Publications by authors named "Daniel B Shin"

68 Publications

Risk of liver disease in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis receiving methotrexate: a population-based study.

J Am Acad Dermatol 2021 Feb 16. Epub 2021 Feb 16.

Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.

Background: Patients with psoriatic disease may be more susceptible to methotrexate hepatotoxicity than those with rheumatoid arthritis (RA) but direct evidence is lacking.

Objective: To compare liver disease risk among patients with psoriasis (PsO), psoriatic arthritis (PsA), and RA receiving methotrexate METHODS: In a population-based cohort study, Danish individuals with PsO, PsA, or RA receiving methotrexate during 1997-2015 were compared with respect to four outcomes: mild liver disease, moderate-to-severe liver disease, cirrhosis, and cirrhosis-related hospitalization.

Results: Among 5,687, 6,520, and 28,030 individuals with PsO, PsA, and RA, respectively, the incidence rate of any liver disease was greatest for PsO, followed by PsA, and lowest for RA. Compared to patients with RA, patients with PsO were 1.6-3.4 times more likely to develop one of the liver disease outcomes while those with PsA were 1.3-1.6 times more likely to develop mild liver disease and cirrhosis after adjustment for demographics, smoking, alcohol use, comorbidities, and methotrexate dose.

Limitations: Confounding by unmeasured variables, misclassification and surveillance bias CONCLUSION: PsO, PsA, and RA differentially influence liver disease risk in the setting of methotrexate use independent of other major risk factors. More conservative monitoring should be considered in patients receiving methotrexate for psoriatic disease, particularly PsO.
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http://dx.doi.org/10.1016/j.jaad.2021.02.019DOI Listing
February 2021

Frequency and influence of "not relevant" responses on the Dermatology Life Quality Index among adults with atopic dermatitis.

Qual Life Res 2021 Feb 4. Epub 2021 Feb 4.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.

Purpose: "Not relevant" responses (NRRs) on the Dermatology Life Quality Index (DLQI) are common among adults with psoriasis and may be associated with underestimation of disease burden. Little is known about "not relevant" responses among adults with atopic dermatitis. We aimed to examine the frequency of NRRs on the DLQI and to determine whether NRRs are associated with underestimation of disease burden among adults with atopic dermatitis.

Methods: Adults with atopic dermatitis were identified and evaluated via online survey. We evaluated the frequency of NRRs on the DLQI, stratified by sociodemographic characteristics. To examine the association between NRRs and other measures of disease burden, Patient-Oriented Eczema Measure (POEM), Patient-Oriented SCORAD (PO-SCORAD), and Short-Form (SF)-12 scores were compared between those who responded "not relevant" versus "not at all".

Results: Among 764 adults with atopic dermatitis, most had mild disease. The median (interquartile range [IQR]) POEM, PO-SCORAD, and DLQI scores were 5 (2-10), 24 (14-34), and 2 (1-6), respectively. Most (55.2%) also had at least one NRR, and 17.9% had 4 or more "not relevant" responses, with differences across several sociodemographic characteristics. There were no substantial differences in SF-12, POEM, and PO-SCORAD scores between those who responded "not relevant" versus "not at all".

Conclusion: NRRs on the DLQI are common among adults with atopic dermatitis and differ across sociodemographic characteristics, suggesting issues with content validity. There is not a clear association between NRRs and other measures of disease severity among adults with mostly mild atopic dermatitis.
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http://dx.doi.org/10.1007/s11136-021-02770-zDOI Listing
February 2021

Age-Appropriate Cancer Screening: A Cohort Study of Adults with Psoriasis Prescribed Biologics, Adults in the General Population, and Adults with Hypertension.

J Am Acad Dermatol 2020 Oct 23. Epub 2020 Oct 23.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA,. Electronic address:

Background: Psoriasis is associated with increased risk of developing and dying from cancer.

Objective: To evaluate whether psoriasis patients prescribed biologics receive the recommended screening for cervical, breast, and colon cancer.

Methods: We conducted a retrospective cohort study using the Optum® de-identified Electronic Health Record dataset. Incidence rates for cervical, breast and colon cancer screening were compared between psoriasis patients prescribed biologics and two matched comparator cohorts: (1) general patient population, and (2) patients being managed for hypertension. Multivariable Cox proportional-hazards regression was performed to assess for differences in the rates of cancer screening.

Results: Compared to those in the general population without psoriasis, psoriasis patients prescribed biologics had higher screening rates for cervical cancer (adjusted hazard ratio [aHR] 1.09; 95% CI 1.02-1.16) and colon cancer (aHR 1.10; 95% CI 1.02-1.18). Compared to those with hypertension, patients with psoriasis prescribed biologics had lower screening rates for breast cancer (aHR 0.88; 95% CI 0.83-0.94) and colon cancer (aHR 0.89; 95% CI 0.83-0.95).

Conclusions: and Relevance: Patients with psoriasis who are prescribed biologic therapies may not be receiving adequate age-appropriate cancer screening, especially for breast and colon cancer.
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http://dx.doi.org/10.1016/j.jaad.2020.10.045DOI Listing
October 2020

Utility of FDG-PET/CT in clinical psoriasis grading: the PET-PASI scoring system.

