At. inheritance.!"
nt of chromosome
lished.

td HLA-DR type
1

ciated with earlier

Assessment Score

Ratings

Description

Score
o

5

Clear

Minimal

Mita

Moderate

No abscesses, no draining Fistulas, no
nodules

No abscesses, no draining fistulas, no
{inflammatory nodules, presence of
non-inflammatory nodules

No abscess or draining fistulas and <5
inflammatory nodules

oR

Single abscess or draining fistula and no
{inflammatory nodules

No abscess or draining fistulas and <5
inflammatory nodules

OR

Single abscess or draining fistula in the
presence of inflammatory nodules

oR

Between 2 and 5 abscesses or draining
fistulas with or without inflammatory
nodules, up to 10

Between 2 and 5 abscestes or draining
fistulas with or without inflammatory
nodules that greater than 10

Very severe _ More than 5 abscesses or draining fistulas

93. 0 (bips

94. pat

o us x

Fig. 628 Sequelae of leprosy. A Te patart has mada, a cad nose, and binangss in he
left oo. B Oca moment and blush dern of accio ki duo lo ment win
Solana. À Coura, Egel Hung, MO; Couto Lous À Pagola e.

DIFFERENTIAL DIAGNOSIS OF LEPROSY

Hypopigmented “= Mycosis fungoides, inciuding the
Testers ypopigmented variant
= Sarcoidsis, but hypopigmented variant
is usualy more papulonadular

+ Postnlammatory hypopigmentation

Circinate (annie) NNN > Mycosis fungoides and other forms of
paques. cutansous ymphama.

+ Sarcoidons
+ Peor
+ Intersil granulomatous dermatitis

+ Granulema annulare
+ Tia corporis

SECTION 12: Infections, Infestations, and Bites

Infitatd plaques! + Lymphoma
nodes a + Sarcoidosis
+ Other infections (amor fungal,
{uberclous).
+ For DDx of lonine facies, see Table 38.1
Newologc + Porphoral neuropathy duo to other
frange Gr (69 debat mets,
Detorming acral + Systeme sclerosis
features 4 + Tabes domais

+ Dupuyton’s contracture

Type 1 reaction + Acute lupus enthomatosus
+ Celui
+ Drug reactions
+ Madiagnosed as wersening of dacase as
subcincal lesions may become apparent

+ Sweet’ syndrome

= Medum-vessel vasculte

+ Panricultido, 6.9 thema nodosum

+ Infectons, ining other myeabacter
bacterial, dmorphe fungal, and other
opportunistic fungal

“Type 2 reaction

‘Table 62. Differential diagnosis of leprosy.

596

95. an hen re etree
Iying peripheral nerve trunks ar fotos that increase
the ri of actions and nerve función impairment
Reversal reaction and ENL may happen together in
some patients (Tbe 12}.

ever wachen can occur in up to 20% of
patents, whereas tuberculid pray cas are
dem act,” the majority of the reactions
«pisadesoscurin bonderie lors mately bonderline-
Tepromatous and borderinetordenine, followed by
Tepromatous leprosy start asa sudden worsening
Gains and nerve Function impairment, wine
apparent system involvement Bskes preeactonal
Tetons presenting mor invitation and desguamaton,
previous and ney developing sions may be right
Po ho and seno tthe uch (15) some
lime lero requendy associated with priperat
nerve enlargement, ad all accompani y pain.
Reversal rection requires immediate intervention,
because ican result nerve impalement and perma
ent debits

NL isan agree vasculitis with immune com-
plex deposton acting diferent organs, resulting
In. among other sequelae, neue, panniculitis lo.
‘erulonphis arthralgia, epididymitis ent, yo
Information, seits and Imphadendís eth ss.
temic sympoms such a fever edema and male

Senne Lei.
o rana te ngs eet
soma pate option so oa
oc ren má sm
+ Vaio ern ayo co ro
aca Colca nt
Pre
Fe ma
CLINICAL COURSE arme.
AND PROGNOSIS ee a
One ofthe most important problems during the lep- Se
sony cal cure the appearance of cue or D. ame
beste episodes of inflammation, deals recon. eg
{Leprosy rotons caused immune response aginst pee
iia amigos ae did int Type! or ever Em
resto, involving mainly peripheral eres and si, en
And Type 2 oF ENL that may have Inliner sp | tama ream) Tanne
(Sie mploma. Acute acts abo may be cone a an
Ends pect econ Be me
Reactors never ocur in Indeterminate patients pee
Up 150% ol al patents on malo therapy may co
[resent resis ring tater ut these actos E
2014 Can al orur fore and aer therapy. Neuropathy Paie tons
Prsentatthetineofdagnon mulibctiary poy, Le mn 7

mass a e. ie

96. 0 (105).p99

Er

97. 0 (106)png

98. 0 (107).p99

Box 87. Infection associated wit biste]

1 Herpes herpes simple, hepesvarcel os), omega,
+ Eoston-Bor ws, eosackerus, pons (van, monkeynon)

Fungal
* Candas neonatal cutaneous versus congenital

99. 0 (108)png

anants of bib
2 There are
rized by the
| distribution
cular defects
an as benign
ant mechano-
cof recurrent
ly involves
vin, inframa-
he neck, but

int in infants
5 gestationis

BON 87.6 Generalized Bisteing dores

nator
vara esting
vara a
mitra profunda
ol
+ Pau pros
Urreata pgmentosa
+ Infor (ee Bx 87 3)

EM era mute

100. 0 (109)png

[BOX 87.8 Dillereial agro of mucosa veses, soso
Mo pustules

2 Herpes simples vus
+ Varela net

+ Hond-feot-mouth disease
+ Condos

Infammatory

2 EM (terens-ichnson syndrome)
+ TEN
+ Dra apt

‘Autoimmune blistering diseases

+ Chronic bulous decos of ire
+ Giatical pemphigoid
+ Locale buous perphigois

Genet
+ EB Quctonal or drop

EM eter mom, 6, puerros alos: TEN. cc epdemal
recs,

101. 0(110),p99

ap used nthe trent of AD wh an

Dope 1472415814
Selphaettanppiane (71451

mme, 1997)
Caine (71485 158,60}
uct 156

Boucle 159,154)
home tel
Récolte moe 161)
Arsen 1820231

“The blistering is suppressed by dapsone or sulphon-
amides, Dapsone is the drug most commonly used, ether
alone or in combination. I was found to be effective in
42% of childhood LAD patients when used as single-
‘agent therapy; 73% of children received dapsone as ether
‘single or combination therapy: The authors typically start

Pr

Womens + Ma o”

ar
ai
be

et

E

102. 0 (111),p99

Table 4.2: Uses of direct immunofluorescence

Pemphigus IgG Fishnet Interellular
(reticulate)

Bullous 1g, C3 Linear BMZ

‘pemphigoid

Cicatrcial IgG (C3/IgM) Linear BMZ

pemphigoid

Epidermolysis IgG(C3/IgM) Linear BMZ

allosa aequisita

Dermatitis. IgA(C3) Granular

herpetiformis

LinearlgA —— IgA(lgG.C3) Linear

dermatosis

Lupus IgG (C3, IgM) Granular. BMZ

erythematosus,

Henoch- Ig Granular Vessel wall

Schönlein

purpura

BMZ: Basement membrane zone

103. 0 (112).p99

‘Table 32.5: Classification of bullous disorders according
to whether they are autoimmune or not
Immune-mediated bullous disorders
Intraepithelial blistering group of disorders
Pemphigus and its variants
Subepidermal immune mediated disorders
Bullous pemphigoid
Mucous membrane pemphigoid
Linear IgA bullous dermatosis.
Epidermolysis bullosa acquisita
Pemphigoid gestationis
Dermatitis herpetiformis
Bullous disorders without associated autoantibodies
Inherited
Epidermolysis bullosa
Metabolic
Porphyrias
Inflammatory
Erythema multiforme
Staphylococeal scalded s
Grover’s disease

n syndrome

104. 0(119).99

tate ir tng mrp fs

105. 0 (114),p99

‘Table 32.8: Subepidermal blistering disorders and their
associated BMZ antigens

Epidermolysis bullosa simplex Plectin
(muscular dystrophy)
Herlitz junctional epidermolysis bullosa Laminin 5
Junctional epidermolysis bullosa with Integrin 064
pyloric atresia
Non-Herlitz junctional epidermolysis bullosa BPAg2 (BPI80),
laminin 5
Dystrophic epidermolysis bullosa ‘Type Vil collagen
Bullous pemphigoid BPAgI (BP230),
BPAg? (BP180)
Cicatricial pemphigoid BPAg2 (BPI80),
Epiligrin
Pemphigoid gestationis BPAg2 (BP180)
Lichen planus pempl BPAg? (BP180)
Linear IgA disease BPAg2 (BPISO)
Epidermolysis bullosa acquisita ‘Type VII collagen

that in the latter group the target antigens may be common to

106. 0 (118).p99

e au
ey as
AS
pa

107. Opa

Create aren pues

FE ox cto ass Tbe 48
argus ie ote
Gers sans men,
Sever

dpto sone

aro rigs

temer eres

“pe rte

rants as

as on vee np a ee man a a,
‘tenons rhs ou ee ae

‘ble 75.4 ina rent gross ern.

peak serum concen, ange erm alle, and more ace
il Sty aa Tea chan ocean aio, mon
Bom appa to be tore bases tha aci Pia de
conne fapentine mosses and mise PAM) may
Be supesor to bmp, ota, and minocl ROM)

Torte vo map inlammatory ecos, ional medications
ln oud. Oral psoe (0.00 me per dy lor po
{eel easton, whe thalidomide (00-200 me po day) Ue
Pia heap for qe 3 teens (them nadısum lepra
Shei corner ae aho ommended forthe Lan phenom
‘om Ang dallas rennin the atest of ho op
Frans, tagen à à map min and Is una
Me in many counts whet eros 6 endemi. Lealdomido and
amade ae thie anges we rn ie ec ro
Rs fe. more myslorspyenson ha cou ave pen ul in
the umm el op vn Aloma drags wh ps be
In pe 2 resco Ince pote, whieh has beet usa br
Sr renant spe | Jene, 2 wei a asinine che
‘in el, nd mien OP te I

Alou es nom cosine acuse discse wid a grd
pros and esco sural ae st be negating and
Egin eis tery important to make the diagno san
[sable and o come cont, sce sry Done parents i
$l Recognition ol epos ins nal phases by heather kes
Sons as wll as the general populaden in endemic counts à
nal det ee the pct tis Base

CUTANEOUS TUBERCULOSIS

Key features

1 Inectn ofthe sin deo Mycobacerum tuberculosa
and hat beau

mA rergene of teres Tithe te 19605 and 190$
red om he epidemic emergence restan sas
tebe anda cis in TB can eons

|= Eogenous espsor produces pir the tubers ance
Pit

I Endogenous incio can do sem, mir and
rare

| Tis inc palencia een
Saldos anderen nda

lemon Canne

a] omgeree | 0 mg mon ana
mn Some

PB Sas) wre -
ety

ono) mr

owe otero car

101 jeun otage. 50mg ence 150mg enon ony ana

se mn men eer

0 es ca MB! scOmg ence 100 mac ony and
front Sorte wey

MULTIDRUG THERAPY SCHEME FORTHE TREATMENT OF LEPROSY

190 me en nn er a

Dopsone Ofoxacin Maryn» Therapy union
CEE - opere
om - = Er maso
za nr

Table 755 muti erp WHO sche forte tea for Te canne ur On y BO

=
pea sp

1503

108. Table 2-2: Differential Diagnosis fr Diaper Dermatitis
nity Clinica Fin

‘Acrodermatitis Enthomatous cused patchedplagues wih laced bulla in perineal erh, and distal
TS rentes, du to Ÿ ln level also {alkaline phosphatase sn dependen may occur
(he "AB in following segs

1. Premature infants (por absorption ad Y reqremen of ic) when

‘reamed off breast milk which has adequate in evel)

