Joy Wan

University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (12)60.7 Total impact

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    ABSTRACT: A black box warning describes a potential risk of malignancy associated with topical use of pimecrolimus to treat atopic dermatitis due to its similarity to oral calcineurin inhibitors used in solid-organ transplantation and spontaneous reporting of malignancies, including lymphomas and cutaneous malignancies. To evaluate the risk of malignancy in a postmarketing study of children exposed to pimecrolimus. A longitudinal cohort study among a nationwide ongoing long-term cohort of children enrolled in the Pediatric Eczema Elective Registry (PEER) who had a history of atopic dermatitis and pimecrolimus use with data available up through May 2014. Reports of malignancy among those in the PEER compared with expected rates from the Surveillance, Epidemiology, and End Results (SEER) program. Overall, 7457 children were enrolled in the PEER, for a total of 26 792 person-years. Children used a mean (SD) of 793 (1356) g of pimecrolimus when enrolled in the study. As of May 2014, five malignancies had been reported. These include 2 leukemias, 1 osteosarcoma, and 2 lymphomas. No skin cancers were reported. The standardized incidence ratio for all malignancies (primary outcome) based on the age-standardized SEER population was 1.2 (95% CI, 0.5-2.8). As secondary analyses, the standardized incidence ratios (based on 2 cases for each) were 2.9 (95% CI, 0.7-11.7) for lymphoma and 2.0 (95% CI, 0.5-8.2) for leukemia. None of these findings were statistically significant. Based on more than 25 000 person-years of follow-up, it seems unlikely that topical pimecrolimus as it was used in the PEER cohort to treat atopic dermatitis is associated with an increased risk of malignancy.
    JAMA Dermatology 02/2015; 151(6). DOI:10.1001/jamadermatol.2014.4305 · 4.30 Impact Factor
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    ABSTRACT: Administration of intravenous immunoglobulin (IVIG) to patients with Stevens–Johnson syndrome (SJS) has been controversial. The objective of this study was to evaluate the effectiveness of IVIG, systemic corticosteroids, or both in treating Mycoplasma pneumoniae–associated SJS (mpSJS). Retrospective series of 10 pediatric mpSJS cases were stratified into four treatment groups: IVIG alone, IVIG and systemic corticosteroids together, systemic corticosteroids alone, and supportive care. The efficacy of therapy was evaluated on the basis of several proxies of disease severity, including hospital length of stay (LOSt) and number of febrile days (Febt) after initiation of therapy. Patients treated with IVIG alone had a longer LOSt and more Febt, despite different baseline characteristics, than patients treated with supportive therapy. Of patients who received IVIG, 50% were treated with corticosteroids concurrently and had similar characteristics of disease severity but showed a non–statistically significant trend toward shorter LOSt and fewer Febt than those who received IVIG alone. A patient treated with corticosteroids alone had the shortest LOSt in this series. Therefore treatment with IVIG alone was associated with a more severe disease course than supportive therapy, although causality cannot be inferred given possible confounding by indication. When systemic corticosteroids were used alone or in conjunction with IVIG, hospital LOSt and Febt trended lower than with the use of IVIG alone, although disease severity at baseline was similar between those treated with IVIG and corticosteroids concurrently and those treated with IVIG alone. It was thus concluded that treatment with systemic corticosteroids as monotherapy or in combination with IVIG may be preferable to IVIG alone. Further large-scale studies are warranted to evaluate this hypothesis.
    Pediatric Dermatology 11/2014; 31(6). DOI:10.1111/pde.12481 · 1.52 Impact Factor
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    ABSTRACT: Objective. To evaluate the safety and efficacy of our institutional beta-blocker protocol for treatment of complicated infantile hemangiomas (IH). Study Design. A retrospective descriptive study of 76 infants/children with IH treated with oral propranolol at the Children's Hospital of Philadelphia between June 2008 and August 2010 was performed, assessing both the safety and efficacy of propranolol. Based on preliminary data showing hemangioma recrudescence off-treatment, we reviewed 9 additional patients with recrudescence between August 2010 and December 2011. Results. Mild adverse events included asymptomatic bradycardia, gastrointestinal symptoms, asymptomatic hypotension, cool hands/feet, asymptomatic hypoglycemia, and sleep disturbance. Sixteen patients had recrudescence of IH off-treatment, with propranolol discontinued at a median age of 14 months (interquartile range 10-15 months). Conclusions. Propranolol appears to be associated with minor, not severe symptomatic adverse events. Propranolol appears to be effective in treating complicated IH. Recrudescence can occur off-treatment, even with discontinuing propranolol as late as 15 months of age.
    Clinical Pediatrics 05/2014; 53(11). DOI:10.1177/0009922814535660 · 1.26 Impact Factor