Am J Nucl Med Mol Imaging 2020 15;10(5):265-271. Epub 2020 Oct 15.

Department of Radiology, Hospital of The University of Pennsylvania Philadelphia, PA, USA.

Psoriatic skin lesions are metabolically active, which makes them candidates for imaging with 18-F fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). The aim of our study was to correlate FDG-PET findings with Psoriasis Area and Severity Index (PASI) scores, the most widely-used grading system for psoriasis. Thirty-three subjects and a total of 84 FDG-PET/CT scans from a prospective clinical trial [NCT01553058] with >2 months moderate-to-severe psoriasis were included. Subjects underwent whole-body FDG-PET/CT imaging 60 min after intravenous FDG administration, prior to the start of treatment. Scans were repeated 12 weeks and 52 weeks after baseline scans were conducted and after treatment or placebo administration was initiated. Each subject and scan was graded by our "PET-PASI" scoring system, a qualitative review of multi-plane reconstructions for both attenuation-corrected (AC) and non-attenuation-corrected (NAC) PET images. PASI and PET-PASI scores were correlated using Spearman's rho analysis. Our study demonstrated a significant positive correlation between each subject's corresponding PET-PASI and PASI scores before and during treatment or placebo administration (r=0.53, P<0.001). We also found positive correlations between PET-PASI and PASI scores across different regions of the body (head and neck: r=0.22, upper extremities: r=0.26, trunk: r=0.48, and lower extremities: r=0.58). In conclusion, AC and NAC FDG-PET/CT images may be utilized to evaluate lesions in subjects with moderate-to-severe psoriasis. Our methodology could have future implications in the diagnosis and therapeutic management of psoriasis.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675113PMC
October 2020

Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings.

JAMA Netw Open 2020 11 2;3(11):e2024583. Epub 2020 Nov 2.

Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Importance: The Press Ganey Outpatient Medical Practice Survey is used to measure the patient experience. An understanding of the patient- and physician-related determinants of the patient experience may help identify opportunities to improve health care delivery and physician ratings.

Objective: To evaluate the associations between the patient experience as measured by scores on the Press Ganey survey and patient-physician racial/ethnic and gender concordance.

Design, Setting, And Participants: A cross-sectional analysis of Press Ganey surveys returned for outpatient visits within the University of Pennsylvania Health System between 2014 and 2017 was performed. Participants included adult patient and physician dyads for whom surveys were returned. Data analysis was performed from January to June 2019.

Exposures: Patient-physician racial/ethnic and gender concordance.

Main Outcomes And Measures: The primary outcome was receipt of the maximum score for the "likelihood of your recommending this care provider to others" question in the Care Provider domain of the Press Ganey survey. Secondary outcomes included each of the remaining 9 questions in the Care Provider domain. Generalized estimating equations clustering on physicians with exchangeable intracluster correlations and cluster-robust standard errors were used to investigate associations between the outcomes and patient-physician racial/ethnic and gender concordance.

Results: In total, 117 589 surveys were evaluated, corresponding to 92 238 unique patients (mean [SD] age, 57.7 [15.6] years; 37 002 men [40.1%]; 75 307 White patients [81.6%]) and 747 unique physicians (mean [SD] age 45.5 [10.6] years; 472 men [63.2%]; 533 White physicians [71.4%]). Compared with racially/ethnically concordant patient-physician dyads, discordance was associated with a lower likelihood of physicians receiving the maximum score (adjusted odds ratio [OR], 0.88; 95% CI, 0.82-0.94; P < .001). Black (adjusted OR, 0.73; 95% CI, 0.68-0.78; P < .001) and Asian (adjusted OR, 0.55; 95% CI, 0.50-0.60; P < .001) patient race were both associated with lower patient experience ratings. Patient-physician gender concordance was not associated with Press Ganey scores (adjusted OR, 1.00; 95% CI, 0.96-1.04; P = .90).

Conclusions And Relevance: In this study, higher Press Ganey survey scores were associated with racial/ethnic concordance between patients and their physicians. Efforts to improve physician workforce diversity are imperative. Delivery of health care in a culturally mindful manner between racially/ethnically discordant patient-physician dyads is also essential. Furthermore, Press Ganey scores may differ by a physician's patient demographic mix; thus, care must be taken when publicly reporting or using Press Ganey scores to evaluate physicians on an individual level.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.24583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653497PMC
November 2020

Commentary.

J Am Acad Dermatol 2021 Mar 8;84(3):e161-e162. Epub 2020 Oct 8.

Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543884PMC
March 2021

Effect of anti-tumor necrosis factor therapy on the risk of respiratory tract infections and related symptoms in patients with psoriasis-A meta-estimate of pivotal phase 3 trials relevant to decision making during the COVID-19 pandemic.

J Am Acad Dermatol 2021 01 26;84(1):161-163. Epub 2020 Aug 26.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.08.095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7448776PMC
January 2021

In response to: "Reply to research letter".