2 Inberted form (AR) manifests hen weaned off beast milk

3 Hey ia fo in level in motel mi

3 Acquire form if malabsorption or inadequate nuron

ces AA
mis | waren
Fe a Toa

Muliple Cabosylase Bath esemble crodemmais enteropathica pericia derma); weatment for both
Dein forms sted below) is Bein
Blain Deficiency 1. Neonatal fr: AR, holocarboxylase synthetase deficeney, = erytvoderma with
alopecia fal no treated
2 Juvenile form: latins deficiency. «seizures, loc. hearing les, developmental

y

Bullous Impetigo Honey-olored ers ad Maid bale

Candida Dermatiis Bight ed patches wit pustules and satelite papules, inrviinos imolvement

en (including Serta thrash

‘Congenial Sypilis | Redih-brown papulosquameus eruption, may be erosive or bullous

(figs BD)

Cystic Fos Resenbles acrodermatits enteropathica, aso due t zine deficiecy pedal edema, flue o

ji {hiv nfctions and mao

Granuloma Glucale Redo violaceous gralomatous nodules ovr ih ala, eranal arc, blocks = scrotum:

Infant le o ition ion cana fection

Jeri Demi | Pod demarcated erythematous plaques pares inguinal folds

‘Kawasaki Disease | Tendeerythema in princa ara which ater desquamates

Langerhans Ca ‘Yellow-trown caste papules with purpur in sehorrheie dsvibaon = systemic

icon (Fig 27) | nvolvememt: Lanperun cells (CD La, 51006)

Mais (Car vesicles or enthematous papulspustules du o bc eccrine ducs fom heat or
ami per trea

eral Pseudo. Fshemaous modules and pupas in children wit eal incontinence

vom Nodeles

Peranal Step ‘Bright red, well-demarcted perianal erythema and involving ceases

Paris Sharly-demaratd right pink to red plagues involving inguinal creuses, minimal ale
‘on common poste presentation inn

Scabies Enytematos nodules involving dape ara, + genial.

‘Seborteie Dermatitis. | Typalsalman-<oeredscaly puches and plaques involving the sal, goin nd other
ineriginous aras

109. ‘The Manual of Dermatology

Diaper Dermatitis

‘Table 22. Diaper dermatitis - potential etiologies and symptoms
Type Symptons

rant derma Drape covered sure: spre TOM

one wets, increased pH dmca

[Cana demas

Bright red. mos patches with satelite posts
nero involvement of this

Fo demas

[Grin scalp. interinos areas
Salmon color, waxy ling patches and plaques

roy

Well demarcated pink plaques with minima cle,
ecass valved
Most commen prsenation of pseiasisin ints

TS
dctciency

Brown, range cased plagues wil vesicles and

te

Peiealperort ares, and distal extremis

2 tote serum in level

[La Prematre inn: poor absorption, inadequate
sores ad] zinc requirement

2) Mah infants low brent ik in levels ith
otal mama serum in evel

[3 Asa fon: malbsorpion andor inadequate
atonal ina Gc, TPN)

(4) Autosomal rossi inherit o: defect in
intestinal ine specific transporter SLC39A4 that
rails when infants weuned off brest mil
(due greater valbiltyof zine maternal breast
milk than non matena cure)

inc prota Gide ery abo

[Make sure ab ses non-zin containing tube

{special collection tube).

Fest capes
(tere Sive Disease)

town brown, cused papas wi ptechae in
a score ditbation

[CD1 $100 Langhans cells with commu shaped
oe eiform noc

Matisse involcment may be presea

OS

[Severe rose papules, nodules. May ca paa with
'Maltactoria log: casita demas, and

CEE

Red: pue, promet modulos
[oca Ivi, maceration und Candida
mue)

[Age conne ennai

Topical reparer foods

(Cie Bron

Rescmbles ame dehieney
Pedal edema common
Failure to trv. hepstosplenomcgay infections.

alabsomtion

Toninas)

110. Peditrie Der

ao

Table 22 (continued)

Type

AS
detcieney

Rescmbles zine viens ba aes a
oi dependent enzymes

Neonatal orm: AR

bolocarboxylas symtictse- vomiting

[nent form: AR bioinidas = epi soph and
heaving los

[A seizures (6 months of age. hypotonia, tai,
acti ados etos, hyperammoncmis, alopecia
|Trument ion ihn

Forma pee rene

Bright red well dieu cba eran and

RTS creasingly common — may ce mode faces

[Balto imperzo [acid bullae with hoey colored crusts

Mina Blocked ecrine ducs secondary to heat and
midi of diaper ara. May be supercil sal,
lear vesicles milicia crystalline) or small,
[erythematous papulevpustoles (nai ube
ira pesos

Semi Lesions tnd to be mor nodular unerihediaper

amas Diese

25 of patents present with confluent tender
erythema in perineum, Laer -> desquamates

ROSES

[Candyloma ka er generalized papuosguamous
[rapto of secondary sy may be present in
liaper area

Penal prados Papes and
Nodes

Erythaoas at topped papules and nodosa
Ihren with cr fecal incomimence

Human immunodeReiene vires HIV)

[Very severe cose dape demas. May Te
[complicated by secondary bacterial and viral

Inteco

111. Bop a a: Pte of ge cas

“Table Dior) pee

Dime ‘Character etre Dia
Demos primary dio wang dape

Inn stc dams Spang ofthe ese: ue and rin fold Ciel
Cand per dermatitis Std papas put de rad KOM
Mi Conil o paro e body meet Calc

des othe ody
itary ing warn dote fever

“Grains te nun.

Pseudovencons pages and pales

Red town puesto noes
nates of preci apes deat
Me remos

nica inte,

late cl por

Demos certe eins ape
‘Serie demana

Inve fd ethemsand sales

thr einen = re np add ca

igor of atopy
Demtosein ape are notated to
A wenn
angosto

Inve manly comes ns

Dist yellowish popes, pare atopic oe

ica

intimo

Atom pata

Sly dere penso piques, veis

‘Sm eleve 40

Acid dame it, peca

Dats inpeio ec ppaes wi ing over pri Clic, gam at, cate
seo

ots eg Dist teat popes ie KOH

Hand oo doth ese Dist paulo md ved ovr hand fot, nica
tea get ei cy

est wae ‘ees pauls plais psa ates Clinic, int
Share soii a ld eau

setter apts mode, exciton ovr pa dl, Clica wodslanp sin.

Floneha gives
of diaper ach,

a lore on how to approach a case

Methods

This howpita-based ebservatonal, prospective study
was Conducted for a period cf $ ment Kom January
2022 10 August 2022 All children below $ yeas of age
‘vith eruptions involving the diaper area presenting 16
the Depatnat of Politic Dematology atthe Indes
Gandhi Insiste of Child Health, Bengala, Kamaak,
were enrolled inthe study. Infrmed ten consent vas
obtained from the caeaives. We calculated the required
Sample size to be 67, based cn he prevalence of DD 10
Ve 223961 À detal istry, including ree infections
story of allge, Fami hitos, general physical
‘examination, and dematological examination, We're done
and recorded in a predesigned proforma Appropriate
‘lineal and abeatory teste such as Tzanck smear, skin
biops KOH examination, swab fr culre sensi,

Gram staining, and hematological investigations were dene
whenever necessary:

Data were compiled in Mirosof Excel and were analyzed
ing sititeal software R version 4.21, Categoria
variables were given in the form of frequency tbls.
Continuous variables were given in mean + SDimetin
minimum msi) form. Chi-square et was used to
‘heck the ait between categorical variables.

Results

A total of 135 children Under the age of $ presenting
‘with lesions on the diper area were noi in the
study. Hospialbasel prevalence of DD was 3.4%
‘The age of the study population ranged from 12 days
Lo 5 years, with a mean age of 146 # 135 years The
majority ofthe cases wee infants agol between 28 days
and 1 year (2135, $3.99, followed by toddlers whose
ages ranged Between 1 and 3 years (MLS, 32590,

‘ines Dsmatlgy Reve | ume su 2 [Age 2025

112. rodent core was composed prima celles uf Ding
that ine several condi sis compared the incidence of
Alper dermat in infaı wing coh diapers ves nts
‘sing disposable diapers” In he md 19806 a superabsorbent
ore mata was developed I was composed ofa eos inked
Seam pohaclte that artos 1 hol a proportionately
Tame amount of Bu within asbtance. Ser ste.
ar cond that superabsecbe des remporte h
ape in prveting duper demati” In lion, super
absoibentdapes may present ocal eal contamination of
hing afore in dyer sing Ame per ino:
‘ato vas fist arte io 2000 Pamper fash Car dupe.
An Incorporated inner ye continuously deposits. a pen.
‘sed bare product he shin. Lite tals with normal
Infants demonstrated tadcion in in micoopogrpty and
‘thera whe compared wi conta The per Can be
ie elective at preventing and ping to fea dios rash
ut the downside ey ate expensive when compared wäh
‘thr dupe on the markt. There have ben eps alero
onc dermaus various Bue pink and ren des wed in
{he prodotion of diapers. Dyesce diapes shouldbe used fr
alleen vida if ees” Routine use of opel prepa
ions to presen dlaper demas is no necessary fr inant
‘wth normal in Some ofthese prods have addhional is
ive hve the potential 1 case contac sensitization iia
tion andor percunaneous roy. Podes applied vigorously
enough o craie pose an aspiran wk This is special
ne for tale (ily ous magnesium state) powders
hi can case ian pacunonlis Tale may abo cause pans
omatos ans when apple to wounds. Contato prev
uy costar doesnotenhance the rots of las
‘onthe skin Boia, once popular sa per ash eaten
nd sil an igre in some per cate producn ia case
‘of dambes eye and auto Une” A nw prod
“ontaiing a combinados of miconsaok snc oide an white
perl sas een reed on the eae, son (Barer
‘Therapeutics, In. Pisco, N). indice fr dh weument
‘of candids disper derma uti cos. alo coms u
‘ance à penta alleen

Approprte weament of per dermatitis gins wit comes
diagnosis of he undeying cause. Mos ina develop acute
per dematits a à soul of the cion desd above
However ether primary pathologie press must be cons
‘ted for any infanı with donk, severe andor recaen diaper
"ash Primary canoso dees that may present wi diaper
‘sk inch contact dem, sort. deat, peas
And did nfanı with atopic demabti may be more
Susceple 10 tan, and diaper dermatitis was common In
{his group prior othe aılabily of superabsorbent dien.
Since that te the dape area of aopi infants mos ofen
drama speed an important diagnose and het

Pros stent in past coma |

>> Bata perongod
>> Gammon sa oc ei ecran seo muy
>> Comments
>> ote roe
Domus patos
Ectmagrgoam
>> Enron mem iso
Encemoyes gos à
Genus gt arm
Hepes api
Langan ct trons
Imad spams
enero tac
Toner pert
Papua
Parana spec man
oscar er regar
foc sat sn ora
ona gus
sat Agen ae.

