THIRTY-FOURTH ISSUE
May 17, 2023
Is a combination of methotrexate and low-dose prednisone more effective in treating alopecia areata totalis or universalis?
JAMA Dermatology
Is a combination of methotrexate and low-dose prednisone more effective in treating alopecia areata totalis or universalis?
JAMA Dermatology
Better together? Methotrexate and low-dose prednisone are the new it couple of 2023!
Alopecia Areata Totalis (AT) and Universalis (AU), the most severe forms of alopecia areata, are notoriously difficult to treat. This multicenter, double-blind, randomized clinical trial was conducted to evaluate the efficacy and tolerance of methotrexate alone versus methotrexate in conjunction with low-dose prednisone to treat chronic and recalcitrant AT and AU.
What did they find?
Limitations: 30 patients dropped out of the study. Selection bias was introduced due to the fact that 58.7% of the trial participants were selected from Saint Louis Hospital, a tertiary care center that manages patients with severe AT and AU.
Main Takeaway: While methotrexate alone did not achieve complete or almost complete hair regrowth, methotrexate in conjunction with low-dose prednisone may be an effective and relatively inexpensive option for treatment of AT and AU, in contrast to more expensive therapies such as oral JAK inhibitors.
Alopecia Areata Totalis (AT) and Universalis (AU), the most severe forms of alopecia areata, are notoriously difficult to treat. This multicenter, double-blind, randomized clinical trial was conducted to evaluate the efficacy and tolerance of methotrexate alone versus methotrexate in conjunction with low-dose prednisone to treat chronic and recalcitrant AT and AU.
What did they find?
- Out of 89 participants, only one patient with chronic AT or AU achieved complete hair regrowth at 12 months (defined as as Severity of Alopecia Tool [SALT] score <10) with methotrexate alone
- 20% (95% CI, 8.4%-37.0%) of patients treated with 6 or 12 months of methotrexate plus prednisone experienced almost complete hair regrowth
- 31.2% (95% CI, 11.0%-58.7%) of patients treated with 12 months of methotrexate plus 6 months of prednisone experienced almost complete hair regrowth
- Improvements in quality of life were observed among patients who achieved complete hair regrowth
Limitations: 30 patients dropped out of the study. Selection bias was introduced due to the fact that 58.7% of the trial participants were selected from Saint Louis Hospital, a tertiary care center that manages patients with severe AT and AU.
Main Takeaway: While methotrexate alone did not achieve complete or almost complete hair regrowth, methotrexate in conjunction with low-dose prednisone may be an effective and relatively inexpensive option for treatment of AT and AU, in contrast to more expensive therapies such as oral JAK inhibitors.
Skin cytokine RNA in situ hybridization correlates with clinical response to dupilumab in patients with eczematous dermatitis
Journal of the American Academy of Dermatology
Unlock the secret of clear skin with dupilumab!
Dupilumab, a monoclonal antibody that inhibits IL-4 and IL-13, has revolutionized the treatment of atopic dermatitis. Although many patients treated with dupilumab achieve clear or almost-clear skin, some patients show suboptimal response; immunologic heterogeneity may be a contributing factor.
In this retrospective study, researchers aimed to determine whether cytokine staining or histologic features were correlated to clinical response to dupilumab. 61 biopsies from patients with eczematous dermatitis who were treated with dupilumab were analyzed using RNA in situ hybridization. Patients were categorized as complete responders, partial responders, or nonresponders.
What did they find?
Limitations: Retrospective study design and a small number of nonresponders (n=8) reduces the statistical power of the study.
Main Takeaway: Increased IL-13 expression may be correlated with optimal clinical response to dupilumab.
Dupilumab, a monoclonal antibody that inhibits IL-4 and IL-13, has revolutionized the treatment of atopic dermatitis. Although many patients treated with dupilumab achieve clear or almost-clear skin, some patients show suboptimal response; immunologic heterogeneity may be a contributing factor.
