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Rencz F, Gulácsi L, Péntek M, Poór A, Sárdy M, Holló P, Szegedi A, Remenyik É, Brodszky V. Proposal of a new scoring formula for the DLQI in psoriasis. Br J Dermatol 2018. [DOI: 10.1111/bjd.17214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rencz F, Gulácsi L, Péntek M, Poór AK, Sárdy M, Holló P, Szegedi A, Remenyik É, Brodszky V. 银屑病中 DLQI 新评分公式的提议. Br J Dermatol 2018. [DOI: 10.1111/bjd.17228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jenei A, Dajnoki Z, Medgyesi B, Gáspár K, Béke G, Kinyó Á, Méhes G, Hendrik Z, Dinya T, Törőcsik D, Zouboulis CC, Prens EP, Bíró T, Szegedi A, Kapitány A. Apocrine Gland-Rich Skin Has a Non-Inflammatory IL-17-Related Immune Milieu, that Turns to Inflammatory IL-17-Mediated Disease in Hidradenitis Suppurativa. J Invest Dermatol 2018; 139:964-968. [PMID: 30391261 DOI: 10.1016/j.jid.2018.10.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/27/2018] [Accepted: 10/22/2018] [Indexed: 12/20/2022]
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Rencz F, Gulácsi L, Péntek M, Poór AK, Sárdy M, Holló P, Szegedi A, Remenyik É, Brodszky V. Proposal of a new scoring formula for the Dermatology Life Quality Index in psoriasis. Br J Dermatol 2018; 179:1102-1108. [PMID: 29968311 DOI: 10.1111/bjd.16927] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND 'Not relevant' responses (NRRs) on the Dermatology Life Quality Index (DLQI) may occur in up to 40% of patients with psoriasis. As these responses are scored as the item of the questionnaire having no impact on the patients' lives at all, it is more difficult for these patients to fulfil the DLQI > 10 criterion required by clinical guidelines to become candidates for systemic treatment including biologics. OBJECTIVES We propose a new scoring system for the DLQI that corrects for the bias in the NRR option and test its construct validity in a sample of patients with psoriasis. METHODS Data from 242 patients (104 of whom marked at least one NRR) from two earlier cross-sectional surveys were reanalysed. For each patient, the DLQI score was calculated in two ways: (i) according to the original scoring and (ii) by applying a new scoring formula (DLQI-R) that adjusts the total score for the number of NRRs. The construct validity of the DLQI-R was tested against the Psoriasis Area and Severity Index (PASI) and EQ-5D-3L. RESULTS The mean DLQI and DLQI-R scores were 9·99 ± 7·52 and 11·0 ± 8·02, respectively. The DLQI-R allowed eight more patients (3·3%) to achieve the 'PASI > 10 and DLQI > 10' threshold. The results were robust when limiting the maximum number of NRRs allowed to two or three. Compared with the DLQI, DLQI-R correlated slightly better with PASI (rs = 0·59 vs. 0·57) and EQ-5D-3L index scores (rs = -0·58 vs. -0·54). CONCLUSIONS The DLQI-R seems to be a valid scoring system for avoiding the bias in the NRR option and can help to improve patients' access to biologics.
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Tamási B, Brodszky V, Péntek M, Gulácsi L, Hajdu K, Sárdy M, Szegedi A, Bata-Csörgő Z, Kinyó Á, Rencz F. Validity of the EQ-5D in patients with pemphigus vulgaris and pemphigus foliaceus. Br J Dermatol 2018; 180:802-809. [PMID: 29897626 DOI: 10.1111/bjd.16883] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND No studies to date have employed the EuroQoL EQ-5D questionnaire to assess health-related quality of life (HRQoL) in patients with pemphigus. OBJECTIVES To evaluate the HRQoL of patients with pemphigus by the EQ-5D and to analyse the convergent and known-groups validity of the EQ-5D in this patient population. METHODS Between 2014 and 2017, a multicentre cross-sectional study was carried out. Outcome measures included the five-level EQ-5D (EQ-5D-5L), Dermatology Life Quality Index (DLQI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and an average pain intensity visual analogue scale (VAS) for the past 3 months. RESULTS In total, 109 consecutive patients with pemphigus participated in the study (mean age 57 years; 64% women). Among the EQ-5D dimensions, the most problems were reported regarding pain/discomfort (50%), mobility (43%) and anxiety/depression (43%). No significant difference was found in mean EQ-5D index scores between patients with pemphigus vulgaris and those with pemphigus foliaceus (0·81 vs. 0·86, P = 0·14). The mean EQ-5D index scores of patients with limited, moderate, significant and extreme pemphigus were 0·88, 0·82, 0·72 and 0·67, respectively (P = 0·001). The number of comorbidities was associated with greater impairment in EQ-5D index scores (P < 0·001). DLQI (rs = -0·62, P < 0·001) and the average pain intensity VAS (rs = -0·59, P < 0·001) more strongly correlated with the EQ-5D index scores than did ABSIS (rs = -0·40, P < 0·001). CONCLUSIONS This is the first study employing the EQ-5D questionnaire in pemphigus. The EQ-5D is a valid measure of HRQoL in patients with pemphigus that can be useful both in clinical practice and in economic evaluations to assess the health gains associated with new effective treatments.