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    ABSTRACT: To determine the risk of chronic kidney disease in patients with psoriasis. Population based cohort study and nested cross sectional study. Electronic medical records database based in United Kingdom. Cohort study: patients with psoriasis aged 18-90 each matched to up to five patients without psoriasis based on age, practice, and time of visit. Nested study: patients with psoriasis aged 25-64 with confirmed data on psoriasis severity, each matched to up to 10 patients without psoriasis based on age and practice. Cohort study: incident moderate to advanced (stage 3 through 5) chronic kidney disease. Nested study: baseline prevalence of chronic kidney disease. 136 529 patients with mild psoriasis and 7354 patients with severe psoriasis based on treatment patterns were matched to 689 702 unaffected patients. The adjusted hazard ratios (95% confidence intervals) for incident chronic kidney disease were 1.05 (1.02 to 1.07), 0.99 (0.97 to 1.02), and 1.93 (1.79 to 2.08) in the overall, mild, and severe psoriasis groups, respectively. Age was a significant effect modifier in the severe psoriasis group, with age specific adjusted hazard ratios (95% confidence intervals) of 3.82 (3.15 to 4.64) and 2.00 (1.86 to 2.17) for patients aged 30 and 60, respectively. In the nested analysis of 8731 patients with psoriasis with measurements of affected body surface area matched to 87 310 patients without psoriasis, the adjusted odds ratios (95% confidence intervals) for chronic kidney disease were 0.89 (0.72 to 1.10), 1.36 (1.06 to 1.74), and 1.58 (1.07 to 2.34) in the mild, moderate, and severe psoriasis groups, respectively. Moderate to severe psoriasis is associated with an increased risk of chronic kidney disease independent of traditional risk factors.
    BMJ (online) 10/2013; 347:f5961. DOI:10.1136/bmj.f5961 · 16.38 Impact Factor
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    ABSTRACT: BACKGROUND: Multiple systemic treatments are available for moderate to severe psoriasis, but dermatologists' perceptions of these treatments are unknown. Physician perceptions can influence prescribing patterns and patient outcomes, and may help to explain variations in clinical practice. OBJECTIVE: We sought to describe the variation in dermatologist's beliefs about the safety and effectiveness of psoriasis treatments and evaluate how these relate to dermatologist characteristics and treatment preferences. METHODS: We conducted a cross-sectional mail survey of a random sample of 500 National Psoriasis Foundation (NPF) members and 500 American Academy of Dermatology (AAD) members who treat psoriasis. RESULTS: Of 989 clinicians who could be contacted, 246 NPF members and 141 AAD members returned the survey (39% response rate). Respondents perceived infliximab, ustekinumab, cyclosporine, and adalimumab to have the highest likelihood of skin clearance in 3 months (67%-75%). Etanercept, adalimumab, ultraviolet B, and ustekinumab had the lowest perceived likelihood of side effects requiring treatment discontinuation (9%-11%). Up to 49% of respondents "didn't know" the effectiveness or likelihood of side effects; calculated coefficients of variation were higher for perceived likelihood of side effects than perceived effectiveness. There were few significant associations between safety and effectiveness perceptions and respondent characteristics, and treatment preferences were not consistently predictive of perceptions. LIMITATIONS: Only dermatologists with interest in treating psoriasis were surveyed and general perceptions were elicited via survey format. Perceptions may differ between survey respondents and nonrespondents. CONCLUSIONS: Psoriasis providers demonstrate wide variation in their perception of the effectiveness and especially safety of systemic treatments.
    Journal of the American Academy of Dermatology 08/2012; 68(2). DOI:10.1016/j.jaad.2012.07.007 · 5.00 Impact Factor
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    ABSTRACT: BACKGROUND: Despite widespread dissatisfaction and low treatment persistence in moderate to severe psoriasis, patients' reasons behind treatment discontinuation remain poorly understood. OBJECTIVES: We sought to characterize patient-reported reasons for discontinuing commonly used treatments for moderate to severe psoriasis in real-world clinical practice. METHODS: A total of 1095 patients with moderate to severe plaque psoriasis from 10 dermatology practices who received systemic treatments completed a structured interview. Eleven reasons for treatment discontinuation were assessed for all past treatments. RESULTS: A total of 2231 past treatments were reported. Median treatment duration varied by treatment, ranging from 6.0 to 20.5 months (P < .001). The frequency of each cited discontinuation reasons differed by treatment (all P < .01). Patients who received etanercept (odds ratio [OR] 5.19; 95% confidence interval [CI] 3.23-8.33) and adalimumab (OR 2.10; 95% CI 1.20-3.67) were more likely to cite a loss of efficacy than those who received methotrexate. Patients who received etanercept (OR 0.34; 95% CI 0.23-0.49), adalimumab (OR 0.48; 95% CI 0.30-0.75), and ultraviolet B phototherapy (OR 0.21; 95% CI 0.14-0.31) were less likely to cite side effects than those who received methotrexate, whereas those who received acitretin (OR 1.56; 95% CI 1.08-2.25) were more likely to do so. Patients who underwent ultraviolet B phototherapy were more likely to cite an inability to afford treatment (OR 7.03; 95% CI 3.14-15.72). LIMITATIONS: The study is limited by its reliance on patient recall. CONCLUSIONS: Different patterns of treatment discontinuation reasons are important to consider when developing public policy and evidence-based treatment approaches to improve successful long-term psoriasis control.