J Am Acad Dermatol 2020 Dec 29;83(6):e445. Epub 2020 Jul 29.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.07.097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387358PMC
December 2020

The risk of respiratory tract infections in patients with psoriasis treated with interleukin 23 pathway-inhibiting biologics: A meta-estimate of pivotal trials relevant to decision making during the COVID-19 pandemic.

J Am Acad Dermatol 2020 11 2;83(5):1523-1526. Epub 2020 Jul 2.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.06.1014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331500PMC
November 2020

Reply to: "Do IL-17 inhibitors increase risk of respiratory tract infections?"

J Am Acad Dermatol 2020 Oct 2;83(4):e305-e306. Epub 2020 Jul 2.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.06.1001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329655PMC
October 2020

The risk of respiratory tract infections and symptoms in psoriasis patients treated with interleukin 17 pathway-inhibiting biologics: A meta-estimate of pivotal trials relevant to decision making during the COVID-19 pandemic.

J Am Acad Dermatol 2020 08 19;83(2):677-679. Epub 2020 May 19.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.05.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235584PMC
August 2020

Association between atopic dermatitis and learning disability in children.

J Allergy Clin Immunol Pract 2020 Sep 26;8(8):2808-2810. Epub 2020 Apr 26.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.

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http://dx.doi.org/10.1016/j.jaip.2020.04.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483744PMC
September 2020

Opioid prescribing in adults with and without psoriasis.

J Am Acad Dermatol 2020 Dec 1;83(6):1777-1779. Epub 2020 Apr 1.

Department of Dermatology, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.1016/j.jaad.2020.03.080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529723PMC
December 2020

Evaluation of the Frequency of "Not Relevant" Responses on the Dermatology Life Quality Index by Sociodemographic Characteristics of Patients With Psoriasis.

JAMA Dermatol 2020 04;156(4):446-450

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.

Importance: "Not relevant" responses (NRRs) on the Dermatology Life Quality Index (DLQI) are common among patients with psoriasis and may be associated with an underestimation of disease severity.

Objective: To evaluate the associations between (1) patient sociodemographic characteristics and the frequency of NRRs on the DLQI and (2) NRR frequency and treatment satisfaction.

Design, Setting, And Participants: This cross-sectional study using data from the Dermatology Clinical Effectiveness Research Network from February 2010 to June 2011 assessed the responses on the DLQI of 1733 patients with psoriasis.

Main Outcomes And Measures: Differences in the frequency of NRRs by sex, race/ethnicity, insurance type, income, educational attainment, marital status, and employment status were evaluated using the 2-tailed χ2 test. Multivariable logistic regression analysis was used to evaluate the associations between sociodemographic characteristics and having at least 1 NRR. Multivariable linear regression analysis was used to evaluate the association between having a DLQI score reclassified from 10 or less to more than 10 using the DLQI-Relevant scoring modification and the scores on the Treatment Satisfaction Questionnaire for Medication. Data were analyzed between July 2019 and November 2019.

Results: Of 1733 patients with psoriasis, 879 (50.7%) were female, and 1470 (84.8%) were non-Hispanic white individuals. The DLQI items 6 (sport, 223 patients [12.9%]), 9 (sexual difficulties, 214 patients [12.3%]), and 7 (work or study, 126 patients [7.3%]) had the greatest frequency of NRRs. In multivariable logistic regression analysis, male sex (odds ratio [OR], 0.63; 95% CI, 0.48-0.82) and income of more than $100 000 (OR, 0.45; 95% CI, 0.26-0.79) were associated with decreased odds of NRRs. By contrast, single (OR, 1.85; 95% CI, 1.31-2.61) or widowed or divorced (OR, 2.60; 95% CI, 1.80-3.74) marital status and unemployed or disabled employment status (OR, 1.98; 95% CI, 1.35-2.89) were associated with increased odds of NRRs. Having a DLQI score that would be reclassified from 10 or less to more than 10 using the DLQI-Relevant scoring modification was associated with lower global satisfaction scores on the Treatment Satisfaction Questionnaire for Medication (coefficient, -9.8; 95% CI, -16.3 to -3.4).

Conclusions And Relevance: There were sociodemographic differences in the frequency of NRRs on the DLQI among this cohort of patients with psoriasis. These differences may be associated with an underestimation of disease burden and treatment disparities owing to subsequent undertreatment among certain sociodemographic groups. Further study is needed to optimize the quality-of-life assessment among patients with psoriasis or other inflammatory skin diseases in diverse settings.
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http://dx.doi.org/10.1001/jamadermatol.2019.4659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7142381PMC
April 2020

A Randomized Placebo-Controlled Trial of Secukinumab on Aortic Vascular Inflammation in Moderate-to-Severe Plaque Psoriasis (VIP-S).

J Invest Dermatol 2020 Sep 21;140(9):1784-1793.e2. Epub 2020 Feb 21.

National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.