PESTER TERE TEES

sgn. Seal uncommon cases of diaper dems ave ei
of cuen Mfihratening implications” (Box 4.1) These cond
tions shoul always be considered In infants presenting in he
Frat month of ie in immunocompromised patents and in
thse who ae not or hing

Nid made ant ape dermati shouldbe teste
niall y reminding caregiver of the imporance of song
‘xcs wetness and exposure 10 fees. This can be achieved
‘wth wana feuent per changes and the use of supra
{bent dape Leaving he aca open impr and se of
3 ar dr may case inadvertent inju Al potent ets
‘or sense, Including ofen oelooked commerdal diaper
‘sips should be dicontinud. ter amp of cathe or
paper om, or mineral con pledges are ae

lane Rha on d'en ig sero
‘ing oem nlp ai
un SENN A ean po

u SRE Der Sr. Cnt pc,
tl peon Como se pe ap
‘Etre see crono socio
en

13%. Ab Seen 4 De mai a

Comi Cn m un ah om

nr ne en
ini

2

113. Eczomatous rats |

tramo
>> Aloe corts Sager dot

>> na door mata

>> nego

>> Parra pouioruceus paps an ales PA
>> Fort San aveu

>> Prend toc

>> os meno

>> Bereits entra re en)

>> senta sc cin

>> Bain try

> Keita sony to mason

>> Ortes

>> mans toco

shin conditions ocutng under the diape. Diaper ashes are
Among the mos common kn conditions een fancy. Mos
‘per ashes occur a disc esl of wating dape and ae
ed 13 tant ler dermatiis art, there te ale
BI conte demas 10 dape. Primary cutaneous disordes
Such as psoriasis and seborrheic dermatitis fequey occu
under the diaper and tend o be worsened by the ca
proper ofthe diaper Systeme disorder, sch a arora

enerpatics and Langehans cl isos oc inde.
pendeni ofthe venin of the dape and may mimi an
“ape deman Dsordes ofthe gasvotnstinal wat such as
‘ti irons, celiac dise and nfammaton bowel die
‘ten produce jenna enupuons as well a other iam
Infos, national and malignant conditions as sted ln
Le

HISTORY OF DIAPERING

The term per dem includes al empions hat ocur in
the arca coveted by the her. These conditions are cased
‘ity by the wearing of diapers (tant contact derma),
those dat ve aggravated by pes eg por) and hone
that ocau wheter or not dupe ae wo (eg. acrdermatits
‘enteropathica in many sois where pen a not mot,
Infant escape a condition a is common sen in pede
Practice in mow industriel count

The fin we description of diaper demi was made by
Page in 1905." although Parte described Jon inthe
per ars in 18973" In 1915, Zabonky described the fe
‘quengy of dhper eruptions associated with an “ammonia
Ac diaper” In Great Bain in the 1970 diaper dema
tis around or 20% ofall in consultations inthe 0. 10
Sat age group” and in pa. the prevalence var Between
9% and 0%, depending on denis and indusion ite
fia Since the vent of newer pain prices aly
the inoducin of disposable ap wit sper absent gel
‘enters the figure has dropped consideably™ Nevers,
‘mothers inthe USA sll guet cons pediticians or
apor ep

‘Duper have only panel were acceptance in the
Wesen word during he ast 70 ea, with he appearance of
the mern diapers the 1920, Tae have eae hough
‘sing lees of cla and ay pins wo the 190s when diaper
Serves became widely aaa and mor recent o dispos
She digen tat have Been sal exi in the as 40
am Theva dos methods of dpi zo in mont
‘cunts Parents can buy rama lth apes aná lander
them at home. Wath ths method re o ete of chemi
let in the diaper despite numbers of iso. 1 the most
common cause of ita diaper dermatis (IDD) in ifn
Major problems n the pas hae rn fom aniepts used in
Fund" Quatemary ammonium compounds ae now
the mot common chemical used in the hunden ol home
pen.

Adar sowie another metho of diapering. Diaper ser
ice uly roid hi customers th her own no dp
that ae land weekly or Bowes, They ae ded though
ds many a 1 ho rines, the it sven being wih deters
Two or more dapes may be used simultaneous inceasing the
lore, The ders are tal covered with a pas an

‘Disposable diem were fst uscd in the 19606 and have
become Inrena acne. They hase changed rom paper
to an abeobable ellos ceme, 1 be most modera disp
hich havea superabsorbent gel ener camping wees om

ven. Hii ihe il gn
RER sind da msn A

el ct ee Du oma asf

sa Retin eBay cht oe

un lepra gebunden

ser en, non en ln ay nen
‘Sera op Soa a BA

ero

114. 19 Etna it Spel opagaphy

Tabie192 comi

had
ener

‘Newt Gomis ype

Anensonn ne
‘Scone as ne poms,
mareos rca nyse
Spleen ce

Booger dene

Cold asii den
Coop spotters
rasan snc rd: pi id,
dr reas
O sens a
Epa

Hype tome

Mail tes hate on,
aloe dom
ns

Rayne deme

Moca Gert erent parmis
Va a aire

rss

opie

Maite ke

Shoes sone

evs sing en
"Tonto nb pare

CUY quemo. ENV pin ar sees HIV nan
CA Essen

tema

Extrema
‘Acute eya shold suggest an infections disease
Such as supbylococcal tou shock syndrome or
Kawasaki disease bt also esielidor infection wi
Siepococcus ioe, as well other inoculation
disease,

“Toxic causes should ot be Forgotten mercury. che-
mother}, as wll as metabolic and paraneoplastic
‘causes (arokeratoss paraneoplastic, nero eral
erythema of elcagonoma) and chronic Val infections
(HIV, HCV (heats € vis,

In connective tissue diseases, hands ar often
eto. parus in pus enthemstoas and
dermato.

Phlebitis and lymphedema ar more edematous
than erythematous,

Physiological, pregnany, chi

Raynaus Phenomencn
Inca of uniera Raynaud phenomenon, a cumprs-
‘on hone ult syndrome, pa nc syndrome)
‘shoul Be suspected biter tic eases, connective
tise dieses, and eryopaties must be searched fr,
nthe posites fronton purple ad
pomos, which are on hallmarked by severe
Raynaud phenomenon, nt forge.

Raynaud disease

19.3 DiaperRash

Examination should specify:

+ Topography: tio are, perianal. and predominance in
folds

+ Associated lesions: papules, erosive andlor este pup
es that should suggest Langerhans cel Hits,
pustules ts are common in ends, olle sal
ing suggesting candidiasis or nero migratory ery
‘tema, and ball congenital pili)

+ General signs

0x 191 Main Causesof Diaper ash ninants
leg tt derma peop ods)
pe dat

Dem Porto

eres

am parton

Gano cron dre ne pp soem)
et sere der demas (ped ponerse
Tete est sad

Lange non

est mir este ea cei
‘ora nin pri

‘Sore demas (Lene Moe)

Seren nn amont pa
PT spot aan

‘Steps ans

115. 19.4 Scrotal Erythema/Edema

Box 192 Main Causes of SrotalEntemasEdema,
tensa

mers pere

puna sane

ati srt main chien
ana Baup tens

Nac pte

Zine en nmin (olaa deny.

195 Intertrigo

Box 193 Main Causes of nero
Amba postion he ls

acera rio

Conc mas und tp eis

Dares dene

Deep

Ends cena ad ep (SDRIFE)
Etam

Fee sde

Gram une

Haley Haley dene

ern mp dpi
Frerserneieienin

german tr Ub sat)
Inte wa
nm apc asec

{ange cl soy
en pan)
yeni noi (ana ack in)
evi mien ey in longe dome,
cpt erat nel nee
Ohne

ponen

Pompe etn.

Pendant en
Suomi Sako Vimos an
resins

tke cea pai ith inc ee
‘Gypsy mira KRG)

san peti sein ls andren
‘seats te pay feos my e wa 2
‘Sitemaps plas este an posts|

Some crtin serous diseases can manifest 3 ir
tego: Langerhans el its glacagonomasyn-
rome, and pemphigus. Primary HIV infection can
manifest as an ineig. Simultaneous afecton of
‘eer folds is charters of a paiculr form of
‘vg eruption,

common
Maceraion (particularly submanmary and abdominal
folds) tie dermatitis, har interrigo, dermato
peto candi, ad ports

116. Paalscadoemucas | Enteros repped veas papes and nutren wth chee cortes
ps and Brown, range ted panies wih ces a ble, Prin peor ma and ei
ee re

recen, 1 Presta plot Pr aspen, pau store, andinas ic rue

2. Hearts Low breast mike ss normal ater serum cee
3. Acute fom: Masago and/or nadegae astra. pete sien)

Aussee rte for Dect instal pee tarots LC AA tt
nest hen iat wean of best mi (tore eyo sen ter
east hanno soe)

Alan hote ne dependent ny) ao ow

A | Velen, cued gape paie store arbuion CDI" S10" meta
errs ess {sent coms shaped re ne ker open ay be set

Gerona gee nan | Res pur. gamma mas
Seco oat ean, mear a Cand (rbd)
let corsa demas | Tpcaleepaaons fend ae des
acres Resanies 2 uen Pelea como
Faber, tro, cines mern.
Bein defence | Recebles cd afec al tr dependent eres
only era fom Auosomalrecesie hate saetas; en

ei fom Autos ces ee opt array ná Pes ss
Al Seaues (6 oo ape) ypotora ataco, cs actos het, hperanmonema opa.

Seater Bette

‘Nope demas ‘Uncommon inary cause of ape dat, bu pt at demas at eased ko
per dem,

a ‘Bld cine dct sendy eat and hoi layer ara Maybe up sra,
‘see (or cya er ana eternas pes (lara ra era puro)

Sabie sons ten te mor ne und dape

Rae “wo thd open present co een poro, Later quant

Corot Gta eet pogo eatin on pn pt

CS Very sear ere dpe nat. ay e cancel sand tra recon:

Figure 3.1.5 Sabah derma

18 2010/2020 Derm i-Revew

117. 246 17. Duper ars Enptione

INFANDIATORY CONDTIONS.
"ant diaper derma
ia des
{Gore tl ay mur
SE coc denna eso dupe components
1 Bap de demi ‘ye dema

mrecnons
1 Bis imeetgesuphoccel seed sin pre
D ate te
in lect
1 Hewes amo ifecton
LH nca congiomat)
olaa corp
1 Conca mal lin nd, fot, ad but earthen)

Merasouc

inn aor

GES pe

(Orne warsarbamylnedefiseney

Born do

EEE dto
Hs

‘ron partos

Srl urna vien

ron loc’ dese of chocs
1 lous remet

in disposable diapers include a dowereene petrolatum surface
and breathable outer sec.

The mos importan factor in preventing IDD isthe fe
“quency and number of diaper changes, Other factors causing
TDD indude episodes of darrhes anti se and anatom
al problems such as short bowel Syndrome. Wheres doh
pers are ls ecient at reducing hin wetness, faction and
pH there isa rik thatthe expense of superabsorbable diapers
may prevent parents from changing the daper suficienty
‘often, thas comribating o Ihe development of IDD.

Cutaneous findings

1DD presents as erythema onthe convex surface ofthe inne
upper thigh he lower abdomen, and butoc ars, the ares
‘mos in contact with the dee The crese and the suprapubic
ta in boys ae sated (F171). The eruption may become
more severe and inflammatory with yeast colonization, and

Faure 174. Inn apr

Figure 172 IN hauts dos

lag aes of oleo, indio e ce tn mare
Sener cs cy muy be acorpaned by gle
ET os

Forest rare dormait preseas ith velldemcned
poneros les ad mains OLA) Kit ee Leu O)
Common with se af dsposhe dape, and has a
‘en auch wih infeguent diaper dings and poor
‘Sal of chemie ne in home laundering may alo be
{cen in infants who have short bowel syndrome or fling
Aer for Hiachoprong dose, ci ny soak in chose
a

Etiology and pathogenesis
At Br, a newborn's skin undergoes a sudden wanstion
‘companied by dying and cooling of the sin sure a 4
Adapı o ts new envionment. Vscher has measured the
changes inthe newborns epidermal barter properties over the
First 4 weeks of life, showing increased surface hydration, les
tranepidermsl water movement under edison, and à
acres in surface pH Diapered and non.diapered ses are
indisingushable a bith, bu over he fist 2 weeks of lie da
pred areas show consent increased pH and ydration, has
Sein the stage for IDD)

118. ;
i

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Etology/Pathogenesis
Ah a monts sin under a men camion
compas by dying and ang of thea ue a à
‘peo non euren Vache has mess the
‘hangs inthe nen’ cpiermal has pets oe he
fist we ie showing increase race Int, Js

a elma wi men und eco, ad a

apre tes stow cnstent nr pH a Aion,
‘ha sting ih se for IDD,

IDD vomits onthe Ines of srl ato: asc.
ssc wth gang coat fhe shin wth combi
ich rin and ess (Tobe 161, The vean of den
Sin à sonic ice in an weinen and PE? Pre.
Jong wein kath to acc of the set coca
dco dort ofthe teers lames

