- Raj M, Raj G, Sheng TK, Jsp L. Use of cyanoacrylate tissue adhesives for wound closure in the head and neck region: a systematic review. J Plast Reconstr Aesthet Surg. 2022;75(1): 183-198. https://doi.org/10.1016/j.bjps.2021.08.015 - Wilson AD, Mercer N. Dermabond tissue adhesive versus Steri-Strips in unilateral cleft lip repair: an audit of infection and hypertrophic scar rates. *Cleft Palate Craniofac J.* 2008; 45(6):614-619. https://doi.org/10.1597/07-072.1 - Kwapnoski Z, Doost MS, Vy M, Eisen DB. Aesthetic outcome of intermediate closure versus intermediate closure followed by 2-octyl cyanoacrylate: a randomized evaluator-blinded split-wound comparative effectiveness trial. J Am Acad Dermatol. 2024;90(3): 577-584. https://doi.org/10.1016/j.jaad.2023.10.028 https://doi.org/10.1016/j.jaad.2025.07.046 # Healthcare resource utilization and economic burden in generalized pustular psoriasis (GPP) among U.S. adults: A large claims database analysis Generalized pustular psoriasis (GPP) is a chronic, systemic, and potentially life-threatening skin disease, characterized by flares of painful pustules and erythema, often accompanied by systemic symptoms.^1,2 Patients have significantly more comorbidities (eg type 2 diabetes, psoriatic arthritis) and serious complications (eg sepsis) than those with plaque psoriasis (PsO), which is a clinically and pathologically distinct disease from GPP.^3,4 Knowledge of healthcare resource use (HCRU) and associated costs may help inform treatment decisions, particularly given the emergence of GPP-targeted medications.⁵ We retrospectively evaluated HCRU and economic burden between 2016 and 2019 in adults with GPP (*All-GPP* cohort, n = 633) and in subcohorts with comorbid *GPP* + *PsO* (n = 344) or *GPP-only* (n = 289), versus *plaque PsO-only* (n = 633), using a U.S. claims database (Inovalon Insights LLC) with cohort definitions based on ICD-10 codes (GPP, L40.1; plaque PsO, L40.0). Patients with claims only for phototherapy were excluded. The patient population was propensity score matched, with no statistically significant differences observed in demographics (Supplementary Table I, available via Mendeley at https://data.mendeley.com/datasets/2k63rtp5rm/1). Overall, 69.1% of patients were female, 58.1% were 45 to 64 years of age, and 64.8% were commercially insured. Patients were located throughout the USA. In the *All-GPP*, *GPP* + *PsO*, *GPP-only*, and *plaque PsO-only* cohorts, median (min, max) duration of follow-up was 2.9 (1.0, 6.9), 2.9 (1.0, 6.9), 2.7 (1.0, 6.9), and 2.5 (1.0, 7.0) years, respectively. Patients with GPP experienced significantly greater HCRU compared with the *plaque PsO-only* cohort, including higher median numbers of total visits (3.0 or 4.0 per GPP cohort vs 2.0, P < .001), outpatient/office visits (3.0 per GPP cohort vs 2.0, P < .001), and laboratory use (2.0 in the *All-GPP* and *GPP-only* cohorts vs 1.0, P < .05) (Fig 1, *A*). Inpatient visits (34 patients) and intensive care unit (ICU) visits (1 patient) were reported exclusively in the GPP cohorts, and most emergency room (ER) visits were experienced by patients with GPP (12 patients) vs *plaque PsO-only* (1 patient). In general, the economic costs mirrored the HCRU findings. Patients with GPP experienced significantly greater median total costs (*All-GPP* \$189, *GPP* + *PsO* \$205, and *GPP-only* \$174) versus *plaque PsO-only* (\$103) (P < .001) (Fig 1, B). This was also the case for median outpatient/office costs: *All-GPP* (\$180), *GPP* + *PsO* (\$198), and *GPP-only* (\$168) versus *plaque PsO-only* (\$100) (P < .001). Median costs associated with inpatient and ICU visits, reported exclusively for patients with GPP, were \$144 (34 patients) and \$84,407 (1 patient), respectively. ER costs in the *All-GPP* cohort ranged from \$58 to \$1490 (12 patients), compared with \$160 (1 patient) in the *plaque PsO-only* cohort. In conclusion, the greater HCRU and associated costs for GPP versus plaque PsO underscore the need for improved long-term management of GPP. Patients with GPP traditionally receive medications intended for plaque PsO, which lack evidence of effectiveness for GPP.