Psoriasis, a chronic immune-mediated disease, is associated with an increased risk of cardiovascular events and mortality. Secukinumab selectively neutralizes IL-17A and has reported high efficacy with a favorable safety profile in various psoriatic disease manifestations. Subsequent to the 12-week randomized, placebo-controlled, double-blind treatment period, patients with moderate-to-severe psoriasis received secukinumab for 40 weeks. Vascular inflammation using F-2-fluorodeoxyglucose-positron emission tomography/computed tomography imaging and blood-based cardiometabolic was assessed at week 0, 12, and 52. The difference in change in aortic inflammation from baseline to week 12 for secukinumab (n = 46) versus placebo (n = 45) was -0.053 (95% confidence interval = -0.169 to 0.064; P= 0.37). Small increases in total cholesterol, low-density lipoprotein, and low-density lipoprotein particles, but no changes in markers of inflammation, adiposity, insulin resistance, or predictors of diabetes, were observed with secukinumab treatment compared with placebo. At week 52, reductions in TNF-α (P= 0.0063) and ferritin (P= 0.0354), and an increase in fetuin-A (P= 0.0024), were observed with secukinumab treatment compared with baseline. No significant changes in aortic inflammation or markers of advanced lipoprotein characterization, adiposity, or insulin resistance were observed with secukinumab treatment compared with baseline. Secukinumab exhibited a neutral impact on aortic vascular inflammation and biomarkers of cardiometabolic disease after 52 weeks of treatment.
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http://dx.doi.org/10.1016/j.jid.2020.01.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434644PMC
September 2020

Association of Race/Ethnicity and Sex With Differences in Health Care Use and Treatment for Acne.

JAMA Dermatol 2020 03;156(3):312-319

Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Importance: Our understanding of potential racial/ethnic, sex, and other differences in health care use and treatment for acne is limited.

Objective: To identify potential disparities in acne care by evaluating factors associated with health care use and specific treatments for acne.

Design, Setting, And Participants: This retrospective cohort study used the Optum deidentified electronic health record data set to identify patients treated for acne from January 1, 2007, to June 30, 2017. Patients had at least 1 International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code for acne and at least 1 year of continuous enrollment after the first diagnosis of acne. Data analysis was performed from September 1, 2019, to November 20, 2019.

Main Outcomes And Measures: Multivariable regression was used to quantify associations between basic patient demographic and socioeconomic characteristics and the outcomes of health care use and treatment for acne during 1 year of follow-up.

Results: A total of 29 928 patients (median [interquartile range] age, 20.2 [15.4-34.9] years; 19 127 [63.9%] female; 20 310 [67.9%] white) met the inclusion criteria for the study. Compared with non-Hispanic white patients, non-Hispanic black patients were more likely to be seen by a dermatologist (odds ratio [OR], 1.20; 95% CI, 1.09-1.31) but received fewer prescriptions for acne medications (incidence rate ratio, 0.89; 95% CI, 0.84-0.95). Of the acne treatment options, non-Hispanic black patients were more likely to receive prescriptions for topical retinoids (OR, 1.25; 95% CI, 1.14-1.38) and topical antibiotics (OR, 1.35; 95% CI, 1.21-1.52) and less likely to receive prescriptions for oral antibiotics (OR, 0.80; 95% CI, 0.72-0.87), spironolactone (OR, 0.68; 95% CI, 0.49-0.94), and isotretinoin (OR, 0.39; 95% CI, 0.23-0.65) than non-Hispanic white patients. Male patients were more likely to be prescribed isotretinoin than female patients (OR, 2.44; 95% CI, 2.01-2.95). Compared with patients with commercial insurance, those with Medicaid were less likely to see a dermatologist (OR, 0.46; 95% CI, 0.41-0.52) or to be prescribed topical retinoids (OR, 0.82; 95% CI, 0.73-0.92), oral antibiotics (OR, 0.87; 95% CI, 0.79-0.97), spironolactone (OR, 0.50; 95% CI, 0.31-0.80), and isotretinoin (OR, 0.43; 95% CI, 0.25-0.75).

Conclusions And Relevance: The findings identify racial/ethnic, sex, and insurance-based differences in health care use and prescribing patterns for acne that are independent of other sociodemographic factors and suggest potential disparities in acne care. In particular, the study found underuse of systemic therapies among racial/ethnic minorities and isotretinoin among female patients with acne. Further study is needed to confirm and understand the reasons for these differences.
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http://dx.doi.org/10.1001/jamadermatol.2019.4818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042795PMC
March 2020

Mental health impairment among children with atopic dermatitis: A United States population-based cross-sectional study of the 2013-2017 National Health Interview Survey.

J Am Acad Dermatol 2020 Jun 15;82(6):1368-1375. Epub 2019 Oct 15.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Background: Atopic dermatitis (AD) is associated with mental health disorders, but its impact on global mental health symptoms is less clear.

Objective: To determine the association between pediatric AD and mental health impairment.

Methods: In a cross-sectional study using 2013-2017 United States National Health Interview Survey data, children with and without AD were assessed for mental disorder with impairment (MDI) using a validated behavioral screening questionnaire. Mental health services utilization was also reported.