In this retrospective study, researchers aimed to determine whether cytokine staining or histologic features were correlated to clinical response to dupilumab. 61 biopsies from patients with eczematous dermatitis who were treated with dupilumab were analyzed using RNA in situ hybridization. Patients were categorized as complete responders, partial responders, or nonresponders.
What did they find?
- Complete responders had significantly higher IL-13 expression than partial responders (p=<0.001) or nonresponders (p=0.013)
- IL-4 expression was also correlated with better response to dupilumab; however, only the comparison between complete responders and nonresponders was statistically significant
- Interferon gamma levels were higher in nonresponders than partial (p=0.053) and complete responders (p=0.024)
- Nonresponders tended to have increased spongiosis and acanthosis on histological examination than complete or partial responders
Limitations: Retrospective study design and a small number of nonresponders (n=8) reduces the statistical power of the study.
Main Takeaway: Increased IL-13 expression may be correlated with optimal clinical response to dupilumab.
Adolescents with genetic skin disorders demonstrate lower healthcare transition readiness compared to peers with other chronic conditions
Pediatric Dermatology
They grow up so fast! But are they ready for adult healthcare?
Healthcare transition (HCT) occurs when adolescents shift from a pediatric to adult model of medical care, which generally occurs between ages 18 to 22. Adolescents with chronic illnesses have lower transition readiness compared to the general population.
Although HCT interventions exist for some chronic illnesses, there are currently no HCT programs for adolescents with genetic skin conditions. In this survey, researchers sought to identify predictive factors of lower transition readiness in 45 adolescents between the ages of 14 and 22 with chronic genetic skin conditions.
What did they find?
Main Takeaways: This study found that adolescents with genetic skin disorders demonstrate lower healthcare transition readiness compared to peers with other chronic illnesses, especially among younger patients and those with public or unknown insurance status.
Healthcare transition (HCT) occurs when adolescents shift from a pediatric to adult model of medical care, which generally occurs between ages 18 to 22. Adolescents with chronic illnesses have lower transition readiness compared to the general population.
Although HCT interventions exist for some chronic illnesses, there are currently no HCT programs for adolescents with genetic skin conditions. In this survey, researchers sought to identify predictive factors of lower transition readiness in 45 adolescents between the ages of 14 and 22 with chronic genetic skin conditions.
What did they find?
- 45 patients with disorders of cornification (i.e., ichthyosis, erythrokeratoderma) (n= 31), ectodermal dysplasias (n=7), epidermolysis bullosa (n=4), and tuberous sclerosis (n=3)
- Patients completed surveys on Quality of Life and HCT readiness via the Transition Readiness Assessment Questionnaire (TRAQ)
- The mean TRAQ score for patients with genetic skin conditions was significantly lower (3.3 ± 0.9) than healthy controls (3.9 ± 0.7; p<0.001) and peers with Type 1 diabetes (3.7 ± 0.7; p<0.01) or sickle cell disease (3.7 ± 1.0; p<0.05)
- Younger patients aged 14 to 17 years (2.9 ± 0.2; p<0.01) had lower TRAQ scores, compared to older patients aged 18 to 22 years (3.7 ± 0.2; p<0.01)
- Overall, patients with public insurance (3.1 ± 0.8; p<0.05) or unknown insurance status (2.9 ± 0.9; p<0.05) had lower TRAQ scores than patients with private insurance (3.5 ± 1.0; p<0.05)
Main Takeaways: This study found that adolescents with genetic skin disorders demonstrate lower healthcare transition readiness compared to peers with other chronic illnesses, especially among younger patients and those with public or unknown insurance status.
Firing up our metabolisms….for wound healing?
Wound healing is a complex yet organized process, involving coordination of inflammatory processes, cellular proliferation, and tissue remodeling. Although chronic wounds affect a significant proportion of our aging population, little is known about the role of metabolism in wound healing. To better understand this process, researchers combined a transcriptomics and metabolomics approach to examine human skin tissue samples.
What did they find?
Limitations: The metabolomics data were obtained from human skin biopsies extracted with methanol, which may have impacted the coverage of lipids visualized.
Main takeaways: Glycolysis and glutaminolysis may be potential therapeutic targets for wound healing.