122. ac (1) png

123. TEE Exosame sauer m develapmen

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Table 4 | Comparison of aKinhibitors used for he treatment f alopecia areata and those curently in the phase ol investigation, and thei acy, safety profiles, treatment outcomes,
Taian Target Royale Hay Safety profile Treatment outcome
Baricinio JAK /2 Phase 3RCT 36.6% of pallens receiving émgof Good tolerabilly, see aboveTor FDA approved (2022), EN approved, URN, nausea, headache, increased

Ailechinib JAKS /TEC Phase20/3

familykinase
Brepocitinib TYK2/JAK1 — Phase2uials
completed
Deurusoiinib Kı/2 Phase 3 als
completed
Ans? Inkl Phase 2 ils
topic) completed
AMAT JAK /3 Phase 2atrals
Gopicad inated
'SHRO302 Selective AKL_ Phase 2 ial

completed

Deigociinib JAKL/2/3and Topically
me tested or
dermatological
diseases and
AR early phase.

barcinib achieved a SALT Score
+20 atweek 36 (10)

23% o patients achieved a SALT score
20 at week 24 and 31% by week 48 9)
SALT score improvement in -30%
(pretiminay)

300% 10 41% achieved SALT + 2021

24 weeks (higher dose)

Modest regrowth in ~28% (based on
investigator global assessment)

Es dat not yet publi

Moderate efficacy: ~25% 10 30%
regrowth in responders

Limited data in AA; effective in eczema

specific

SGoodtolerabliy nasophanyngitis,
headache, URT, and nausea
Welltolerated in Umited studies

Welltolerated, dose-dependent
adverse effects

Excellent topica safety, minimal
systemic absorption

Designed for minimal systemic
exposure

Mil; AKı selectivity lowers
‘systemic ik

high patent satisfaction

FDA approved (2023), EMA approved,
well suited for younger patients
Promising due to dual inhibition of
TAZA

Promising alternative to baicnib
with similar response rate

Las effective than oralJAK ow risk
makes it suitable for limited patches
Sl nvestigational; ould suit
patent wit Localized AA
Considered safe and moderately
fete in Asian populations

Safe topical use; no serious systemic Possibly helpul in scap application;

malting AA-specifi results

cholesterol levels, elevated ver
enzymes

Nasopharynitis, headache, acne,
armen, fatigue, nausea

‘Acne, upper respiratory infections,
headache

Headache, acne, nasopharynitis,
elevated CPX iver enzymes

[Mild ration at application site

Local skin effets only

Headache, mild I symptoms, increased
cholestra levels, tombocytopeni,
raisedliverenzymes

Application ste iitation

AA = alopecia renta, CPk = creatine phosphokinase, EMA European Medical Agency, FDA = food and drug administration, G = gastrointestinal. JAK = anus nase, JAK= anus nase inhibitors, RCT= randomly controled al,
SAUT =Severy o Alopecia Tal EC = yosine Kinase, URT = upper respiratory act Infection, UN = unary tract infection, KI = Sine Kinase 2.

Dar HVESEOE | Vay 1HBUBAOTEUIOG CY

‘apne mayne: yy w SINGIN

126. Janus Kinase (AK) Inhibitors vs

‘TABLE 25.3
Differences in the Frequency of Adverse Events by Oral JAK Inhibitor
ery Common (May Act Common May Mec up tin Uncommon May Auto

10 Paint) 10 Pen) in 100 Patent)
+ Abo + ave
+ Asse + Morrison piden.
> Dies MPa)
2 es + Lynette
2 Ise CPK + Ponen
Ilona + Thomboapent
(ps impo. has)
Dci + Hopertoleeria. + Aci pia + Diels
Upper regia et ovine
nection : + Feblaweting
: Nypemigheritemia
+ Ioannes > tres WN

(Gemerzener hemer nimes, + Neo
smart UI poramona) + Unica

palais + Acne 2 Abia in + Doi
+ Upper regia * anemia + Hopensapceitmia
Pe 2 Cour | Ones
+ Fe en

+ Hence

+ Hypertens

2 Ire CPK

+ Irae weight

(tee eres zur apes

simples tia ier

+ Neapora

+ py

2 caña

Abireitins: ALT, aig wanna: AST asun some CPK. ee pospokinse: DVT ep veo
‘eombors: HDL Mh deny pope LDL, low dns op P palmer non UTE.

+ Variation in adverse effects: Adverse events experienced by AD patients receiving

atment with other oral JAK inhibitors are similar to those experienced by patients
receiving treatment with barichinib, alhough gastrointestinal adverse events such
as nausea and vomiting may be especially common in patients receiving abroctinib.
Upadacitinib and abroctinib preferably inhibit JAKI while minimally inhibiting
JAK2; this theoretically decreases the risk of unwanted haematological adverse events,
such as anaemia and neutropenia, as compared tothe risk with therapeutic agents with
increased inhibition of JAK2.

127. 4. Compliance denise

the likehood of side ell development, motivational
imervewing and cesto con (Tables 12 and 4.3). For
example, Ls important to give sufeen instructions to
Patients about he us oftheir systemic and topical therapy.
aswell as educaron regarding sde ef profiles of e re
‘rant medications. Motivaioalinevendng successfully
resulted in positive comelton between increased pent
‘education and greater adherence for oseoporotc patients
ho recived a muliiscplinry paint education program
[Bi], Another study of Seven patients reed ith dali
‘uma showed that paient education can be used a 1900
increase adherence [1

“Another method of dcressing paient far of mediation
sde fis by puing into practice theo adage of "art
Low and go slow” Minimizing dug dosage in system ther
‘apy may necesite mulimodsl therapy for optima rate
ment results and limitation of sie ets (20). Though

adding more medications may minimize dose and side
elects, thus increasing reumen efficacy, it may also con-
use patients and lead to lower compliance.

‘Conversely, more aggressive therapy administered for
sorter periods of tie may be another appreach 10 avoid
Adverse effects of medication. This theory supports hat
short durtion, hgh-potency pharmacotherapy can be bet
terthan lower potency medication admiisteed over alo
Be period of time and may be ideal for patients who end
Lo be nonadherent |] Aggressive therapy places he focus
on decreasing me of itervention and increasing ecay.
providing an alternative to increase patent adherence [0]
Since the patient receiving agresive therapy may see
results more quickly. this may further increase their rust
‘nthe mediation and thei adherence. Ultimate, route of
medication administration, severity of disease. patent
preference, and lifestyle should al be considered when

Table A2 Conran ope medias edo ves pa 10] a ded fo Tc Comparison Buss
(tr hppa on Sur cap Natl Pins Fondation 201

“Centr esl epi
Ci Une option Lapse sui ia
na cc Non ape Torn FD)
Scion (Coens) Upper rite infini bowel diese ‘eters TB)
Comp estan le ei o
Das pert rec
Bec) Inicio ondaa Coma ont cat
pan sce la Beni M
pest nie a
TN na
Ana mi) He on as Comic ons out
Inj te etn epa Bain Des
preven, nl Laporte dose ‘Toren )
Neuro mpc Seen
Nor mcg bet are
Inicio Remi) Ai ain Bll rss. Cone Hd out
es epa Bean Hep fn
O otr ‘Tete in)
ewes Sree
Newer sonra bet ae
eins sd ter nlp
‘Tolman Injen eon Blond cris Cone Had out
Sapo Uppers min Heat Breton Hepa fon
ne Lupe sui ‘Tres cid)
Ses Seen
mp andthermalpancie
Vecina Sc) Fae Race pointu Toba TE)
frs es Sena
A rt
Tatiana Te) ong infections ep Brean permi reci

nee ren

128. “able 172 Ey loli eii pois

ao [mime paie | wats SSE tan
De rn M in (0
tinct
noe Erg a o a
Gol etes | 4 CET 1
RS Gr
nc)
D E, 08 CS 1)
Er Scent
EE SSRI Ass
Sei Oca TSR SS Dm aT
Er LS EEE
peer o.
ima met or a iin
Res LS pres
Dors pere Do
tr

Leg co ee tr wk, NAPS alr rer inde, RDAPCT od ich cle il

of patents with psoriasis imolving the hands andor fet,
“demonstrated 50% improvement in NAPSL&t 16 weeks com
pared with 8% fr placebo [2], ln a stay evaluating bath
Fingemails and toenails, open-Jabel adlimumab showed
improvements at 6 mons in NAPSI of 885% and 72% in
fingemails and toenails, respectively (51). An open-label
study of ctanerep in rail pros compared patients an.
‘domine to two dosing regimens: 0 mg twice weekly for
12 weeks followed by SO mg weekly für 12 weeks oF 50 me
weekly for 24 weeks. À 50% improvement in NAPS was
‘Semone in 58.15 and 823% of pins in the twice
wecty/necky group and 50.5% and 30.7% in the weekly
group at 12 and 2 weeks respectively (2. Ina RDBPCT
Pins with provi arts were tte wäh placebo,
golimumab 80 mg evry 4 wee, or goimumab 100 mg
every 4 weeks for 24 weeks. Median percent change in
INAPSIa weeks L and 24 was 0%, 25%, and 43% and 0,
33%, and 54% for he placebo, polimumab 50 mg and gol
‘mumab 100 me groups, respective Patent inthis a or
psoriti arts wer allowed to use stable doses of metho-
treat and prednisone during the ty [3]. Curent gol
munab & FDA approved for psoriatic artis but nt for
pod. ln a RDBPCT of fliximab, paints were ru.
“omizedto cr placebo or itiximab Smp/k at wees 0,
2 6,andevery 8 weeks through week 46, with placebo cross-
‘over at week 24. Mean percentage improvement in tet nai

NAPSIat weeks 10 and 24 was 26.8% and 7.2, compared
with 7.7% and —4.1% for infiimab ad placebo, respec»
tively [8 Ina reosectv anal of palets om this
same infliximab study, mean NAPS improvement vas
28.3, 61.4%, and 67.8%, at weeks 10,24, and 80, respec
tively HS

No controlled comparisons of anicTNF agents in nil
pri ave ben performed, However, an open abe pro
fpectve stay showed that ini was spero 1 dal
‘mab and etaneroept a 14 weeks (Wl. A respective
‘comparison of hese agents abo showed high fay of all
the TNF blocking agents in nal psoriasis wäh some preter
improsement wih infixnab [17]. The dierences ine
‘acy ofthese agents In mal poras may parle de dile
fences sen in sin response Iliximab may alo hive an
advantage in de speed lo which clearance is achieved.
However aller months or more al aticTNF therapies are
succesful in improving mal disease by atleast 50%, as mea
sored by NAPSL

Robust ets also available for IL-12723 lockte ai
psoriasis. Data from a large phase I il of ustekinumab
Showed significa improvement in NAPSI compared with
placebo at 12 weeks. Additionally he utekinumab 45 mg
and 90 mg groups showed 468% and 487% NAPSL
improsement respectively at 24 weeks [5] Long-term data
with 68 weeks of wtekinumab ina Japanese toy showed a

129. ter E
BE ee
ee
meter |
+ se Bet io u pi rin |
‘Stour sae aay seer na ee
‘eed asa aia Se sap os

&

en de ee

ve men cls ae 5

Inc he boop mastery to pri
‘tings be ing hyn ate Pty

‘ipa pres
Es Ces

‘legis san Usage saat toes ra costs tons

130. SECTION 3: Papulosquamous and Eczematous Dermatoses

INDICATIONS AND CONTRAINDICATIONS FOR COMMERCIALLY AVAILABLE
"TARGETED IMMUNE MODULATORS (BIOLOGIC” AGENTS)

Indications
General cations

+ Patents wih moderate to severe psoriasis, olgble for a systemic treatment
+ Patents with poorali att, particulary those who have aled to improve with other
‘dseaco-modtyng antiheuratis drugs (DMARDs)

estreted Indication

+ Patents wih moderate to severe psoriasis who are not candeates fr topical treatment
Phototherapy, or casete system treatments because of isulicion effeacy or
ontaindieatons

Contraindications

(The exact contradeations vary by agent; some sed below ae eave, while others are
‘absolute

+ Signcant va, bactoal, or fungal Infection"
+ Increased risk for developing sepsis”
+ Acto tuberculosis”

Immunosuppressed patient
Past history of het B
Pregnancy (TNF-« inhibtors, aletacept! and usteinumab are category 8)
breast fed
Malignancy within the past $ years (does not incudo adequately treated cutaneous
squamous or basal cl carcinoma)
Exeossive chronic sun exposure or phototherapy
Allergic reaction to the Bologc agent”
Sdlectve fr altacept: CDS counts <250 colma; HIV infection"
¡aleta for TNF-a inhibitors: ANA: (especialy i high ta) or autoimmune connective
tissue dscaso, lymphoma, congestive ear alure (NYHA grade or) or
omyeliizaton dsordes (ho lar aso n frst-dogrue rates
Salte for ustekinumab: BCG vaccination thin the past 12 months (made of acton
feapocted 10 ncroaso sutcopbbity to mycabactera fectons)

Production daten into Unted States was dscotnund n 20.

