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Background Methotrexate is an immunomodulatory therapy that may offer benefit to patients with hidradenitis suppurativa (HS). Despite its theoretical advantages, there is a paucity of available data regarding long-term methotrexate use in patients with HS. Objective This study aimed to assess whether methotrexate treatment leads to improvement in HS disease severity. Methods We conducted an institutional review board–approved, single-center, retrospective chart review of patients with HS who were treated with methotrexate between 2000 and 2018. Primary outcome measurements included the HS Physician's Global Assessment (HS PGA), Hurley staging, abscess count, fistula count, and inflammatory nodule count. Results A total of 29 patients were identified; 14 were excluded for reasons including never starting methotrexate and missing follow-up data. For remaining patients (n = 15), the average cumulative dose of methotrexate was 520.1 mg (range, 30–1665 mg) and the average length of treatment was 11.7 months (range, 1–38 months). Patients taking methotrexate as a primary therapy had a higher cumulative dose and length of treatment (520.13 mg; 14.6 months) compared with those taking biologics concomitantly (468.44 mg; 9.1 months). Patients using methotrexate as primary therapy demonstrated nonsignificant reductions in HS PGA, inflammatory nodule count, and abscess count. Patients on concomitant biologic therapy failed to demonstrate any change in HS PGA, inflammatory nodule count, and abscess count. Limitations Limitations of the study include its retrospective nature, small sample size, length of time on methotrexate between groups, and homogeneity of the patient population. Conclusion Methotrexate may represent an effective treatment option in older patients with lower body mass indices but fails to offer benefit in patients taking concurrent biologic therapy.

Aging skin is a consequence of both intrinsic factors, including genetics, and extrinsic factors, including environmental exposures such as ultraviolet (UV) radiation and smoking. This contribution focuses on intrinsic factors that promote aging skin. Specifically, in this contribution we review the literature describing how single nucleotide polymorphisms, epigenetic changes, variable gene expression, microRNA, and mitochondrial depletion relate to skin aging. Investigations studying intrinsic factors associated with skin aging are important as they promote a better understanding of the underlying pathophysiology of aging skin. This contribution also describes potential avenues for future genetic research in skin aging. Molecular mechanisms that may be therapeutically intervened upon are of particular interest given the cultural value placed on youthful appearing skin. Future research efforts will hopefully reveal a means upon which to intercede on the skin aging process.

Cutaneous T-cell lymphoma (CTCL) represents a diagnostic challenge because of its large symptomatic overlap with other common skin conditions such as atopic dermatitis (AD) and psoriasis. Dupilumab has offered promising results in AD treatment; however, concerns exist that its use may exacerbate undiagnosed CTCL. We present a patient with CTCL and concomitant AD who experienced improvement in both CTCL blood involvement and AD following the addition of dupilumab therapy.

Many women report improvement in psoriasis during pregnancy; others report that psoriasis becomes worse during pregnancy. Balancing effective management of psoriasis against potential risk in pregnancy is important, especially because the severity of psoriasis can have an impact on the pregnancy experience and possibly the outcome. This article discusses current understanding of pregnancy risk profiles of medications used to treat psoriasis.

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Little HS-specific data exist to guide pharmacologic analgesia, however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This manuscript incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacological, and complementary and alternative treatment modalities.

Background In 2003 and again in 2011, the Accreditation Council for Graduate Medical Education (ACGME) mandated increasingly stringent resident duty hour restrictions. With less time required at the hospital, residents theoretically have more time for other academic activities, such as research. Our study seeks to examine whether the number of research publications by orthopaedic residents increased following implementation of the 2011 ACGME duty hour restrictions. Design Pubmed was queried using publicly available alumni lists from programs across the United States. The years 2008 to 2011 were included to assess pre-2011 productivity. The years 2012 to 2015 were included in the post 2011 group. Paired t tests were used to assess differences between groups. Statistical significance was set to p Setting A total of 10 orthopedic surgery residency programs across the United States. Participants The study group was composed of 5 of the 2015 top 20 National Institutes of Health (NIH) funded programs and 5 programs without NIH funding. Results When corrected for number of residents per year, there were 0.290 publications per resident/year from 2008 to 2011 increasing to 0.528 publications per resident/year from 2012 to 2015 following implementation of the 2011 work hour restrictions (p = 0.033). When corrected for number of residents per year, there remained no difference in publications per resident from 2008 to 2011 (p = 0.81) or from 2012 to 2015 (p = 0.10) between NIH and non-NIH funded programs. Conclusion There has been little data to support the theory that resident work hour restrictions have improved education or patient care in any meaningful way. In our study, there was a statistically significant increase in publications after 2011; however, the number of publications between NIH funded and non-NIH funded programs did not differ. Our study is the first to demonstrate that with increasing duty hour restrictions, orthopaedic surgery residents may be using more of their free time to conduct research.

