The Surface by PSOLVE+, Issue #9, December 2021
Issue #9, December 2021

In this issue of The Surface, we highlight five new publications covering occupational contact dermatitis, corticosteroid injections for dactylitis, a review and a case report addressing nail psoriasis, and the international use of dose-reductions of biologic agents for psoriasis. View archived issues of The Surface at

A methodical approach to occupational contact dermatitis

An individualized approach to occupational contact dermatitis, the most common occupational skin disease, is newly published in Current Dermatology Reports. Houle and colleagues describe the differences between allergic contact dermatitis (an adaptive immune response to chemical penetrating the skin) and irritant contact dermatitis (a non-immunological, non-specific reaction to an irritant). They note that an occupational history should be conducted to investigate suspected cases, including the industrial sector, work site description, number of years on the job, and materials contacted at work. The schematics demonstrating common clinical patterns of hand and face contact dermatitis are particularly helpful (see the hand schematic reprinted below). Considerations for occupational contact dermatitis observed during the COVID-19 pandemic are also described, with these reactions resulting most frequently from use of personal protective equipment, frequent handwashing, and sanitizer.

Hand schematic:

[View full size image]

Common clinical patterns of hand contact dermatitis: a irritant contact dermatitis from handwashing, b exogenous dermatitis, c ring finger dermatitis, d chronic paronychia, e grip hand dermatitis, and f 3-digit pulpitis

Image reprinted from "Occupational Dermatitis: An Individualized Approach to the Worker with Dermatitis" by Houle et al, licensed under CC BY 4.0

Read more: [Sosido Link] Houle MC, Holness DL, DeKoven J. Occupational Contact Dermatitis: An Individualized Approach to the Worker with Dermatitis [published online ahead of print, 2021 Sep 14]. Curr Dermatol Rep. 2021;1-10. doi:10.1007/s13671-021-00339-0


Case report of transverse nail grooves in a patient on monthly ixekizumab

Yamanaka and Kondo present a case report of a 47-year-old male patient treated with monthly self-injections of 80 mg ixekizumab. The describe three equidistant transverse grooves developing on the left middle fingernail, which reminded them of annular rings of a tree. They suggest the grooves could have developed as the blood concentrations of ixekizumab declined near the end of the monthly cycle, a time when psoriatic activity would have been highest. They note however that drug concentrations were not measured in the described case.

Read more: [Sosido Link] Yamanaka K, Kondo M. Psoriatic transversal nail grooves on biologics. Clin Case Rep. 2021;9(8):e04606. Published 2021 Aug 25. doi:10.1002/ccr3.4606


Review of nail psoriasis pathophysiology and treatments

A comprehensive review of nail psoriasis was recently published by Ji and colleagues. They describe the epidemiology and pathogenesis of nail psoriasis, including an elegant image of the inflammatory pathways implicated in the disorder, which can affect over half of psoriasis patients. There are very helpful photographs of different nail manifestations, including pitting, leukonychia, onycholysis, and nail plate crumbling. The authors also describe in detail the evidence supporting topical agents alone and in combination, intralesional corticosteroids, phototherapy, conventional systemic therapy and each of the biologics and small molecule targeted agents. A suggested treatment algorithm based on inflammatory conditions and nail involvement is provided.

Read more: [Sosido Link] Ji C, Wang H, Bao C, et al. Challenge of Nail Psoriasis: An Update Review [published online ahead of print, 2021 Sep 3]. Clin Rev Allergy Immunol. 2021;10.1007/s12016-021-08896-9. doi:10.1007/s12016-021-08896-9


International survey of attitudes towards dose-reducing biologics

An international survey was sent to members of the International Psoriasis Council to evaluate thoughts and behaviours related to dose-reducing biologic agents used in the treatment of psoriasis. The survey consisted of 27 questions, there were 57 respondents to the survey, and 53 respondents who prescribed biologics were included in the analysis. There were 4 Canadian respondents included.

Overall, 70% (n = 37) respondents did report dose-reducing biologic therapies, while 30% (n = 16) did not. Dose reduction was applied by the largest number dermatologists for adalimumab (n = 28/37), secukinumab (n = 24/37), ustekinumab (n = 19/37) and etanercept (n = 19/37). Smaller dose reductions were made in biologics with longer injection intervals compared to shorter injection intervals.  Cost savings, safety/side effects, and patient request were cited as the most common reasons to dose-reduce biologics. Those who did not dose-reduce biologics cited the lack of evidence of safety and efficacy supporting this strategy. The risk of disease flare, antibody formation, and loss of effectiveness were also cited as reasons to avoid dose reductions.

Read more: [Sosido Link] van Muijen ME, van der Schoot LS, van den Reek JMPA, de Jong EMGJ. Attitudes and behaviour regarding dose reduction of biologics for psoriasis: a survey among dermatologists worldwide [published online ahead of print, 2021 Aug 31]. Arch Dermatol Res. 2021;10.1007/s00403-021-02273-4. doi:10.1007/s00403-021-02273-4


Blind and ultrasound-guided corticosteroid injections for dactylitis

Carriero and collaborators provide a new review on dactylitis in PsA patients. Dactylitis occurs in 30-50% of PsA patients and is often a presenting manifestation of PsA. Despite its prevalence, dactylitis is typically only assessed as a secondary endpoint in PsA treatment trials, so the available evidence on ideal treatment is limited. The GO-DACT study did evaluate golimumab in combination with methotrexate with dactylitis as the primary endpoint and demonstrated significant improvement over methotrexate monotherapy.

Despite a lack of formal evidence, GRAPPA recommends non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections as first-line therapy, and EULAR recommends corticosteroid injections. The authors review the corticosteroid preparations that are appropriate for dactylitis and the use of anesthetics. They also describe, with photographs, both blind and ultrasound-guided injection of corticosteroids into the flexor tendon sheath of the affected digits.  

Read more: [Sosido Link] Carriero A, Lubrano E, Picerno V, Padula AA, D'Angelo S. Corticosteroid injection treatment for dactylitis in psoriatic arthritis. Ther Adv Musculoskelet Dis. 2021;13:1759720X211041864. Published 2021 Aug 28. doi:10.1177/1759720X211041864


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