Wound healing is a complex yet organized process, involving coordination of inflammatory processes, cellular proliferation, and tissue remodeling. Although chronic wounds affect a significant proportion of our aging population, little is known about the role of metabolism in wound healing. To better understand this process, researchers combined a transcriptomics and metabolomics approach to examine human skin tissue samples.
What did they find?
- Upregulation of glycolysis and carbohydrate metabolism, TCA cycle intermediates, glutamine metabolism, and fatty acid oxidation were observed during later stages of acute wound healing and in chronic wounds
- Enhancement or inhibition of glycolysis impacted wound healing much more than oxidative phosphorylation and fatty acid oxidation
- Similarly, but to a lesser extent, enhancement or inhibition of glutaminolysis affected wound healing more than oxidative phosphorylation or fatty acid oxidation
Limitations: The metabolomics data were obtained from human skin biopsies extracted with methanol, which may have impacted the coverage of lipids visualized.
Main takeaways: Glycolysis and glutaminolysis may be potential therapeutic targets for wound healing.
What are the capabilities and limitations of ChatGPT in the medical field?
Innovations in Dermatology
Chat GPT, MD?
ChatGPT has changed the way that we acquire information– quickly analyzing data, searching the internet, and formulating a digestible summary. With such power, it leads us to question, what is its future role in not only society, but in medicine? We decided to put ChatGPT to the test and use it to summarize the article “Benefits, Limits, and Risks of GPT-4 as an AI Chatbot for Medicine” for this section. The output did not disappoint:
“The article discusses the potential benefits, limitations, and risks of using the GPT-4 language model as an AI chatbot for medicine. AI chatbots could help address the issue of physician shortages and improve access to healthcare for patients. They suggest potential benefits such as providing personalized medical advice, triaging patients, and assisting with administrative tasks. However, the authors also caution that the technology is not yet advanced enough to replace human doctors and may struggle with providing accurate diagnoses or understanding complex medical situations. Additionally, there are concerns around data privacy and the potential for AI chatbots to perpetuate biases in healthcare.”
This summary was pretty spot on! See below for more of our analysis from the article:
What were the capabilities and limitations of ChatGPT-4?
Main takeaway: Chat GPT-4 is emerging as a tool in the medical field that may be useful in assisting physicians and informing patients. However, GPT-4 is not perfect and should be used with caution when making medical decisions.
ChatGPT has changed the way that we acquire information– quickly analyzing data, searching the internet, and formulating a digestible summary. With such power, it leads us to question, what is its future role in not only society, but in medicine? We decided to put ChatGPT to the test and use it to summarize the article “Benefits, Limits, and Risks of GPT-4 as an AI Chatbot for Medicine” for this section. The output did not disappoint:
“The article discusses the potential benefits, limitations, and risks of using the GPT-4 language model as an AI chatbot for medicine. AI chatbots could help address the issue of physician shortages and improve access to healthcare for patients. They suggest potential benefits such as providing personalized medical advice, triaging patients, and assisting with administrative tasks. However, the authors also caution that the technology is not yet advanced enough to replace human doctors and may struggle with providing accurate diagnoses or understanding complex medical situations. Additionally, there are concerns around data privacy and the potential for AI chatbots to perpetuate biases in healthcare.”
This summary was pretty spot on! See below for more of our analysis from the article:
What were the capabilities and limitations of ChatGPT-4?
- Answered questions to prompts not restricted to English language (e.g. mathematical equations)
- Listened to the patient/physician encounter and produced a note in many formats such as SOAP and included the appropriate billing
- Produced errors within the note, however when prompted to reread, GPT-4 was able to correct its own mistakes
- Generated appropriate laboratory and prescription orders
- Answered a series of USMLE questions with 90% accuracy
- Answered health questions with proper medical rationale, summarized research material, and provided technical analysis of research content
- Unable to read medical images
Main takeaway: Chat GPT-4 is emerging as a tool in the medical field that may be useful in assisting physicians and informing patients. However, GPT-4 is not perfect and should be used with caution when making medical decisions.