Thursday, February 15, 2018

Dupilumab Conjunctivitis

The patient is a 55 year-old woman who has been on dupilumab (Dupixent) for two months.  She had life-ling severe atopic dermatitis and states that her skin has never been this clear in her memory.  She has, however, developed a conjunctivitis of her lid and bulbar conjunctivae.  She is so happy that her skin is clear that she is not complaining, and her eyes are not uncomfortable.

There are no references to conjunctivitis on dupilumab, but the package insert indicates that 10% of patients have experienced this.  If you have any recommendations, I would appreciate hearing them.

Photos presented with patient permission


Reference:

Conjunctivitis Occurring in Atopic Dermatitis Patients Treated with Dupilumab - Clinical Characteristics and Treatment.
Wollenberg A, et. al. J Allergy Clin Immunol Pract. 2018 Feb 9. pii: S2213-2198(18)30089-8.

Here, we report our experience with this clinically relevant complication of dupilumab treated AD seen in 25% and 50% of patients from our two centers from April 2016 to February 2017, and give treatment recommendations based on our personal experience with 13 moderate-to-severe dupilumab-treated AD patients developing conjunctivitis as adverse event. This conjunctivitis is reported in temporal association with dupilumab treatment, but a causal relation is not establishedDescription: https://ssl.gstatic.com/ui/v1/icons/mail/images/cleardot.gif.

However, in our limited experience, antihistamine eye drops and artificial tears did not confer any alleviation in this type of conjunctivitis. In 11 patients, dupilumab-related conjunctivitis was treated with topical tacrolimus or steroids, leading to clinically significant improvement or full recovery in all 11 patients treated.

Two treatment options were particularly effective.
In 5 patients conjunctivitis was treated with fluorometholone 0.1% eye drops, leading to significant improvement.
In four patients, conjunctivitis was treated with tacrolimus 0.03% eye ointment. Signs and clinical symptoms improved significantly in all patients, and in 2 patients, full recovery of conjunctivitis was achieved.


Thursday, February 01, 2018

Mal Perforans Ulcer

The patient 74 year old divorcee who lives alone.  He is an insulin-dependent diabetic with peripheral neuropathy.  He has had a plantar ulcer for > 6 months that began after a callosity was pared down by a podiatrist.  He has been seen at a wound care clinic for six months where dressings are done.  He is afraid he may lose his foot.

O/E:  On the plantar aspect of the left foot, he has a clean. painless ulcer measuring about 1.4 cm in diameter.  There was a thick callosity the ulcer's periphery.  His pedal pulses are strong.


Clinical image:
Question:  How would you approach this ulcer?



Reference:
Lu SH, McLaren AM. Wound healing outcomes in a diabetic foot ulcer outpatient clinic at an acute care hospital: a retrospective study. J Wound Care. 2017 Oct 1;26(Sup10):S4-S11
Abstract
OBJECTIVE: Patients with diabetic foot ulcers (DFU) have an increased risk of lower extremity amputation. A retrospective chart review of patients with DFUs attending the Foot Treatment and Assessment chiropodist-led outpatient clinic at an inner-city academic hospital was conducted to determine wound healing outcomes and characteristics contributing to outcomes.
METHOD: We reviewed the complete clinical history of 279 patients with 332 DFUs spanning over a five-year period.
RESULTS: The mean age of patients was 61.5±12.5 years and most patients (83.5%) had one DFU. The majority of wounds (82.5%) were in the forefoot. Overall, 267/332 (80.5%) wounds healed. A greater proportion of wounds healed in the forefoot (82.5%) and midfoot (87.1%) than hindfoot (51.9%; p<0.001). Using a logistic regression model, palpable pedal pulse and use of a total contact cast were associated with better wound healing.
CONCLUSION: Our findings are the first to demonstrate the benefits of chiropodists leading an acute care outpatient clinic in the management of DFUs in Canada and delivers wound healing outcomes equivalent to or exceeding those previously published.