^2-4 We acknowledge that claims database studies may be affected to some degree by medical miscoding, and that HCRU and costs were assessed between 2016 and 2019, before billing changes and approval of spesolimab (an interleukin-36 receptor antagonist) for the treatment of GPP flares in various countries, including the USA.⁵ Future studies should assess the impact of new therapies on GPP-related HCRU. The authors would also like to acknowledge the contributions of Dr Hannah Kwiatkowski of Boehringer Ingelheim for discussions supporting development of the manuscript and Dr Thomas Zimmermann of Boehringer Ingelheim for contributing to the ideation of the study. The authors also thank Dr Bridget Balkaran from Cerner Enviza (now Oracle) for support with statistical analysis for the study. Priyadharshini Ramakrishnan, MDS, and Shilpa Chennakrishnaiah, PhD, of Cytel Inc, Waltham, MA, USA provided writing and editorial support on the initial draft, which was contracted and funded by ^{© 2025} The Author(s). Published by Elsevier Inc. on behalf of the American Academy of Dermatology, Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ![](https://assets.reachrx.ai/images/10.1016%E2%98%8Dj.jaad.2025.07.031/_page_1_Figure_2.jpeg) **Fig 1. A,** All-cause HCRU visits and **(B)** all-cause costs contributed by all-cause HCRU visits for propensity score-matched cohorts at maximum follow-up. \*\*P < .001; \*P < .05 (Mann Whitney U test). ^†Other visits included telehealth, school, home, assisted living facilities, skilled nursing facilities and Centers for Medicare and Medicaid Services place of service information. *ER*, Emergency room; *GPP*, generalized pustular psoriasis; *HCRU*, healthcare resource utilization; *ICU*, intensive care unit; *PsO*, psoriasis; *USD*, United States dollars. Boehringer Ingelheim. Michael Riley, PhD, and Samantha Lommano, PhD, of Bioscript Group, Macclesfield, UK, provided writing and editorial support on later drafts, funded by Boehringer Ingelheim. - Mark Lebwohl, MD,^a Bhargav Lakshminarasimhan, PharmD, MBA,^b Layla Lavasani, PhD, MHS,^b Juan Semeco, MD, MBA,^b Alice B. Gottlieb, MD, PhD,^a and Bruce Strober, MD, PhD^c,d - From the Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York^a; Boebringer Ingelheim International GmbH, Ingelheim, Germany^b; Department of Dermatology, Yale University, New Haven, Connecticut^c; and Central Connecticut Dermatology, Cromwell, Connecticut.^d - Funding source: This study was funded by Boehringer Ingelheim. - Disclosures: All authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. Boehringer Ingelheim was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. The authors did not receive payment related to the development of the manuscript. - IRB approval status: The study received Institutional Review Board ethics approval. - Key words: cohort study; economic burden; generalized pustular psoriasis; healthcare costs; healthcare resource use; medical claims; plaque psoriasis. - Correspondence to: Dr Bruce Strober, MD, PhD, Central Connecticut Dermatology, 1 Willowbrook Rd, Suite 2, Cromwell, CT 06416 ### E-mail: [brucestrober30@me.com](mailto:brucestrober30@me.com) #### Conflicts of interest ML is an employee of Mount Sinai; receives research funds from AbbVie, Amgen, Arcutis, Avotres, Boehringer Ingelheim, Cara therapeutics, Dermavant Sciences, Eli Lilly, Incyte, Inozyme, Janssen Research & Development, LLC, Ortho Dermatologics, Pfizer, Sanofi-Regeneron, and UCB; and is a consultant for Almirall, AltruBio Inc., AnaptysBio, Apogee, Arcutis, Inc, AstraZeneca, Atomwise, Avotres Therapeutics, Brickell Biotech, Boehringer Ingelheim, Bristol Myers Squibb, Castle Biosciences, Celltrion, Corevitas, Dermavant Sciences, EPI, Evommune, Inc, Facilitation of International Dermatology Education, Forte