Table 6:7 Indications and contraindications for commercially avalable targeted immune
‘modulators (biologie agents) Aamnstation of Ive vaccines © contraindeste in patents
Feeeiving bogie agents for para Cory, Pater O, an de Keno MD

‘TREATMENT OF THE PSORIATIC PATIENT WITH COMORBIDITIES OR

SPECIAL SITUATIONS.
‘Comorbidity or Special Situation Potential Treatments)
History of intemal malignancy (eg. Topical agents
Iymphoma and ung cancer UVB phototherapy
Oral retinoids
Liver cise Topical agents
vB photothrapy
Targeted immunomoduiators (blog agents)
(eg eier)
Hopatts or C viral infecton Etanorcep > adalimumab, ustekinumsb

Table 68 Treatment ofthe psoriatic patient with comorbidities or special situations,
Targeted mmunomoduitors (loge agents) are contraindicated in patents with active
tuberculosis, Continue”

131. ‘Table 68 Continued Treatment ofthe psoriatic patient wth comorbicities or special
‘situations. Targeted inmunomodulatore bologee agent) ar contrancicted patiente with
Acte tuberosa.

‘Comorbidity or Special Situation Potential Treatment(s)

‘Metabolic syndrome Topical agent
Phototherapy
Methotrexate
Oral retinas
Targeted mmunomodutors (Biologic agents)
Pregnancy Topical CS (ested uso of mid- to moderato-
“strength CS)
vB phototherapy
Targeted mmunomodultors (Bologe” agents ant
"TNF agents and ustoknumab are category 8)
Cyclosporine (category C)

Immunosuppresson (eg. HIV Topical agents
Infecten/AIDS) VB phototherapy
Ora etnias
Numerous skin cancer Topical agents
Oral einige

Pop 8 toco antgen Bg) carr, ether arts HEV Moment or props equ to
pren reas rachat, cers requ cart montana
‘Caton wth se patin ty

[RECOMMENDED LABORATORY EVALUATION FOR PATIENTS RECEIVING TARGETED
IMMUNOMODULATORS FOR PSORIASIS

Drug Prior to treatment ‘During treatment
‘TNF-cinhibtors Tubercuin ki tst/interbron-y Annual tuberculin skin test
(eg adalimumab, roeaso assay andor(eg | interferon release assay
‘tanoreept Immunosuppiessen history and/or chest xray
intima) or Otubereuoss) chest xray CBC oF CMP every 3-12
sonas 80, CMP. ‘months (or a cincaly
Hepatitis B and C vies incites)

Serobge potes:
Consider HW testing
“35 mm of raton sre bo considered as postie
"ag QuarFeRON? TB Gat or SPOT TB.
(UP, comprahensie matabote pana (nados er urn est); PPO, pure prton dran

‘Table 69 Recommended laboratory evaluation for patients receiving targeted
Immunomodulators for psoriasis. A completo medical hetory and physical examinaton should
iso be performed, with particular attention to hstryk/symploms/igns of tubercles, her
Crone infections, malgrancy. rourloge disorders and cards disease (especialy congestwo
ear Faure in palets recorng TNF-a OS)

For further information sce Ch. 8, From Dermatology, Third Edition:

PSORIASIS

o

132. TABLE 28-7
Biologic Treatments for Psoriasis
Min ‘indo te conmensibank UNIR COMA: Dr MONO analy Fulykumintecnbiunt | Fuyhumanronbunt | Hurunsedmonschnl
EAS Mme nee gp ocre ab topa
A dre Mae a EGIL ITA
Prien Kr
Coins SCinpevncagitoed 2510S0mainkalensscune Mint 25-10 mg 150.0 0mainpcions | OmgInecionat we
‘inp vea coman granos mesa and MO zhane Ollonedby emg et
Imaging O1 mg co rT Corn orcos es 2.460,100012
ET fond so move brie es Denon sik
évite». Forged pts cam
ns Tmndedseing soamang
Incio tucan seau mamans"
are ve oper week
ey Core Su AMEN UPAIREN CMD PASSION ISR Dae
TT Dw sorte 25 m9 sed 9180p gat 26 CGR ATI nar SO
oceano Bande fers ange ouh Rol PES INA ndPA ICON
fers ie y sg es man PASS, SI IPs
est inne SS mado
se Sen mani ers lc: ect! nudos ne Incontri, Iciar parry cion pere
Aralar vel os HS CERA mn dors wosenngl lg tons las rg crec
Emp _ weeinpengetiehen munrmehopräfne dona wenseang CNO O
me ecards pilla mans dna waren ea a per pame
cren Una ORO Iveco Ieu e SmpIonS moments oué
on ODE (DNA DOM hera vou ota.
po Vi one
eii sie POQNFENONTE BPE MEDION GALO EPA Br PORRO
teo ‘lnkalvilshoeesalshed Prseneommee AMES | Cinlalashwesheem Oct reos
nO PTA MR E AI agedA pS MAO ret manette
Damon br ptetswihber——_ahrinmunoage des Sophia ot been emer
tro die rt nc chine ter ES
ser
prono ceo 8 ® . . . .

133. PNOLOSS

[NOY ORUSAC CNV ALLI TEO: NO CSW SESOLOSIO AOL

mareo
Bolo Treatments o Pauta
eer Taman ETS cory Boa
Medien GndsMBonTene, Bnse(Ditaknabunt Mmes Cremona Flyluman sont
Domi LAA} Baste MAR ta Pathshgh tordo
innen Due cin dat wh Cea ted too hat sea

fecwatedacha- Ec asia, MEME as TNR,
Bora eu delet Fo
oats. chat tfc, nd
aerate.
Dem ASOMO east. 251050 ginn Mate Angie te
Dag 07 note, Aaa Me 00 ZN ION Gama en
Maman! nohg me. mis ae thr Wok
ms

ag PEU PSHARMAE PASTILLA PASTA
Bert IMA AMA NO esoo

Paimentonen 42 and 27 mt Img) Atk 25 (6
arar nde man, Jour sg casa,
OS STR atra na
Prostcarasan ste ‘ae PIT dE
ee ananea 75."

Sy am Sant Skins. Moss cen to
ny a ne. cis png. ton cr. mer ro, tes,

tren, enc
one Mamadas abatido be ona alg IS nalganay gus acne,
dot ta Manic _ Igprhrahe.ds: waning haat

cy nes mens, an Line en hate ct Du
ates roles MEN fe Lita mp ringe em Um
es ae ac ‘abe evr ks aban gos vans shal
Der Fonte gen. fw, eau oe gen
lana pen
Monten COM Toscan pas Bas O, aa #70. ane.
fey 2 wk dt te
PT ea
sms Denain Dhaebmn DA Lapdikbien MECA
fo Salmos armada — Léman met ls
Moers" pts receng kg» peis wher Immo dons
ente mami apy Maui ds Inca le sky.
toate, ‘ese ey.
Pen 8 © D D s
cy

MA tl ae OKA Yoon incor esca nz US «sr PA = Sonne Fara Sty
‘snc oponen seo Say mao WE Samer mc

lished phenomenon in parie epidemal iferemation Furthermore, ene applied vice dls more effective
Longe topical conicosrids may viamin D inhibis production of sev. han oncedady use Hypercakeria la
cauce (1 )andadrenslsup- erl proinimmaum eynkines by he only major concer with th ue of
pression This dass of agents is dis psorte Tel cones, induding IL? topic vin D preparations When
‘ised in dei in Chap. 25. Sed Fy the amoune ued does or exceed the
“Analogues of viamin D shat have — recommended 100 ghveek,cakipot
TAMU, AND ANALOGUES Vitamin D bem ued forthe testment of kin dis ene canbe used witha gua margin of
exe hs aeons by binding tothe vias eases are clepouiene, (alıpowid, — Safe Vitamin D analogues ae often
nin D receptor another member ofthe cale, and masacakiol In shore use in combination with or in tation
oder hormone receptor superfamily, tem dis potent pia conicotods with topialcondcostereds in an effort
Vitamin D, ac to regulate cell gon, were found à be super w clepout. o maumize theapedtc efciveness
diferencia, and immune fancion, — e. When compared wth horse Whe minimiza, Steroid lated skin
Se well as cm and phosphorous anal or 15 erent coal rcakipo- Sophy.
‘meabolism, Vitamin. Dos teen wine was the more effective agen The
hou tint prlieraion fe. fico) of ealposene i ot reduced ANTARALIN (OITARANOL) Dino! (LB.
notes in cule and to modulate wir longterm esement 2 Calopow> ddr Sartre) a natal oo

134. 08 Saracen etal

“able 81.1 Therapie for piss
Recommend dose Rem

"Topic! therapies

Coin Once di Limited period of 2-4 cs
Nomen 0 pk

Viami DS deren Talon d.cliorio! Their se ean be ge han
twice ly coroners alone oia

‘combinaton)

Combined herp wih vitamin Once ily Limited perio of 2 weeks

1 drat al re

Retin One Posi leona hey

“opie cakinena inhibins Once daily Asmansenance they fot

Photferapy and sr therapy UVAL medium 40-80 em?)
nu high (30-120 em) doses

ANB-UVB ini ine (75-100

Le

Puva Same (MOF) 3-
OS mer: 1.2 por UVA exposure
e eden increasing UVA ds

Systeme therapie

Celosa 25-S mel opa!
Amon)

Mara 5.10 mg wooly as na de,
con dose upto 30mg weekly

Asien 03-08 mite
(opimal D mei)

Fame wi ere Upto12 géaly

Adaline mgt oc 040 mg atwek
then 40mg every 2 weeks

Bunerept Om inet pa ais
SO mg weekly for pri ate

tats mo a weak 0,2, and Gand
Secs

tina ‘Omg bodyweight <100 ig,
100 mg boy wah >100 La
ey ines

Una 4S mg body weight <10 kg.

img dy el 10 N at

sek at ek and ey I weeks

Recomended oss für bah pica pt epi

ines ass
pac

VE 308-311 ser they
VA! phoutbeapy

"VA! SS nm ser herapy

‘The erage daran of eaten
een ad 16 wes and
‘esa ine 1 lps about
Trays

‘Two deg sheds ne
vey or emite a cede
Weinen einen)

Useful in psa ca
sass

ntiproliferaive and antiinflammatory effets
“and isa useful drug in rheumatoid artis sy
temic lupus erythematosus, dermatomyositis,
‘sarcoidosis, immunobullows disorder, and pso-
asis, MTX has an antiprolieraive let as a
Folic acid antagonist on th basis ofits competitive

binding to dihydrofolate reductase. Despite these
‘well-known pharmacological effects, the mecha
nism of action of MTX at low dose in the
treatment of psoriasis remains unclear, having
both immunomodulatory and. profound. anti
Inflammatory properties.

