Six of the eight patients saw a reduction in PDAI at 6 months with no increase in adjuvant therapy. Patients 1 and 6 had increases in PDAI at 6 months, by 14 and 5 points, respectively, with patient 1 receiving an additional cycle of rituximab. Seven of the eight patients had an available score for PDAI at 12 months, with a reduction seen in all, and a mean improvement from baseline of 90%. The reductions in PDAI are clinically significant given the impact that blistering skin conditions have on quality of life. There was variation in PDAI at baseline between patients, ranging from 4 to 20. This may represent a milder spectrum or partially treated disease, and could have impacted the time to endpoints.The prednisolone dose at baseline ranged from 0 to 25 mg per day (Figure 1). This decreased to a range of 0-5 mg per day at the end of follow-up. All patients saw a decrease in daily prednisolone dose from baseline, with exceptions being patient 6, who remained on 5 mg per day throughout, and patient 7, who was not on prednisolone at baseline.The minimum time at which B-cell subset depletion was observed varied from 75 to 1262 days. Reduction in baseline antidesmoglein levels was seen in all patients following administration of rituximab for varying lengths of time (Figure 1).No serious adverse events occurred in any patients following administration of the 200-mg protocol. Previous adverse events with rituximab have been reported to include infusionrelated reactions and infections. 6,7 In Australia, the use of rituximab in pemphigus is off label. Ultralow-dose rituximab is a cost-effective option and may be particularly useful where cost is a barrier to access. Uncertainty still remains over optimal rituximab dosing in pemphigus, with no formal dose-finding studies to date. Small studies have proposed low-dose and ultralow-dose protocols. 2,8 This study suggests that two infusions of rituximab 200 mg given 14 days apart may be an efficacious and safe option in patients with mild pemphigus disease in conjunction with more traditional adjuvants, and offers an alternative to the 500-mg and 1000-mg dosing protocols.As this study was retrospective there was variation in review timeframes and pathology based on clinical need rather than set intervals. Additional limitations are the small number of heterogeneous patients and lack of controls. Larger prospective randomized controlled trials are required to investigate these findings further.
Given their prevalence, skin diseases are an important public health issue. In 2013, over 25% of the US population was impacted by dermatologic diseases, resulting in $75 billion in direct healthcare costs. Through 2010, non-dermatologists diagnosed a majority of skin diseases in outpatient visits. We sought to assess whether this was still true in 2016 and to determine the most common dermatologic diagnoses seen in dermatology and non-dermatology practices. We assessed visits in the 2016 National Ambulatory Medical Care Survey, an annual representative survey of visits to U.S. outpatient physicians. We analyzed all diagnosis codes reported at visits with dermatologists and non-dermatologists to determine the most common dermatologic diagnoses. Observed visits were weighted to obtain a nationally representative estimate of all visits in the U.S. There were an estimated 49.9 million visits to dermatologists with 107 million dermatology diagnoses and 834 million visits to non-dermatologists with 106 million dermatology diagnoses. The top 5 diagnoses for dermatologists were actinic keratosis, seborrheic keratosis, acne vulgaris, unspecified melanocytic nevi, and unspecified external cause. The top 5 dermatology diagnoses for non-dermatologists were unspecified dermatitis, rash and other nonspecific skin eruption, unspecified viral infection, unspecified atopic dermatitis, and unspecified chalazion. Seborrheic keratosis, malignant neoplasm of the skin, melanin hyperpigmentation, melanocytic nevi, and actinic keratosis were the most commonly referred diagnoses to dermatologists. In 2016, dermatologists diagnosed a majority (50.2%) of skin diseases in the outpatient setting. The skin conditions most commonly seen by non-dermatologists differ from those seen by dermatologists. These differences as well as the top diagnoses and referrals can be used as a foundation for tailoring dermatology training for non-dermatologists.
Greater psoriasis disease severity is associated with higher prevalence of co-morbidities and differences in prescribing patterns. To understand effects caused by different therapies, researchers need to accurately account for disease severity. To address this gap in knowledge, using a gold standard for psoriasis severity, we developed and validated a score to predict severity in a large administrative database. Two registries, the Center for Excellence in Psoriasis and Psoriatic Arthritis (CEPPA) at Oregon Health & Science University (OHSU) and the Corrona national psoriasis registry, were linked with Medicare data for 2006-2017. Both direct linkage using social security number and probabilistic linkage utilizing date of birth, sex, dermatology provider name, and most recent dermatology encounter date were used to link data with Medicare. Registries were combined, and analyses limited to patients with !12 months of continuous Medicare coverage and !1 dermatologist-assigned psoriasis diagnostic code. Validated claims-based algorithms were used to identify potential covariates. Outcome was body surface area (BSA) dichotomized as mild (<3%) vs. moderate-to-severe (!3%). LASSO regression was used for variable selection with 0.15 cut-off. Model fit was assessed by classification error. Sixty-four CEPPA and 172 Corrona patients met eligibility criteria (Table 1). We developed an indirect score for psoriasis severity using diagnoses of anxiety, depression, diabetes, lower back pain, and psoriatic arthritis as well as adalimumab and phototherapy use, joint surgery, lipid testing, dermatology and outpatient visits, and gender. Our model correctly predicted moderate-to-severe BSA 74.6% of the time. Misclassification was non-directional with 6 false negatives and 9 false positives. Our psoriasis disease severity score using indirect measures of BSA may be a potential method for accurately controlling for disease severity in the analysis of administrative databases.
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