Results: The prevalence of any MDI was 26.7% (95% confidence interval [CI], 25.1-28.3) among children with AD and 17.7% (95% CI, 17.2-18.2) among those without AD, with severe MDI being present in 10.9% (95% CI 9.9-12.1) and 6.2% (95% CI 5.9-6.5), respectively. Adjusted for sociodemographic factors, AD was associated with higher odds of MDI (odds ratio, 1.52; 95% CI, 1.39-1.67), including impairments in conduct, emotions, peer relationships, and attention. Among children with AD, 19.9% (95% CI, 16.6-23.8) and 53.5% (95% CI, 48.5-58.5) of those with mild or severe MDI, respectively, had seen a mental health professional in the last year.

Limitations: Misclassification bias may arise from self-reported data.

Conclusion: AD is associated with clinically significant mental health symptoms, but many affected children may not seek or receive care for their symptoms.
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http://dx.doi.org/10.1016/j.jaad.2019.10.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156313PMC
June 2020

Prescribing Patterns Associated With Biologic Therapies for Psoriasis from a United States Medical Records Database

J Drugs Dermatol 2019 Aug;18(8):745-750

INTRODUCTION: Selecting a systemic therapy for patients with psoriasis is a complex process, based on a variety of factors including psoriasis severity, comorbid health conditions, access to care, and both patient and provider preference. The objective of this study was to use data from electronic health records to understand prescribing patterns associated with biologic therapies for psoriasis and utilization of concomitant non-biologic psoriasis therapies in patients on biologics. METHODS: A retrospective cohort study was performed using OptumInSight’s electronic health records database. Patients were classified as having psoriasis if they had 2 diagnosis codes for psoriasis or 1 diagnosis for psoriasis and a subsequent prescription for a systemic psoriasis therapy or phototherapy on a separate day. Only patients with at least 1 prescription for a biologic medication were included. The time between the first and last prescription in each prescription episode was calculated; at least 1 prescription every 180 days was required to be considered continuous therapy. We also identified a subgroup of patients with prescription episodes of at least 12 months duration in which to evaluate concomitant use of topical medications, phototherapy, and other systemic agents in patients receiving prescriptions for biologics. RESULTS: There were 34,714 eligible psoriasis patients. The median time between first and last prescriptions was 3.3 - 7.0 months, depending on the drug and up to 50% of patients that received a prescription for a biologic medication did not receive a second prescription for the same medication. In a subset of patients with prescription episodes of at least 12 months duration, more than 50% continued to receive prescriptions for topical therapies, most commonly topical steroids. DISCUSSION: Recognition of prescribing patterns associated with biologic medications for psoriasis is important to understand healthcare utilization and improve health systems practices for patients and providers.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6764093PMC
August 2019

A Phase IV, Randomized, Double-Blind, Placebo-Controlled Crossover Study of the Effects of Ustekinumab on Vascular Inflammation in Psoriasis (the VIP-U Trial).

J Invest Dermatol 2020 01 19;140(1):85-93.e2. Epub 2019 Jul 19.

Section of Inflammation and Cardiometabolic Diseases, National Heart Lung Blood Institute, Bethesda, Maryland, USA.

Psoriasis is a T helper type 17 autoimmune disease associated with an increased risk cardiovascular events and mortality. Ustekinumab, an antibody to p40, blocks cytokines IL-12 and IL-23, and is a highly effective and safe treatment for psoriasis. We conducted a randomized double-blinded placebo-controlled trial to determine the effect of ustekinumab on aortic vascular inflammation (AVI) measured by imaging, and key biomarkers of inflammation, lipid, and glucose metabolism in the blood of patients with moderate-to-severe psoriasis. A total of 43 patients were randomized, and at week 12, ustekinumab-treated patients had a -18.65% (95% confidence interval = -29.45% to -7.85%) reduction in AVI, a reduction in inflammatory biomarkers, and an increase in apolipoprotein B lipoproteins compared with placebo. At week 12, placebo patients were crossed over such that all patients received ustekinumab for 52 weeks. At the end of 52 weeks of ustekinumab treatment, there was no change in AVI compared with baseline, inflammatory markers were reduced, and there were increases in selected measures of lipids and leptin. These results show that blockade of IL-12 and/or IL-23 may transiently reduce AVI, with more durable reduction in inflammatory cytokines associated with cardiovascular disease.
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http://dx.doi.org/10.1016/j.jid.2019.07.679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926160PMC
January 2020

The clinical utility of laboratory monitoring during isotretinoin therapy for acne and changes to monitoring practices over time.

J Am Acad Dermatol 2020 Jan 19;82(1):72-79. Epub 2019 Jun 19.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Background: As a result of concerns about hypertriglyceridemia, liver enzyme abnormalities, and leukopenia during isotretinoin therapy for acne, patients are often monitored closely with routine laboratory assessments, although the value of this practice has been questioned.

Methods: We conducted a cohort study of patients receiving isotretinoin for acne between January 1, 2008, and June 30, 2017, using the OptumInsights Electronic Health Record Database (Optum, Eden Prairie, MN) to evaluate the frequency of laboratory abnormalities. Poisson regression was used to evaluate for changes to the frequency of routine laboratory monitoring over time.

