Issue #14, June 2022
We are pleased to bring you Issue 14 of The Surface! In this edition, we feature a report on desensitization following hypersensitivity to mRNA vaccines, commentary on new data for JAKi in HS, and review management strategies for pediculosis capitis infestation. We also highlight a new Canadian expert panel report on the use of systemic psoriasis treatment in people living with HIV and a review of the evidence and mechanism of action for tars in psoriasis treatment.
Desensitization following immediate hypersensitivity to a first mRNA vaccine dose
A subgroup of patients from the Allergic Reactions to COVID-19 Vaccine (ARCOV) cohort were selected for desensitization to polyethylene glycol (PEG) based on confirmed or suspected immediate hypersensitivity reactions to the first dose of an mRNA COVID-19 vaccine. Skin prick testing (SPT) for PEG and polysorbate-80 was conducted. There were six patients, all female, who underwent the desensitization protocol. Five of the patients had significant past medical history of allergy. SPT was conducted at the allergy clinic at least two months after the first dose of vaccine.
Four of the patients had negative SPT to PEG, while two had delayed positives (3 hours and 5 hours delayed). Three patients received the Pfizer-BioNTech vaccines and three received the Moderna vaccine. The Pfizer-BioNTech vaccine was administered in three undiluted doses: 0.05ml, 0.1ml, then 0.15ml, each 20 minutes apart. The Moderna vaccine was given in four undiluted doses: 0.05ml, 0.05ml, 0.2ml, 0.2ml, also each 20 minutes apart. Patients were observed for 60 minutes following the last dose. Three patients were premedicated with oral antihistamines. Two patients reported immediate cutaneous reactions that were treated with antihistamines. One patient experienced dizziness and a drop in systolic blood pressure, they received a bolus of IV fluids. Patients also reported mild delayed adverse reactions, including rash, pruritus, and headache. The second dose of an mRNA vaccine may be safely given following a desensitization protocol in patients who experienced an immediate hypersensitivity reaction to the first dose.
Read more: [Sosido link] AlMuhizi F, Ton-Leclerc S, Fein M, et al. Successful Desensitization to mRNA COVID-19 Vaccine in a Case Series of Patients With a History of Anaphylaxis to the First Vaccine Dose. Front Allergy. 2022;3:825164. Published 2022 Feb 2. doi:10.3389/falgy.2022.825164
JAKi for hidradenitis suppurativa
Sibbald and Alhusayen provide expert commentary of JAKi in hidradenitis suppurativa (HS) following two multicentre Phase II trials of INCB054707. This agent was studied on a daily oral schedule at doses of 15mg, 30mg, 60mg, or 90mg in a total of 45 patients across two studies. Fatigue (3%) and headache
(15%) were the most common treatment-related adverse events. Asymptomatic thrombocytopenia was observed in four patients who received the 90mg dose (50% of patients at this dose). Platelets recovered following two weeks of withheld therapy. The rates of clinical response at week 8 in the larger study were: placebo, 57%; pooled INCB054707, 65%. JAKi represent a potential new option for HS patients and may be particularly useful in patients with comorbid atopic dermatitis or inflammatory arthritis. The authors note that studies are also underway with upadacitinib, brepocitinib, and ropsacitinib.
Read more: [Sosido link] Sibbald C, Alhusayen R. Janus kinase inhibitors for hidradenitis suppurativa: expanding the therapeutic toolbox. Br J Dermatol. 2022;186(5):768-769. doi:10.1111/bjd.21297
Management of head lice infestations
Leung and colleagues have published a new narrative review of management strategies for pediculosis capitis infestation. Head lice do not directly cause disease in humans, but can cause scalp irritation, anxiety, peer bullying, and exclusion from schools and camps. Itching results from sensitization to fecal or salivary antigens. Severe itching with excoriation may result in secondary infections, including S aureus. Lice eggs are typically observed adhered to the hair shaft close to the scalp. Wet combing with a fine-tooth metal comb is the most sensitive method for detecting lice.
The review covers the most commonly used topical and oral pediculicides, including permethrin, pyrethrin plus piperonyl butoxide, malathion, ivermectin, lindane, as well as mechanical removal with wet combing and various natural remedies. The review notes that oral therapies should be reserved for patients who do not respond to topical therapies, and that mechanical methods are preferred for children under two years of age as well as pregnant or nursing mothers.
Read more: [Sosido link] Leung AKC, Lam JM, Leong KF, Barankin B, Hon KL. Paediatrics: how to manage pediculosis capitis. Drugs Context. 2022;11:2021-11-3. Published 2022 Mar 14. doi:10.7573/ dic.2021-11-3
Co-management of psoriasis and HIV infection
A group of Canadian dermatologists, HIV, and infectious disease specialists have published a new expert guidance document on the management of psoriasis in people living with HIV (PLHIV). There are theoretical concerns that systemic psoriasis treatments, which suppress the immune system, may worsen infections with agents such as HIV or increase the risk of malignancy. Owing to a lack of direct evidence, the authors reviewed indirect evidence using a formalized inference-based approach to create recommendations for the co-management of psoriasis and HIV infection.
HIV guidelines recommend starting antiretroviral therapy as soon as possible once the infection is detected, which leads to undetectable viral loads and a largely normal life for PLHIV. The authors found that benefits and risks of systemic psoriasis treatment are similar in patients without HIV infection and PLHIV with suppressed viral loads from antiretroviral therapy and normal CD4 counts. HIV replication should be addressed prior to initiating psoriasis treatment. They also recommend caution in patients with suppressed viral load but discordant CD4 responses.
Read more: [Sosido link] Papp KA, Beecker J, Cooper C, et al. Use of Systemic Therapies for Treatment of Psoriasis in People Living with Controlled HIV: Inference-Based Guidance from a Multidisciplinary Expert Panel. Dermatol Ther (Heidelb). 2022;12(5):1073-1089. doi:10.1007/s13555-022-00722-0
Review of coal and pine tar evidence in psoriasis
Ávalos-Viveros and colleagues have published a review of the use of tars for psoriasis. Despite reported use dating back to the 1600s, the mechanism of action of tars has not been fully elucidated. The authors searched the literature for evidence published on tars from 2010 to 2021. The review focuses mostly on coal tar (CT) and pine tar (PT).
The proposed mechanism of action involves CT activating the keratinocyte aryl hydrocarbon receptor, which has downstream cutaneous effects that create an antimicrobial milieu less susceptible to infection and inflammation. Pine tar acts as a keratolytic agent that promotes normal keratinization. Clinical studies with various formulations of coal and pine tar are reviewed. Not surprisingly, these different formulations demonstrate highly variable efficacy and tolerability in studies that included between 22 and 62 patients. The authors found no conclusive evidence about the risk of malignancy with CT treatment. They suggest that tars could be used in patients who have relapsed on biologic therapy, though they acknowledge that the product characteristics of tars do not align with patient preferences in topical psoriasis agents.
Read more: [Sosido link] Ávalos-Viveros M, Esquivel-García R, García-Pérez M, et al. Updated view of tars for psoriasis: what have we learned over the last decade? [published online ahead of print, 2022 Apr 10]. Int J Dermatol. 2022;10.1111/ijd.16193. doi:10.1111/ijd.16193
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