    Journal of the American Academy of Dermatology 07/2012; 68(1). DOI:10.1016/j.jaad.2012.06.035 · 5.00 Impact Factor
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    Archives of dermatology 04/2012; 148(4):539-41. DOI:10.1001/archdermatol.2011.1399 · 4.31 Impact Factor
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    ABSTRACT: To compare the effectiveness of biologic systemic therapy, nonbiologic systemic therapy, and phototherapy for treatment of psoriasis. A cross-sectional design was used. Ten outpatient dermatology sites across the United States participating in the Dermatology Clinical Effectiveness Research Network contributed to the study. A total of 713 patients with plaque psoriasis receiving systemic monotherapy (ie, methotrexate sodium, adalimumab, etanercept, or ustekinumab) or narrowband UV-B phototherapy. The primary outcome of the study was clear or almost clear skin on the Physician Global Assessment scale. Secondary outcomes were score on the Psoriasis Area and Severity Index, affected body surface area, and score on the Dermatology Life Quality Index. The proportion of patients with clear or almost clear ratings on the Physician Global Assessment scale differed among treatments: methotrexate (23.8%), adalimumab (47.7%), etanercept (34.2%), ustekinumab (36.1%), and narrowband UV-B (27.6%) (P < .001). In adjusted analyses, patients receiving adalimumab (relative response rate, 2.15; 95% CI, 1.60-2.90), etanercept (1.45; 1.06-1.97), and ustekinumab (1.57; 1.06-2.32) were more likely to have clear or almost clear skin vs patients receiving methotrexate. Patients receiving phototherapy showed no significant difference (1.35; 95% CI, 0.93-1.96) compared with those receiving methotrexate. No response difference was observed with respect to quality of life. Treatment doses were double the recommended doses in 36.1% of patients taking etanercept and 11.8% of those taking adalimumab;10.6% of patients undergoing phototherapy received the recommended treatment frequency. The effectiveness of psoriasis therapies in clinical practice may be lower than that reported in previous trials. Although relative differences in objective response rates among therapies may exist, absolute differences are small and may not be clinically significant. Dosing of common therapies varied from trial recommendations. These results provide novel benchmarks emphasizing the critical importance of studying effectiveness in real-world practice.
    Archives of dermatology 04/2012; 148(4):487-94. DOI:10.1001/archdermatol.2012.370 · 4.31 Impact Factor
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    Archives of dermatology 02/2012; 148(2):257-9. DOI:10.1001/archdermatol.2011.1406 · 4.31 Impact Factor
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    Journal of the American Academy of Dermatology 01/2012; 66(1):e18-20. DOI:10.1016/j.jaad.2011.03.017 · 5.00 Impact Factor
  • Archives of dermatology 11/2011; 147(11):1328-9. DOI:10.1001/archdermatol.2011.332 · 4.31 Impact Factor
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    ABSTRACT: Despite increasing therapies for moderate to severe psoriasis, dermatologists' treatment preferences are unknown. We sought to assess dermatologists' preferences for first-line treatments and their selection determinants. We surveyed 1000 US dermatologists (500 National Psoriasis Foundation and 500 American Academy of Dermatology members who treat psoriasis) about their preferences for first-line treatment of moderate to severe psoriasis in healthy adults of childbearing age using standardized patient vignettes. The response rate was 39% (N = 387). Preferred therapies for male and female patients were: ultraviolet (UV) B (40% and 56%, respectively), etanercept (15% and 19%), methotrexate (16% and 4%), and adalimumab (12% and 10%). Of respondents, 66% administered phototherapy in their practice. After adjusting for all physician characteristics, those preferring first-line UVB for male or female patients were significantly more likely to have phototherapy in their practice (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.8-6.6 and OR 2.8, 95% CI 1.5-5.3, respectively) and to have used UVB in more than 10 patients in the last 3 months (OR 8.0, 95% CI 3.9-16.4; OR 9.6, 95% CI 4.3-21.6). Dermatologists in the Midwest were more likely than those in the Northeast to prefer adalimumab first line for male and female patients. We surveyed only dermatologists with interest in treating psoriasis and elicited their treatment preferences for a single base case scenario. Treatment preferences may differ between survey respondents and nonrespondents. UVB is most commonly preferred as a first-line treatment for moderate to severe psoriasis in healthy adults, and preferences vary based on region, phototherapy availability, and prior treatment use.
    Journal of the American Academy of Dermatology 08/2011; 66(3):376-86. DOI:10.1016/j.jaad.2011.03.012 · 5.00 Impact Factor

Publication Stats

59 Citations
60.70 Total Impact Points

Institutions

  • 2011–2013
    • University of Pennsylvania
      • Department of Dermatology
      Philadelphia, Pennsylvania, United States
  • 2011–2012
    • William Penn University
      Filadelfia, Pennsylvania, United States