Results: Among 1863 patients treated with isotretinoin, grade 3 or greater triglyceride and liver function testing abnormalities were noted in fewer than 1% and 0.5% of patients screened, respectively. No grade 3 or greater cholesterol or complete blood count abnormalities were observed. There were no meaningful changes in the frequency of laboratory monitoring over time.

Limitations: Limitations include that we are unable to evaluate the clinical notes to understand the exact clinical decision making when clinicians encountered abnormal laboratory values.

Conclusion: Although laboratory abnormalities are rare and often do not influence management, frequent laboratory monitoring remains a common practice. There are opportunities to improve the quality of care among patients being treated with isotretinoin for acne by reducing the frequency of lipid and liver function monitoring and by eliminating complete blood count monitoring.
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http://dx.doi.org/10.1016/j.jaad.2019.06.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911828PMC
January 2020

Patient-reported outcomes of adalimumab, phototherapy, and placebo in the Vascular Inflammation in Psoriasis Trial: A randomized controlled study.

J Am Acad Dermatol 2019 Oct 1;81(4):923-930. Epub 2019 Jun 1.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Electronic address:

Background: There are limited data about the impact of narrowband ultraviolet B phototherapy on patient-reported measures of health-related quality of life.

Objective: To evaluate the impact of adalimumab and phototherapy on health-related quality of life.

Methods: We examined patient-reported outcomes from a multicenter, randomized, placebo-controlled trial (ClinicalTrials.gov no. NCT01553058). The Dermatology Life Quality Index and EQ-5D-3L were evaluated every 4 weeks.

Results: We enrolled 97 patients: 30.9% were female, mean age was 43.5 years (standard deviation, 14.0), and median Psoriasis Area and Severity Index score was 16.7 (interquartile range, 13.9-21.6). At week 12, patients being treated with adalimumab (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.02-8.17) and phototherapy (OR, 8.83; 95% CI, 2.47-31.57) were more likely to achieve the minimal clinically important difference in the Dermatology Life Quality Index compared with those receiving placebo. There were higher odds of achieving the minimal clinically important difference for the EQ-5D-3L Index score when comparing phototherapy versus placebo (OR, 9.78; 95% CI, 2.99-31.95) and phototherapy versus adalimumab (OR, 4.07; 95% CI, 1.42-11.70).

Limitations: Small sample size, secondary analysis, generalizability.

Conclusion: Phototherapy and adalimumab both improve skin-related quality of life and overall health-related quality of life compared with placebo in patients with psoriasis; however, patients treated with phototherapy achieved more improvement in overall health-related quality of life compared with patients treated with adalimumab.
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http://dx.doi.org/10.1016/j.jaad.2019.05.080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746579PMC
October 2019

Prevalence of clinically significant incidental findings by whole-body fludeoxyglucose F 18 positron emission tomography/computed tomography scanning in moderate-to-severe psoriasis patients participating in clinical trials.

J Am Acad Dermatol 2019 Jun 14;80(6):1630-1639. Epub 2019 Jan 14.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Electronic address:

Background: There has been an increase in the number of psoriasis treatments being investigated in clinical trials. Patients may have undiagnosed issues at the start of a study which may become identified during follow-up as incident medicinal conditions. The prevalence of incidental findings in patients with moderate-to-severe psoriasis presenting for clinical trials is unknown.

Objective: Determine the prevalence of incidentalomas and rate of malignancy identified by fludeoxyglucose F 18 (FDG) positron emission tomography/computed tomography (PET/CT) imaging in clinical trial patients with moderate-to-severe psoriasis.

Methods: A cross-sectional secondary analysis of patients with moderate-to-severe psoriasis who underwent FDG PET/CT scans at the baseline visit, before randomization, for 3 phase 4 clinical trials on vascular inflammation in psoriasis. Only patients without active infection, malignancy, or uncontrolled comorbidities were eligible for the clinical trials.

Results: A total of 259 healthy patients with moderate-to-severe psoriasis underwent an FDG PET/CT scan as part of the study procedures. In all, 31 patients (11.97%) (95% confidence interval [CI], 8.28-16.56) had clinically significant incidentalomas on the baseline FDG PET/CT scan. Univariate logistic regression demonstrated that with every increase of 10 years of age, there was an approximate 30% increased risk of discovery of an incidentaloma (odds ratio, 1.30; 95% CI, 1.01-1.68). Of those patients with findings suggestive of malignancy (n = 28), 6 were confirmed to have cancer, resulting in a 2.31% (95% CI, 0.9-5.0) prevalence of malignancy. The positive predictive value of a true cancer was 31.58% (range, 21%-54%).

Limitations: Generalizability and lost to follow-up.

Conclusion: Incidentalomas on FDG PET/CT imaging are common in otherwise healthy, asymptomatic patients with moderate-to-severe psoriasis in clinical trials. Our results can help inform interpretation of clinical trial safety data and emphasize the importance of compliance with cancer screening recommendations.
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http://dx.doi.org/10.1016/j.jaad.2019.01.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536299PMC
June 2019

Influenza Vaccination Rates in Adults with Psoriasis Compared to Adults with Other Chronic Diseases.