Leukemia cutis (LC) and eosinophilic dermatosis of hematologic malignancy (EDHM) are rare cutaneous manifestations of hematologic malignancies. Various therapeutic options have been reported, with largely underwhelming responses. We present a patient with chronic lymphocytic leukemia (CLL) with concomitant LC and EDHM who was treated with dupilumab.

Patients with hidradenitis suppurativa (HS) often experience disease flares, which can culminate in a visit to the emergency department (ED) and inpatient admission. Appropriate management of HS patients in the acute setting is integral to controlling disease activity, limiting further sequelae, and preventing readmission. The pathophysiology of HS is poorly understood but likely involves a host of hormonal, microbial, and immunological factors. Laboratory abnormalities, including leukocytosis, thrombophilia, an elevated erythrocyte sedimentation rate, as well as an elevated C-reactive protein level, are common in HS patients and generally represent a chronic inflammatory state rather than overt infection. The Hurley staging system is an appropriate way to triage patient severity and guide treatment, as reviewed in this article. In all cases, expedited outpatient follow-up with dermatology and primary care is imperative to limiting disease morbidity.

BACKGROUND Increased interest in hidradenitis suppurativa (HS) research is encouraging. A critical analysis of the state of HS literature may demonstrate the strength of existing knowledge and highlight current gaps. OBJECTIVES To analyse changes in HS literature from 2008 to 2018 with focus on quantity and quality of annual publications. METHODS Review of all indexed publications reporting on HS on PubMed. Publications were categorized based on study design, study topic and treatment type where applicable. Publications were dichotomized into high level of evidence and low level of evidence groups. Linear regression analyses were performed to investigate the change in publication number over time. Annual average growth rate and distribution of high versus low level of evidence publications were calculated. RESULTS Publication number increased over time overall (R2 = 0.64, P = 0.003) and for all publication types except randomized clinical trials. Case reports and case series represented the majority of HS publications (n = 479, 40.3%). Treatment was the main focus of publications (n = 445, 37.6%) with increasing interest in medical management evident in recent years. Distribution of low level of evidence studies (n = 974) compared with high level of evidence studies over time (n = 209) was significant (x2 : 11.45, P = 0.0007). High level of evidence studies had a higher average annual growth rate (49.9%) compared with low level of evidence studies (23.7%). Few randomized clinical trials were performed (n = 16), focusing equally on medical or procedural treatments. CONCLUSIONS Hidradenitis suppurativa research is undergoing a tremendous shift, suggesting rapid maturation of the field. Current HS literature, however, remains primarily based on limited clinical observation data, with a particular lack of randomized clinical trials. Despite this, the increase in high level of evidence studies is encouraging and may herald a shift towards improved disease understanding and treatment paradigms.

Hidradenitis suppurativa (HS) is a complex disease with a dramatic impact on the quality of life of patients that it afflicts. Despite this, there are few treatment options offering long-term relief. The exact pathophysiology of HS is unclear, although the current theory involves follicular obstruction, rupture, and subsequent inflammation leading to fistula and abscess development in intertriginous skin. Several inflammatory modulators have been implicated in the development of HS, including tumor necrosis factor (TNF)-α as well as interleukin (IL)-1β, IL-10, and IL-17. Initial evidence for the use of TNF-α inhibitors in HS stemmed from recognition that inflammatory bowel disease patients treated with these medications saw a concurrent improvement in their HS symptoms. Early case reports and case series illustrated TNF-α inhibitors’ value in the treatment of HS. Later, two phase III clinical trials, PIONEER I and PIONEER II, demonstrated that adalimumab is an efficacious treatment for HS. Infliximab represents another effective HS treatment option with its main advantage being dosing flexibility. In contrast, clinical trials have failed to show evidence for application of etanercept in HS. There is limited data on other TNF-α inhibitors such as certolizumab-pegol and golimumab. This review outlines the history, dosing, response, and adverse effects of TNF-α inhibitors in the treatment of HS.