Biosciences, Foundation for Research and Education in Dermatology, Galderma, Genentech, Incyte, LEO Pharma, Meiji Seika Pharma, Mindera, Pfizer, Sanofi-Regeneron, Seanergy, Strata, Takeda, Trevi, and Verrica. Research funding: ABG receives research/educational grants from Bristol Myers Squibb, Janssen, Moonlake, and UCB Pharma (all paid to Mount Sinai School of Medicine). Honoraria/speaker fees: ABG has received honoraria as an advisory board member and consultant for Amgen, Eli Lilly, Highlights Therapeutics, Janssen, Novartis, Sanofi, SunPharma, Takeda, Teva, UCB, and Xbiotech (stock options for RA). BS reports honoraria as a consultant or speaker for AbbVie, Acelyrin, Alamar, Almirall, Alumis, Amgen, Arcutis, Arena, Aristea, Asana, Boehringer Ingelheim, Bristol Myers Squibb, Capital One, Celltrion, CorEvitas, Dermavant, Eli Lilly, Imagenebio, Incyte, Janssen, Kangpu Pharmaceuticals, Leo, Maruho, Meiji Seika Pharma, Monte Carlo, Novartis, Okura, Pfizer, Protagonist, Rapt, Regeneron, Sanofi-Genzyme, SG Cowen, Takeda, UCB Pharma, Union Therapeutics; stock options from Connect Biopharma and Mindera Health; consulting fees from CorEvitas Psoriasis Registry (Scientific Co-Director and Investigator); and honorarium from the Journal of Psoriasis and Psoriatic Arthritis (Editor-in-Chief). LL, JS, and BL are employees of Boehringer Ingelheim. ### REFERENCES - 2. [Krueger J, Puig L, Thaci D. 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Current treatments for](http://refhub.elsevier.com/S0190-9622(25)02540-X/sref5) [generalized pustular psoriasis: a narrative summary of a](http://refhub.elsevier.com/S0190-9622(25)02540-X/sref5) [systematic literature search.](http://refhub.elsevier.com/S0190-9622(25)02540-X/sref5) Dermatol Ther (Heidelb). 2024;14: [2331-2378](http://refhub.elsevier.com/S0190-9622(25)02540-X/sref5). #### ## Wound healing outcomes in skin cancer patients on sirolimus: Insights from dermatologic surgery Sirolimus (rapamycin), an mTOR inhibitor, effectively prevents allograft rejection in kidney transplant recipients.1 However, it may impair wound healing via reduction of VEGF and nitric oxide levels and inhibition of fibroblast proliferation and collagen synthesis.2 While retrospective studies have linked sirolimus to higher surgical complication rates, these data derive from more invasive surgeries compared to that typically seen in dermatologic surgery.3 Transplant recipients face a markedly elevated risk of skin cancer, for which surgical excision remains the mainstay of treatment. To date, there has been limited investigation into sirolimus's effect on dermatologic wound healing. This study compares postoperative outcomes in kidney transplant patients on sirolimus versus tacrolimus to contribute meaningful insights into the risks and benefits of sirolimus in this growing population. A 20-year retrospective cohort (2003-2023) at the University of Wisconsin included adult kidney transplant recipients with histologically confirmed skin cancer who underwent dermatologic surgery on either sirolimus or tacrolimus. Recorded data comprised demographics, tumor histology (SCC, BCC, melanoma, other), defect depth ( fat to bone), anatomical site, and immunosuppressive regimen. Chart review identified wound complications (infection, dehiscence, hematoma) as the primary outcome, with secondary analyses by tumor type and defect depth. Relative risks were estimated using Poisson regression with cluster-robust standard errors, and continuous variables were compared via cluster-adjustedWilcoxon rank-sumtests. Analyses were performed in R sofware (version 4.4). ^1. [Gooderham MJ, Van Voorhees AS, Lebwohl MG. An update on](http://refhub.elsevier.com/S0190-9622(25)02540-X/sref1) [generalized pustular psoriasis.](http://refhub.elsevier.com/S0190-9622(25)02540-X/sref1) Expert Rev Clin Immunol. 2019; [15:907-919.](http://refhub.elsevier.com/S0190-9622(25)02540-X/sref1) ª 2025 by the American Academy of Dermatology, Inc.