J Invest Dermatol 2019 02 10;139(2):473-475. Epub 2018 Oct 10.

Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

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http://dx.doi.org/10.1016/j.jid.2018.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6755675PMC
February 2019

Effect of 2 Psoriasis Treatments on Vascular Inflammation and Novel Inflammatory Cardiovascular Biomarkers: A Randomized Placebo-Controlled Trial.

Circ Cardiovasc Imaging 2018 06;11(6):e007394

Department of Dermatology, Perelman School of Medicine (D.B.S., Z.C.F., J.T., S.B.V., J.M.G.)

Background: Psoriasis is a chronic inflammatory disease associated with dyslipidemia, cardiovascular events, and mortality. We aimed to assess and compare the effect of treatment of moderate-to-severe psoriasis with adalimumab or phototherapy on vascular inflammation and cardiovascular biomarkers.

Methods And Results: Randomized, double-blind, trial of adalimumab, phototherapy, and placebo (1:1:1) for 12 weeks, with crossover to adalimumab for 52 weeks total. Outcomes included vascular inflammation by F-fluorodeoxyglucose positron emission tomography/computed tomography and biomarkers of inflammation, insulin resistance, and lipoproteins. Ninety-seven patients were randomized, 92 completed the randomized controlled trial portion; 81 entered the adalimumab extension with 61 completing 52 weeks of adalimumab. There was no difference in change in vascular inflammation at week 12 in the adalimumab group (change compared with placebo, 0.64%; 95% confidence interval, -5.84% to 7.12%) or the phototherapy group (-1.60%; 95% confidence interval, -6.78% to 3.59%) or after 52-week adalimumab treatment (0.02% compared with initiation; 95% confidence interval, -2.85% to 2.90%). Both adalimumab and phototherapy decreased inflammation by serum CRP, interleukin-6. Only adalimumab reduced tumor necrosis factor and glycoprotein acetylation at 12 and 52 weeks. Neither had an impact on metabolic markers (insulin, adiponectin, and leptin). Only phototherapy increased high-density lipoprotein-p at 12 weeks. At 52-week of adalimumab cholesterol efflux and high-density lipoprotein-p were reduced.

Conclusions: Adalimumab reduced key markers of inflammation including glycoprotein acetylation compared with phototherapy with no effect on glucose metabolism and vascular inflammation, and potential adverse effects on high-density lipoprotein. Glycoprotein acetylation improvement may partially explain the beneficial effects of adalimumab seen in observational studies. Larger studies with more detailed phenotyping of vascular disease should assess the comparative differences in the effects of adalimumab and phototherapy seen in our study.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01866592 and NCT01553058.
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http://dx.doi.org/10.1161/CIRCIMAGING.117.007394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991103PMC
June 2018

Risk of Serious Infection, Opportunistic Infection, and Herpes Zoster among Patients with Psoriasis in the United Kingdom.

J Invest Dermatol 2018 08 2;138(8):1726-1735. Epub 2018 Mar 2.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Department of Epidemiology Biostatistics and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.

The risk of infection among patients with psoriasis of varying severity in a broadly representative population remains poorly understood. Using The Health Improvement Network (THIN), an electronic medical records database representative of the general UK population, we performed a cohort study to determine the risks of serious infection, opportunistic infection, and herpes zoster among patients with versus without psoriasis and according to psoriasis severity. We identified 187,258 patients with mild and 12,442 patients with moderate to severe psoriasis based on treatment patterns. Using Cox proportional hazards regression, the adjusted hazard ratios (95% confidence intervals) for serious infection were 1.18 (1.16-1.21) and 1.63 (1.52-1.75) for the mild and moderate to severe psoriasis groups, respectively. Among a nested cohort of 8,569 psoriasis patients with disease severity classified by body surface area involvement, similar results were obtained with the exception of an attenuated but significantly increased risk of serious infection among the moderate to severe psoriasis group (1.27 [1.10-1.47]). Overall, the risks of opportunistic infection and herpes zoster were significantly increased only among the moderate to severe psoriasis group and were associated with immunosuppressive therapy. Our analyses suggest that psoriasis is associated with an increased risk of serious infection, and psoriasis severity is a predictor of serious infection risk.
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http://dx.doi.org/10.1016/j.jid.2018.01.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083876PMC
August 2018

Health care utilization for psoriasis in the United States differs by race: An analysis of the 2001-2013 Medical Expenditure Panel Surveys.

J Am Acad Dermatol 2018 01;78(1):200-203

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2017.07.052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6035870PMC
January 2018

Psoriasis and the risk of diabetes: A prospective population-based cohort study.

J Am Acad Dermatol 2018 02 8;78(2):315-322.e1. Epub 2017 Nov 8.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Electronic address:

Background: Data evaluating the impact of objectively measured psoriasis severity on type 2 diabetes mellitus (T2DM) risk are lacking.

Objective: To determine the risk for T2DM in patients with psoriasis compared with that in adults without psoriasis, stratified by categories of directly assessed body surface area (BSA) affected by psoriasis.