135. Table 81.2 Common potent

Agents

Infiximab

Etanereept

Adalimumab

Golimumab

Ustekinumab

Potential occurrence of important side effects

Very frequent

Infusion reactions

Injection-site reactions,

infections (upper
respiratory tract,
bronchitis, skin

inf

>

Injection-site reaction

Upper respiratory tract
infection,

Frequent
Infections, headache, flush,
pruritus, urticaria, fever,
transaminase elevation

Pruritus

injection-site reactions,
headache, and rash
Hypertension, dizziness,
paresthesia, constipation,
liver enzyme elevations,

Itching, joint pain, muscle
pain or tenderness, injection
site reaction, skin rash

or rashes, sore throat,
urticaria, depression,
diarrhoea, hypersensitivity

‘Occasional
Serum-sickness-like disease,
(Cutaneous) lupus
erythematodes syndrome,
severe infections, tuberculosis,
anaphylactoid reaction
‘Thrombocytopenia, urticaria,
angio-oedema, severe
infections (pneumonia,
cellulitis, sepsis), weight

gain

‘Tuberculosis

Other infections

1 adverse events related to the use of systemic conventional therapies and biologics

Rare Very rare
Opportunistic infections,

‘demyelinating diseases

‘Anaemia, leucopenia, Aplastic anaemia
neutropenia, pancytopenia,

vasculitis, subacute and

discoid lupus erythematodes,

demyelinating disease,

tuberculosis

Drug-induced lupus,
lymphoma

‘Vasculitis, other infections
and infestations

Facial palsy

(continued)

608

136. Table 81.3. Screening tests required for systemic drug prescription

Full
blood Liver Serum Urne

Agent count enzymes cres

MTX ax x = E
Cya x Xx x = x
Retinoids =X =X x x
FAES ms = x x
Adalimumab X X x x x
Etanercept x X x x x
Infliximab X X x x x
Ustekinumab X X x 5 a
Golimumab XX x x x

x

o

=

PINNP
Pregnancy HBV/ Serum where

x

x

Uric Cholesterol,
sediment test(urine) HCV albumin available Electrolytes acid triglycerides Magnesium sugar CRP HIV

x

DOO OO OO

Fasting

blood ESR,

=

Ban“

vu”

gold
quanti-
feron

Bee

us

137. ES

‘The Manual of Dermatology

Psoriasis - Biologics (Dosing)
‘Table 92 Biologics commonly used inthe treatment of psoriasis
rade
¡Generic name name _[Treatmentrgimen _|Montring |Comments
[Alacept [Anevie [iS me Mg weekx12 [CDI at bases [May repeat coune 17
coke md weckt fects ateren of lt
couse in normal CD
Funes [Enid [MS0meSCHT [PPD wast [pie ars dog
pres mont den 25 mg SC Zune
rene mania
[ae o 0 mg SC
(some scav
cet mont en
35 mg SC uk,
A [PPD basins [ck box wari =
[Timo amet
Início. porn
att
[Ram [Sa 7 make SC [Monos plz |The only Boge at
ns 200 mde), [mon aly, ight base May
len Imps Sq |neng mont [potently case a in
eck tt symprom.

Remove from US
market in April 2009

8 mg SC at eek 0,
eek, q 12 weas
>100 ke

(0 mg Cat neck,
ck 2.412 weeks

or increased risk of
PM)
Fab |Remicade [San mph VXI on [PPDa baseline [Prod ar doing
secs 0,2. 6 en 5 isthe same
meri IV q 8 weeks Black box warning e
ITB invasive fungal
nico. opportunistic
nfestone
(sum [Sci Teig [PPD abuse Approved or pora

ot ot fr parte
ns

D History of CHE?

1 Family history or mi
5) istry of thereat?

19 Mistry ot heats?

9) PPD 2 Chou say

10) CBC ai, LFTs, CMP
1) Document body surfe

Work prior to staring biologi:

2) History mile seen?
5) History any malignancy (except NISC)?

I ss?

6) History con nections?
17) History IV Ansbioisin past year?

ares (BA)

ale of Neo sure wen:
nd (ach) 9%

ead + Neck =
¡Genital Area (perineum) ~ 1%

138. Table 42 Biologics used in psoriasis

Alefacept (Amevive®)

Etanercept (Enbrel®)

infliximab (Remicade®)

Adalimumab (Humira®)

[Ustekinumab
(Stelara®)

and proliferation by
blocking LFA-3/CD2
interaction, resulting in
selective apoptosis of
cells

its interaction with cell surface
receptors

TNFa.

interaction with cell surface
TNF receptors

Description Fusion protein of human [Fusion protein of the Feof [Chimeric antibody against |Recombinant human IgG1 [Monoclonal antibody
LFA-3 and the Fe portion [human IgG! and the extracel- TNFa. composed of a monoclonal antibody against | (fully human)
lof IgG lular TNF receptor human IgG! constant [TNFa
[domain and murine variable
regions
[Mechanism Inhibits T-cell activation [Binds soluble TNF and blocks [Binds soluble and bound [Binds TNF and blocks its Target the p40

subunit of interleukin
(AL)-12 and IL-23
which are related to
the differentiation of
naive T-cells into Thi
[and Th17 cells

[FDA indication

Moderate-to-severe
plaque psoriasis in adults

Moderate-to-severe plaque
psoriasis in adults; psoriatic,
Fheumatoid. and juvenile RA:
ankylosing spondylitits

[Severe recalcitrant psoriasis,

[Crohn's disease, RA

Moderate-10-severe RA in
adults

Moderate-to-severe
plaque psoriasis in
adults

Dosing

15 mg IM q week x 12
weeks, wait 12 weeks,
then consider a second
course x 12 weeks

50 mg SC BIW x 12 weeks,
then 50 mg SC q week

3 mg/kg IV over 2h at
[weeks 0, 2, 6, then 5 n
(y 8 weeks (preferred
psoriasis dose)

[40 mg SC over 3-5 min q2

<100 ke

weeks x 12 weeks: can ? 10 q
week doses if not on

145 mg SC at week 0,
[weck 4, q 12 weeks

methotrexate

>100 ka

90 mg SC at week 0,
[weck 4, q 12 weeks

[FDA monitoring

[CDA at baseline and
weekly (hold dose if<250
cells/iL.)

Screen for latent TB (PPD andi
[or CXR) at baseline

Screen for latent TB (PPD
and/or CXR) at baseline

¡Screen for latent TB (PPD and/
Jor CXR), routine CBC/

chemistries at baseline:
anti-dsDNA Ab if lupus

present

[Screen for latent TB
(PPD and/or CXR) at
baseline

139. [Pregnaneyand [Preg Cat B, lactation | Preg Cat B, lactation safely ? [Preg Cat B, lactation safety [Preg Cat B, lactation safety [Preg Cat B, lactation
nursing safety unknown (secreted in breast milk) unknown unknown safety unknown
[Optional PPD and/or CXR,and [PPD and/or CXR, BUN, Cr, [BUN, Cr, SGOT, SGPT, — [PPD and/or CXR and B-HCG [PPD and/or CXR,
[monitoring B-HCG at baseline SGOT, SGPT, Hep C serology |Hep C serology and/or |at baseline and B-HCG at
and/or B-HCG at baseline | -HCG at base! baseline
[Consider periodic CBC, ESR, | Consider periodic CBC and
and clinical follow-up q clinical follow-up q
3 months 3 months
Side effects, (Cough, dizziness, nausea, [Injection site reactions (37%), [Nausea, abdominal pain, [Injection site reaction (8%), — [Nasopharyngitis,
[common pharyngitis, pruritus, [cough and resp sx (45%), [back pain, arthralgi positive ANA (12%) (URL, headache,
myalgias, chills, in infections (35%), headaches | fatigue, headache fatigue, diarrhe

(17%), positive ANA (11%)

back pain, dizziness,
pruritus, injection site
reaction

¡Side effects, serious

site reaction,
transami

Tymphopenia, malignan-
cies, serious infections,
hypersensitivity,
transaminase elevations
(rare), cardiovascular

events

Allergie rans (2%), leukope-
nia, pancytopenia, new onset or
lexacerbation of CNS demyeli
nating d/o(rare), 1 incidence of
lymphoma, infections

Hypersensitivity ron,
infusion rxn, exacerb of
CHF, infections (same as
placebo), TB, invasive
fungal infections, lupus-like
[syndrome

Hypersensitivity ran,
confusion, MS. paresthesia,
subdural hematoma, tremor,

: |cephalopathy

Infection, malig-
nancy. reversible
posterior leukoen-

syndrome

[Contraindications

Hypersensitivity to
alefacept, de if CD4<250
x 1 month

Hyperens to etanercept or
[components active infections
lor sepsis. No live vaccines.
[CHE poorly controlled
diabetes, or immunosupp

Hypersens to infliximab or
murine products, CHF
(NYHA Class III/IV)

Hypersens to adalimumab,
chronic or recurrent infections,
latent TB, immunosupp. Avoid
concomitant tx with anakinra
and TNF-blocking agents

Hypersensitivity to
lustekinumab

[Acute infection,
[caution if latent
tuberculosis, caution
if chronic/recurrent
infections

(continued)

140. ‘Table 42 (continued)

(2 weeks post dosing)
PASI 50: 42% at week 14
PASI 50 began 60 days
after start

Most maintain PASI 50
through 3 months
observation period

154% at 6 months

PAST 50: 71% at 3 months
/Median time to PASI 50 and 75
was 1 and 2 months, respec-
tively, after start

land 33% at week 26 (5 mg/

kg)

PASI 50: 40% at week 26
(on 5 mg/kg)

Statistically significant

reduction in PASI w/respect
to placebo 2 weeks after
start

in one out of two patients
¡(maintained though week 40)
PASI 50: achieved by week 12
land week 16 in 2 out of 2
patients

Ustekinumab
Alefacept (Amevive®) _ | Etanercept (EnbrelO) Infiiximab (Remicade®) |Adalimumab (Humira®) | Gtelara®)
Precautions Infection, history of [Concurrenttx with anakinra, — [High risk of infection, those [Mild CHF (NYHA Class VII) Infection, history of
malignancy, live vaccines |natalizumab, TNF-blockers or | with preexisting or recent |- close cardiac monitoring. DC malignancy
use in patients with preg, renal |onset of CNS demyelin dz [if lupus-like rash develops.
[dz, asthma, CNS demyelin dz. [or seizure d/o, or who have |Caution in elderly, patients
or blood dyscrasias received live vaccines with preexisting or recent
lonset of CNS demyelin dz
[Manufacturer [Astellas Amgen, Wyeth [Centocor [Abbott [Centocor
Pharmaceuticals
Other Can use with Fe Can use with methotrexate |* Can use with MTX * Can use with MTX, steroids,
phototherapy ‘Improvement after first | salicylates, NSAIDs
[* Max reduction in few weeks
psoriasis at 8 weeks after
last dose
* 16-week cycles are
lunder investigation
Relative efficacy [PASI 75: 21% at week 14 [PAST 75: 47% at 3 months, | PASI 75: 82% at week 10 [PASI 75: achieved by weck 20 | PASI 75 (week 12):

[67% with 45 mg
dose, 78% with
}90 me

141. ‘Table 307: Combination erp

Spe and ope ge

PUVA spa eme al ein. le a UVA ne irre na

een sp ri Bees inn nan er

Reini tpl es wer doe of rene met

Copains pi, ey da opin lr pages ce bed ec

pea an à Sea te

PU spatial Rap eign ced a UVA dose

UVB pa tr terran tan UVB Bray lr

Space agents

PVR ceo (FU) unter of PUVA tenn rey Sei shuld ese 1-2 wees eater

PUVAsuvE amor PUVA ener te 90%

VA logan ‘Asctive Re PUVA, homer onal ep UA mach ger

vB mece Face in sewing pis a per eine marin anne

PUVA sete Treu UVA cure ral y hal he combi nen Be a of in
coral mate intel pon

Matos + pope ‘Cees sl cece yi eo er crc Ce
‘ted rc ptr mb acia pie aes

yoo + ns Yate ction

More soi Udi conto ecco pen hepticy

Madow sala {sed ice eas peta Dpto

Slain UVA Normal re: of leas need pen

Combinado hry with ea

ones sie cl peri with in fc. Aci rt

ann cn Ete ines ptas io nl ee

acres epic omen fe aan prin with aon iets. Al fie aris

Alec + UVB eel thm sal compres wi lege mn

JR. ot quo ad cren ven eve een cnc

{tcp cans, pre immo

"mse me mal

‘allies

“able 308: Rotana therapy

Meee OVA PUVA he eur abr or te gene e a ee er
Fenol punto Meca vara ve PUVA moron

create och trae con incl y metete lab ooh op.
ome io we may

Mere oie eos do pode one nr dns oc cB doe Reni site
Sed Smo re sep mar da

Baie o es Resi canbe ppd amp wi prc recon

Cyber eee Cru mena ofl nn gl ding ron en non do at

‘orton op tite an sere de

Cae bes namen ae eer A
sise

CS Bon ree ee whe ptet coco hp
isos sn dpe Win ua py sg on pp say
eel mm rt moe

142. 166

Lens nd. Reddy

Cost of Psoriasis and Psoriatic Arthritis
Therapies

Biologic therapies generally offer good efficacy
and safety and have revolutionized the treatment
of psoriasis and PSA. However, this comes ata
significan financial cos, with the average whole
sale price of most biologic therapies reaching

Lens of thousands of dollars per year. By contrast,
MTX is relatively inexpensive, costing only a
few dollars per week. To help adjust cost for efi
cacy, a recent study examined the cost of several
drugs in terms of the cost per month per patient
‘who reaches a PASI 75 response, Even when
costadjusted for recommended lab monitoring.

