A distinct pustular flare follows some biologic withdrawals, and ANA predicts which children with discoid lupus progress

The edition in brief

In a multicentre cohort of 1,198 biologic withdrawal episodes in plaque psoriasis, 7.2% were followed by a distinct pustular flare: painful, diffuse, intense erythema with pustules and swelling, mostly on the legs. Risk rose with each cycle of withdrawal and relapse, and was independently associated with a family history of psoriasis, psoriatic arthritis, a previous flare of this type and slower initial response. In a 17-site retrospective cohort of children with skin-limited discoid lupus, 14.4% progressed to systemic lupus within a year; a positive antinuclear antibody (HR 3.71), older age, antiphospholipid antibodies and cytopenias predicted progression, and the systemic disease was usually mild. A phase 2 trial in 64 adults with cutaneous lichen planus found that ruxolitinib 1.5% cream achieved clear or almost clear skin in 50% versus 22% with vehicle at 16 weeks, with similar gains in itch. A network meta-analysis of 12 trials (736 patients) found scalp cooling continued for more than 90 minutes after chemotherapy ranked best for preventing chemotherapy-induced alopecia, on low-certainty evidence. The pearl: in lichen planus, look in the mouth and genitals and consider hepatitis C.