Methods: A prospective, population-based, cohort study from the United Kingdom in which 8124 adults with psoriasis and 76,599 adults without psoriasis were followed prospectively for approximately 4 years.

Results: There were 280 incident cases of diabetes in the psoriasis group (3.44%) and 1867 incident cases of diabetes in those without psoriasis (2.44%). After adjustment for age, sex and body mass index, the hazard ratios for development of incident diabetes were 1.21 (95% confidence interval [CI], 1.01-1.44), 1.01 (95% CI, 0.81-1.26), and 1.64 (95% CI, 1.23-2.18) in the groups with 2% or less of their BSA affected, 3% to 10% of their BSA affected, and 10% or more of their BSA affected compared with in the groups without psoriasis, respectively (P = .004 for trend). Worldwide, we estimate an additional 125,650 new diagnoses of T2DM per year in patients with psoriasis as compared with in those without psoriasis.

Limitations: Relatively short-term follow-up and exclusion of prevalence cases, which may have masked associations in patients with less extensive psoriasis.

Conclusion: Clinicians may measure BSA affected by psoriasis to target diabetes prevention efforts for patients with psoriasis.
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http://dx.doi.org/10.1016/j.jaad.2017.10.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768452PMC
February 2018

Risk of Incident Liver Disease in Patients with Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis: A Population-Based Study.

J Invest Dermatol 2018 04 2;138(4):760-767. Epub 2017 Nov 2.

Department of Dermatology, Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Relatively little is known about the risk for incident liver disease in psoriasis (PsO), psoriatic arthritis (PsA), and rheumatoid arthritis (RA). We performed a cohort study among patients with PsO, PsA, or RA and matched controls in The Health Improvement Network from 1994 to 2014. Outcomes of interest were any liver disease, nonalcoholic fatty liver disease, and cirrhosis (any etiology). Among patients with PsO (N = 197,130), PsA (N = 12,308), RA (N = 54,251), and matched controls (N = 1,279,754), the adjusted hazard ratios for any liver disease were elevated among patients with PsO (without systemic therapy [ST] 1.37; with ST 1.97), PsA (without ST 1.38; with ST 1.67), and RA without an ST (1.49) but not elevated in patients with RA prescribed an ST (0.96). Incident nonalcoholic fatty liver disease was highest in patients with PsO prescribed an ST (2.23) and PsA with an ST (2.11). The risk of cirrhosis was highest among patients with PsO with an ST (2.62) and PsA without an ST (3.15). Additionally, the prevalence of liver disease and cirrhosis increased in a stepwise fashion with increasing body surface area affected by PsO (P for trend <0.001). More so than RA, PsO and PsA are associated with liver disease, particularly nonalcoholic fatty liver disease and cirrhosis, and this was true even among patients without ST exposure.
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http://dx.doi.org/10.1016/j.jid.2017.10.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6287638PMC
April 2018

Racial and ethnic differences in health care utilization for childhood eczema: An analysis of the 2001-2013 Medical Expenditure Panel Surveys.

J Am Acad Dermatol 2017 Dec 28;77(6):1060-1067. Epub 2017 Sep 28.

Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvannia; Department of Biostatistics Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvannia. Electronic address:

Background: Eczema is a common chronic inflammatory disease of the skin. Studies suggest differences in disease prevalence and severity by race/ethnicity. Our knowledge of health care utilization for eczema among different racial/ethnic groups remains limited.

Objective: To evaluate health care utilization for childhood eczema among different racial/ethnic groups in the United States.

Methods: We performed a cohort study of non-Hispanic white (reference), non-Hispanic black, and Hispanic white individuals under the age of 18 years with caregiver-reported eczema (N = 2043) pooled from the 2-year longitudinal cohorts of the 2001-2013 Medical Expenditure Panel Surveys. Health care utilization outcomes were evaluated over the 2-year follow-up period by race/ethnicity using multivariable regression.

Results: Among all children with eczema, non-Hispanic blacks were less likely than whites to report an ambulatory visit for eczema (adjusted odds ratio [OR] 0.69; 95% confidence interval [CI] 0.51-0.92). Among those with ≥1 ambulatory visit for eczema, non-Hispanic blacks reported more visits (adjusted incidence rate ratio [IRR] 1.68; 95% CI 1.10-2.55) and prescriptions (IRR 1.22; 95% CI 1.01-1.46) than whites and were more likely than whites to report a dermatology visit (OR 1.82; 95% CI 1.06-3.14) for eczema.

Limitations: We used caregiver- or self-reported data.

Conclusion: Our findings suggest disparities in health care utilization for eczema among non-Hispanic black children despite utilization patterns suggestive of more severe disease.
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http://dx.doi.org/10.1016/j.jaad.2017.08.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916760PMC
December 2017

Objective Measures of Psoriasis Severity Predict Mortality: A Prospective Population-Based Cohort Study.

J Invest Dermatol 2018 01 23;138(1):228-230. Epub 2017 Aug 23.

Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

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http://dx.doi.org/10.1016/j.jid.2017.07.841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748628PMC
January 2018