‘Table 7.4 ag of DMARDS an logis for resumen of psoriasis ad PA

ma Evidence
Evene approved CES
Molecular faction) for eus appv
Dog Tae ovis doing inpsoviass porns PsAdosing PAA fOrPsA
Metro Dire 1025mgPOr Yer Ve ‘105mg. Ve No
reduce ad USC PONMSC
tyme vk
mes
‘Aciusin Retinoic aid 10-S0mgFO Ve Yes NA NON
wen daly
Leonie Diydvortne NA Minimal No 20mg diy Yes No
dehrmeenne
Cclopaine Cyclin vs Ve NA wm
Apremist PDE Ye Yes Ye er
Bunecept TNF Yo Xs Yee
Adalimumab TNFa Yo Yes Homes Vs Yes
eats
Intima TNR Yo Yes Small Ve Yes
tne 0.2,
Sion gis
Golioum TNFa Yo No Sms Vs Yes
gor
ELO
o
inten
‘nts
Celine Tha Yo Yes ME Vs Yes
puso
Soren
Mom
OR
ng

ais

143. 7_ Protas and Prorat Arts

vr

able 7.4 (coined)

Dug Tant
steko 11223 pad

Secskinumad ILA7A

AS

Bralumab L-17eeqae

Abe —CDSOCDES

Gurb 12319

Riankizumab 11-23 p19

“ecto JAKVIAKS.

Prins doing
a8mpsC a
Poren
ias Gr
S100. use
50m)

200:mg SC uk
sus he
ins

{omg scat
O
SmeSCa
seks. 46,8,
10 Een
gs
210meSCat
webs 0,1, Zen
CS

NA

100mg scat
Kobe
then wis

15OmgSCat
Konad,

Gen gts
NA

ma
Evidence approved
freticxy for
pots parias
Yeo Ye
Ye Yes
Ye Yes
Ye Ye
we
Ye Ye
Ye Xe
ES

MIX was the most cost-effective option at
'$79405-1,502.51 per month. The most expen-
sive therapies were infliximab and ustekinumab
90 mg costing $8,704.68-15,235.52 and

'$12,505.26-14.256.75 monthly,

(Table 74) 216).

respectively

References

|. Pasi Ro Symmons DPM. Grits CEM.
hero DM. Gba! pieds) of purs
1 gaa ero of cence and pence
3 Invest Dermal 2012: ipso 101088)

PsA dosing
Sig scat
wht en
ass ar
S100, we
50 mg)
150-300 mg
SCaqwkxs
inks
‘omg sc
SO den
Some sc
ais

Homer
280mg SC ot
mon,
Zoe
as

Es mesc
gi OR
20000 me
gins
omg scat
hand
en is
Na

Smeponin
ORI mg
aly

else in
Pa

Yes

Ye

Ye

Yes

Ye

NA

Ye

RP

va

2. O'Neil Simon A. Pa ais, Hira
‘background and cpemiolog iles Cin

Roma

199430121541

Map ncd

il go pbm 010180 Assess Apr 1S

20,

3. Alias GM StenbrgB, icon 1, Lund

Me Dahl SR. tam jit man

ons ae prevalent in por: Pace dy 0
Join and al movement in pri pets an
‘alton ascii an ati questions Y
Rheuma, 20229 1292577-82 pooch
inh bd 2468155, Ascer Apo,

dors.

iin BI, Sian A, Barct EM. Seot DG,
Sym DP. Presence of pores des ot is
ce the pesen or Shorten outcome of

pain

de cuy tamal poly. 1
Ear

ORO. pr

144. HEED AAA

ot oman toy and requieeglarbbortry monitoring
{able 25.) Methorenate and cren are lo pregnancy
‘egy Xin fat females should not become pregnant for
yearlong helas dove facie

‘Apremis i a newer oral agent approved for bah
psoiss and psoria aes 2014 premia binds
Lo and Inhibits phosphodiesterase-, which respon
in e pathogenesis of psoriasis Unlike methotrexate
«closporine, and crei, apremilas has no known is
of organ tic and us requires no monitoring tes
(ato dose should be adjusted for decreased real
nc

BiologicTherapy

Biolog agents ar Immunomadulaing monocnal ant

In e ls decae, biologic thenples have resolu
‘hetreatment pora and furthermore hey have She
ew night nto the Immunophogenesis of psoriasis
and er inmune medite disse There ar cumendy
the clases ofbaoge agents approved y FDA forthe
aient of moderate to severe psoas. Tis ines
the TNE tibios etanercept (bel), alaimumab
(uni). and inma (Remicade) I-12/2-nitr
‘tenia (Sela aL 7A nt seculimumab
(Coseny)andinekiaumab (Tale), Alf rse medications
ane adnniaered ssubewansousinjerions exept ori
Isa which sadministeredaaninason Aug in
te the leconventence of infaions and oso fiery
‘overtime cantine The newer ant IL agents hase

also shown rat fea The desing regimens each of
Uhebiologiagentsareshown in Table 234

Fossils arse reactions Waring an pentes

50mg SO BTS
men, hen mg

[Adana TNF-pha

some soo,
then 40 mg COW

staring a
aah

Tia Smoke.

snd Don GO

tiens
He stereactont

ie steeactons

Ineione
en ratorscten
He

sr pan

Sense inehone
Malnancy
Deneiatng ease

Malignancy
Bean

op resto
Demyeinaing rose

Opel
Congestive eat fire
Lapse.
Serausiteciont

Natancy

Hop reactivation

Hepatosety
Congestive a an

pei

Creuse esse
Demyenaing ease

Las sta

(cont)

145. S|

(cont)
‘are Toga Doing ‘Posse dera mectens amigo nd pecar
Cat NESARA 40 mg SO SON hata O
Pood aoe Malena
Cargar har re
poopie
tp Bretton
Damian roses
Smet
Liste yore
Utairumb 11229 4505 mgSo nt | mhciens Sous tons
CAES Macs
Fe pare tec
ttre pote msowcephalpthy
None mamans
bie crecio
Es
Season
Noes snlxinectons
ann 12 100 MOOD A, cios Horace
Sinan e tac Ste ce
suc LITA S00mgS0.aV0,1, intone sas nitene
23 de OA " Dames Hanna Sor ane
rr ein
holmes LTA 16)mgSOm0, neon starencans Save cion
Senlimgauz tone Haras
200 format? Nee Emma Dovel ease
den 20m ON Messi
om IRA 2i0mg Som, 1, Ara il ote noter
From | ea Emsa me
e, Ent bowel sare
panes
ign
ican sta rocina
Mes
Nearopenia
“inate
Chen kt mmunemodulakry ef, are ar agen may increase ak Cisne dealin

‘nie necios diseases such as tuberculosis hepails
and C, and HIV shouldbe ruled out prior to nation
‘mended years. Although controversia, some bale

ing disease, heart disease, and malgnany a sen Wit
TN inibtore” Newonset psoriasis inpatient th
sel sacs” granulomatous eruptions” ecaematous

146. Table 2 Antag and age teni gen forthe me last cy poston

Mela res Distant

Aci aimons | Daly in my sa wea

RE mn mc AR MR abc,

pet mits
LE de tae
pue to

Meares DR opie | Doe mado ith desen
[escama Esas
send ag lola

capi Rapid ont ln sy
rimes cele
(Gettin ACE nso
pain dre

open Mati No do men nr de loin mage nc darts
‘Sorte pin de ame in
ponme medie
on mea

an (Nee ra cr ara Ga ama | Wane CH kon
dan mations pod gc fe) aan of hres a
‘pu poble nen
riens denen
demain res
D nina men en WneeCHE,immunnpgreen,

pa os noma
pionera des,
demain sre eon
‘ats opts of sons
‘ala anal nam ‘ev Crees
pa pa ingen n
riens denen.
demain des
en Mima medion ites dard of Long em sft) di a
De tor opc
‘mii a
eones vend oe ie
anon Maina tion me Lim gem ey da
‘nmap. esd
arcade ein none BD
ry A Lima long te ey a
ES
ma rss ik Fr
‘Sistem were BD

Ari nein rk menge Lim gem dde
‘eal ats un. eth ep “shine reine dent
{sie ang rcs wi O

‘ae wig os peso
‘ita ie

147. Table Gomis)
“eset [Pob

=e je i soe iz
lents Sinus tige | prior EC MPS a
So —_|macowiningwceet (il mr une
rien me olde vse [vence] themen a
Set np Re GA or
one Se gsc mee
pa ER
‘wie ay sig
So mola)
Ont Aland 075-1 mee eds) Minune Se Dib o same MB
Sens (ue lemme, Mime Sets [ie | meme
rede) Mer coins |, moi
saone 3 es in
Sere, Stale
‘pou ty
“able 222 Onl ages indecent ro demas Saca History

‘Arent POE NC
Ferm (IE immer. NOTONS
AV aan compas

DGA Rubin ne? NEIL

rer

Tenis NK Pine? NOTE
Sa ange Nenas
ZU ig ne? NES
ion

ep 2, DOLL de pa len UR
Ine Mco JAN has Le, PDE amp à
Dl pta DL MATA sil ep

Case Report
A 42-ycal white male presents with lifelong history of
“eczema? which has Mare ove the pas few yes. He Was
previously managed with topical agents but these have not
been working for im Ley He complains af severe itching,
which intemupe is sleep Given the night shift at work he
Sins ica to sleep during the day with omgoingith nd
has been having dieu coping. He notes he has been
short” and moody” with his Family and attributes his 10
lack f sleep. Ther fal history of topic demain
is danger as well

Past Medical History
+ Hypentension

+ Amey

+ Asta

+ Drinks social

+ Married, 2 children

+ Floor manager ra distribution plant, working shi work,
nly ight shits

Previous Therapies
+ Topica steroids

Physical Exam

+ Enematoos excorited ficheified plagues on the
rss, antecubital and popes fesse: cl erythema
and scaling with Dene Morgan folds noted.

Management
‘Doe tothe severity of his pie demas are and his di
il coping systemic therapy with yclospeine was nt
sted at 150 mg PO BID. He à also managed with topial
tscrolimas 01% oitment BID or the facfbody and beta
mehasoe valerate 0.1% ointment for he body Hares pen.
He has good contol of his skin with improved sleep while
taking eycloxpoine but besuse f his hypertension. hs dose
is reduced 1 100 mg PO BID when possible. To manage
fares in symptoms he inermitenly increases back 4
150 mg PO BID with close monitrn

References

|. Race EL Sul PL Rac, Linge, Shi. iy
And stay of see er ar me see
pie demas: 2 syne re. J Allg) Ci Immun
Fersen

2 Samat Seat NM, KW Meurer M. Ouen ae
{ned wenn of kn un sabe wi une

148. ‘Supplementary Table 1: Biologics and small molecules for nail psoriasis (NP) and alopecia areata nail dystrophy (NA A)"

Name Drug Mediaian of USFDA Evidence for Highest LoE for US FDA ‘US FDA Most Common US FDA Warnings and
ass Action Approvalfor Inflammatery Inflammatory Administration’ Adverse Reactions Precautions
Dermutalogie Nall Disease” Nal Disorder — Domge Frequency
Indications Treatment
Apremilast Small Phosphodiesterase-4 Plaque NP Level 1- Oral/18+/30 me (53%) Diarrhea, ‘Hypersensitivity, depression,
Molecule tr ras Sema review BID afer diy 6; mans, headache, upper wea decrease ug
vaio tidaosover real dosing advised respiratory Wat infection interactions, severe dates,
its aay coer nausea, venting
Dewersvactinb Small Allostesicallyinhitts Paque NP Level5-m0 — OraV18+6 m8 daly (2199 URTL elevated Hypersensitivity, infection,
Malecale.irosineliomee2 — peonasid™ significance in Blood cenine nubereuloi, maignany,
the TAK-STAT meta-analysis phovphokinase(CPK), habdomyolyas and devated
pathway? herpes simplex, mouth CPK, laboratory abnormalities,
teers flies, acne immunization interactions,
her rates a lease mortality
related o JAK inition
“ofan “TwgesTAKI,TAK2, PRAM NRNAA NPLevil- Oral18+/Tofatiib 2500) URTT, Serious infections, iberentosis,
Molecule andJAK3 enzymes, senc reties SmgDIDor masopaynsits, malien gasroitesinal
inhibiting the NAA: Level 4 Tofactiib extended dias, headache peores laboratory
TAK STAT sn one cone tay Fase XR 11 mg Somalie and inmunizaion
pathway? ‚once daily; renal interactions
and hepatic dosing Black box warning for
advised heart-related events, cancer,
thrombosis and dent
Contraindestedin brentfeedng:
Combination with poten
immunosmppresats not
recommended
Upaduciiib Small SelectiveAKI—PeA,atopic. NP Level3— __ora124/15mg once PSACIPO/URTL hapes Hypersensitivity, astro
Molecule inhibitor German ciwervationsl diy; pedatie, zoster, hrpessunpler, inteal prfortions, laboratory
study without renal andconsage bronchi amen, abnomaltier, abryo-fetl
dramatic effect of CYP3AM coh, pyresin, acne and toxicity
inhibitor dosing may headache Fa bee
beadvised ‘AtopicDeatis (199: serious infections, mortal.
UR, acne hepes matiza, cardovascalar

simples, headache,
neteased, CPK, cough,
hypersensitivity,
folliculitis, nausea,
abdominal pain, pyres
nereased weight, herpes
zoster influenza, fatigue,
neutropenia, myalga, and
infuenza-ike mess

death, and thrombosis)

Contraindicatedin severe
‘hepatic impairment, use with
immunosuppressants or JAK
inhibitors live vaccines, and
strong cytochrome P450 344
(CYP3A3) inhibitors not
recommended

Coma.

149. Supplementary Table 1: Contd.

Name Drug Mechankmet USFDA Evidence for Highest LoE for US FDA US FDA Most Common US FDA Warnings and
Class Action Approval for Tnflammatory Inflammatory Administration Adverse Reactions Precautions
Dermatologie Nail Disease Nail Disorder _ Dosage Frequency
Indications ‘Treatment
Biologie TNFialibitor Plaque NP Level — TSubeutaneousd (10% infections, Serious infections, tuberculosis,
(ecombinant psoriasis systematic review PSA: 40 mg every injection site reactions, malignancy, invasive fungal
Inman TG. PSA, NP. her week Plague headache, rash infection, hypersensitivity
Gnmunoglobutin Hidradeiti Psoriasis 40 reaction, Hepatitis
@)monocional—_Suppuratvat? every other week reactivation, demyelinating
antibody}? stating one week: case, cytopenia heart failure,
afer ital dose and lupus ik syndrome
Cartolizumab Biologie TNFinlibiter Plaque NP Level 18+Subeutaneous! (279%) URTL rash, Serious infections, tuberculosis,
Pezol Qumanized Fab’ psoriasis, systematicreview plaque Psoriasis. Urinary tract infection invasive fungal infections,
antibody agent PSA 0 400 mg (given at malignancy, heat failure,
that binds to and 2 sibeutaneous hayperseniivity reaction,
‘locks TNF-alpha) injections of 200 mg Hepatitis B reactivation,
cach) every other demyelinating disease,
ol pate ‘jtopenis, pus ike syndrome
for body weight

advised. PsA: 200 or
400 mg every other
week after week 4

Etanercept Biologie Plaque NP Level 1 24/Subsutmeous! (5%): infections and
(Qiuman dmeric psoriasis, systematicreview Plaque Psoriasis injection site reactions
fusion protein that PsA? 50 mg once weekly infection, demy el
‘competitively binds after 3 mouths disease, congestive heart
to-nd inhibits Pediatie dosing failure, pancytopenia or aplastic
‘TNF-alpha and. advised PsA 50 anemia, Hepatitis B reactivation,
‘TNF-beta") img once weekly Iiypersensiiity reaction,
whe leo! Ipus-like syndrome
methotrexate (MTX) Use with ive vaccines,
anakinra, abatacept and
yaophosphamide not
recommended”)

Biologie TNF-Inhibitor Paar NP Levd 1 18+/Subeutaneous (SP): URTI, Serious infections invasive
(unan IG aossover and or TVinfusion! masopharymeitis®" fungal infections, Hepatitis B
‘monoclonal systematic review Subcutaneous 50 reactivation, malignancy, heart
antibody that blocks mg once per month, failure, demyelinating disease,
TN) IV infusion 2 me/ Inypersensitivity reactions

Ka at weeks 0 and 4,
and every 8 weeks
thereafter

Contd.

150. Supplementary Table 1: Contd.

Name Drug Mechankmet USFDA Evidence for Highest LoE for US FDA US FDA Most Common US FDA Warnings and
Class Action Approval for Tnflammatory Inflammatory Administration Adverse Reactions Precautions
Dermatologie Nail Disease Nail Disorder _ Dosage Frequency
Indications ‘Treatment
fisio Bios MiFnhibier Plaque NP Level — SHntravenousls (1009 infections —— Senionsinfecins, invasive
(ecombinant psoriasis, PsA systematicreview mg/kg every 8 (ex URTT,simustis, tuberculosis, fungal infections,
weeks after week 6 it malignancy, HepatisB
reactivation, hepatotoxicity,
Heat failure, cytopenias,
Iypersensiiity, cardiovascular
and cerebrovascular reactions,
ing disease, lupuslike
Use with lve vaccines not
recommended
Doses > make
contraindicated in patients
Bimekizumab Biologie IL-17 inhibitor (binds Plaque NP Level 2- 194 (196): URTI oral Suicidal ideation and behavior,
the IL-17A, 1L-17R, psoriasis randomized Subeutancous/320 candidiasis, headache, tions, uberaloss,
‘andthe IL-174.£F control mg (two 160 mg injection site reactions, liver enzyme abnormalities, BD
heterodimer ectins) every 8 tinea, gastroenteritis,
weeks after week herpes simplex, acne,
16. Weight based folliculitis, other candida
dosing advised infections, fatigue
Brodalumab Biologie IL-17 Inhibitor fully Plaque NP Level 1- 194 19%) arhralga, Serious infections, tuberculosis,
Iman monoclonal psoriasis” systematic review Subcutaneous/210 headache, fatigne, Crolu disease
1262 antibody) me every 2 wecks dhanhen, oropharyngeal lack box waming for suicida
afer week 2 pain, nausea, myalgla, ¡demon aad chorion
injection site reactions, .
int nea pet, Sian Cotas
tinea
{Use with live vaccines not
recommended
Iekiamab Biologie TL-17 Inhibitor Plaque NP Levd1- G#Subeutaneons 190): injection site Serious infections, tuberculosis,
Qumanized 1864 i systematic review Plaque Psoriasis 80 reactions, URTT, nausea, IBD
me every 4 weeks {Use with live vaccines not
after week 12 PsA: Fr)
30 mg «very 4
weeks after initial
dose

‘Contd,

151. ‘Supplementary Table 1: Contd.

Name

Drug

Mechanian of
Action

USFDA

Evidence for Highest LOE Tor

Approvalfor Inflammatory Inflammatory
Dermatologic Nail Disease Nail Disorder

Indications

Treatment

USFDA
Administration’
Dosage Frequency

US FDA Most Common US FDA Warnings and

Adverse Reactions

Precautions

Secukimmab,

Biologie

ILA7 inhibitor
(human 18618)

Plague
psoriasis,
ES]

w Ledi-
Sstematie review

Pedi and
emconitnt Hague
Poorinas and Poa
dosing acid
64 Subeutaneous
{plaque psoriasis),
Subcutaneous or
Intravenous (PsA)
Plague psoriasis:
150 300 mg
vey 4 weeks
A esk. Pat:
Subcutaneous
‘it foadng
dove 150 mg
every weeks
ater weet
"Vitor loading
dove 150 ma
every weeks
Dosage 06300 me
vay ¿vee
come
contd ae PA
Intavenons
ito
dosage: 175
gh every
‘tweak ater

loading dose
Without a loading.
dosage: 1.75 me
kg every 4 weeks
‘Dosing for pediatric
and concomitant
plaque psoriasis and
PsA advised.

(19: nasopharynsitis,
Garshea, URTI

Serious infections, tuberculosis,
IBD, hypersensitivity reactions

recommended

Contd.

152. ‘Supplementary Table 1: Contd.

Name Drug Mechanismof USFDA Evidence for Highest LoE for US FDA US FDA Most Common US FDA Warnings and
Class Action Approval for Inflammatory Inflammatory Administration’ Adverse Reactions Precautions
Dermatologic Nail Disease Nail Disorder Dosage Frequency
Indications Treatment
Gusclkumab Bidoge 23e Plage NP Levd 1-847 150) nasopharyits, Serious infections, tuberalods,
ma psoriasis systematic review Subeutaneous/100 dhanhea, URTIO3 "TBD, hypersensitivity reactions
joalobutin and crossover Use with lve vacines not
lambda (G12) recommended
Ionoelonal
antibody)

Risankizumab Biologie 11-23 Inhibitor. Plaque NP Level 1 194 190) URTI, headache, Hypersensitivity reactions,
QumanizedkG psoriasis, systematic review Subeutancous/150 fatigue, injection ste serious infections, tuberculosis
‘monoclonal antibody Psa? me reactions. tinea" Ve with live vaccines not
that selectively weeks after recommen:
inhibits the p19 ener +
submit)

Tidakizumab Biologic 11-23 Iuhibitor Plaque NP Level t= 190) URTL injection Hypersensitivity, serious
(iumanized psoriasis systematic review site reactions, danhica infections, tuberculosis
monoclonal IgG
antibody that
selectively bi
pig subunit)

Ustekinumab Biologic 11-23 inhibitor NP Lev 1— __GHSubartaneous'4S 3%): nasopharynsitis, Serious infections, tuberculosis,

systematic review mg every 12 weeks URTI,headache, malignancy, hypersensitivity
antibody that binds PsA? mdgomoter alerweckd fatgnel®) reactions, Reversble Posterior
toIL-12RBI, which Pediatric and Leukoencephalopathy Syndrome
concomitant plaque
psoriasis dosing
vised.
{Note that ypersentiity reactions can occur with all Biologie and sal-moleaiTe vas for iflnımatary nail sense Fie table contains inated infonnation Details about dosing,

including loading dosages, indications, and side effects should be obtained from trained physicians and US FDA-approved sources