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Lovászi M, Gácsi A, Csányi E, Kovács D, Eyerich K, Kemény L, Szegedi A, Zouboulis C, Eyerich S, Törcsik D. 1029 Sebum component lipids penetrate through the epidermis and modulate macrophage – P. acnes interaction. J Invest Dermatol 2018. [DOI: 10.1016/j.jid.2018.03.1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Dajnoki Z, Béke G, Kapitány A, Gáspár K, Póliska S, Hendrik Z, Péter Z, Törcsik D, Bíró T, Szegedi A. 720 Topographical differences in immune and barrier functions of human skin. J Invest Dermatol 2018. [DOI: 10.1016/j.jid.2018.03.729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Popova M, Trendafilova I, Zgureva D, Kalvachev Y, Boycheva S, Novak Tušar N, Szegedi A. Polymer-coated mesoporous silica nanoparticles for controlled release of the prodrug sulfasalazine. J Drug Deliv Sci Technol 2018. [DOI: 10.1016/j.jddst.2018.01.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Lovászi M, Mattii M, Eyerich K, Gácsi A, Csányi E, Kovács D, Rühl R, Szegedi A, Kemény L, Ståhle M, Zouboulis CC, Eyerich S, Törőcsik D. Sebum lipids influence macrophage polarization and activation. Br J Dermatol 2017. [PMID: 28646583 DOI: 10.1111/bjd.15754] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND As lipids are known to regulate macrophage functions, it is reasonable to suppose that a sebocyte-macrophage axis mediated by sebum lipids may exist. OBJECTIVES To investigate if sebocytes could contribute to the differentiation, polarization and function of macrophages with their secreted lipids. METHODS Oil Red O lipid staining and Raman spectroscopy were used to assess the dermal lipid content and penetration. Immunohistochemistry was used to analyse the macrophage subsets. Human peripheral blood monocytes were differentiated in the presence of either supernatant from human SZ95 sebocytes or major sebum lipid components and activated with Propionibacterium acnes. Macrophage surface markers and their capacity to uptake fluorescein isothiocyanate-conjugated P. acnes were detected by fluorescence-activated cell sorting measurements. Cytokine protein levels were evaluated by enzyme-linked immunosorbent assay and Western blot analysis. RESULTS Sebaceous gland-rich skin had an increased dermal lipid content vs. sebaceous gland-poor skin to which all the tested sebum component lipids could contribute by penetrating the dermoepidermal barrier. Of the lipids, oleic acid and linoleic acid promoted monocyte differentiation into alternatively activated macrophages. Moreover, linoleic acid also had an anti-inflammatory effect in P. acnes-activated macrophages, inhibiting the secretion of interleukin (IL)-1β, IL-6 and tumour necrosis factor (TNF)-α. Squalene, palmitic acid, stearic acid and oleic acid augmented the secretion of IL-1β, even in the absence of P. acnes, whereas oleic acid had a selective effect of inducing IL-1β but downregulating IL-6 and TNF-α secretion. CONCLUSIONS Our results suggest a role for sebaceous glands in modulating innate immune responses via their secreted lipids that are of possible pathological and therapeutic relevance.
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Rencz F, Poór AK, Péntek M, Holló P, Kárpáti S, Gulácsi L, Szegedi A, Remenyik É, Hidvégi B, Herszényi K, Jókai H, Beretzky Z, Brodszky V. A detailed analysis of 'not relevant' responses on the DLQI in psoriasis: potential biases in treatment decisions. J Eur Acad Dermatol Venereol 2017; 32:783-790. [PMID: 29114942 DOI: 10.1111/jdv.14676] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 10/16/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Dermatology Life Quality Index (DLQI) is the most common health-related quality of life measure in dermatology that is widely used in treatment guidelines for psoriasis. Eight of the 10 questions of the DLQI offer a 'not relevant' response (NRR) option that is scored as the item had no impact on patients' life at all. OBJECTIVE To explore the occurrence of NRRs on the DLQI in psoriasis patients and to examine the effect of several socio-demographic and clinical factors on giving NRRs. METHODS Data were obtained from two cross-sectional surveys among psoriasis patients at two academic dermatology clinics in Hungary. Health-related quality of life was measured by employing DLQI and EQ-5D-3L, while disease severity was graded by Psoriasis Area and Severity Index (PASI). Multivariate logistic regression was applied to determine the predictors of providing NRRs. RESULTS Mean age of the 428 patients was 49 years, and 65% were males. Mean PASI, DLQI and EQ-5D-3L index scores were 8.4 ± 9.5, 6.8 ± 7.4 and 0.74 ± 0.28, respectively. Overall, 38.8% of the patients had at least one NRR: 19.6% (one), 11.5% (two), 5.1% (three) and 2.6% (more than three). Most NRRs occurred in sport, sexual difficulties and working/studying items of the DLQI (28.4%, 16.4% and 14.0%, respectively). Female gender (OR 1.65; 95% CI 1.04-2.61), older age (OR 1.05; 95% CI 1.03-1.07) and higher PASI score (OR 1.03; 95% CI 1.01-1.06) were associated with providing more NRRs, whereas highly educated patients (OR 0.34; 95% CI 0.16-0.72) and those with a full-time job (OR 0.47; 95% CI 0.29-0.77) less frequently tended to tick NRRs. CONCLUSION The high rate of psoriasis patients with NRRs, especially among women, less educated and elderly patients, indicates a content validity problem of the measure. A reconsideration of the use of the DLQI for medical and financial decision-making in psoriasis patients is suggested.
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Szabó I, Herczeg-Lisztes E, Szollosi A, Szegedi A, Bíró T, Oláh A. 263 (-)-cannabidiol differentially influences hair growth. J Invest Dermatol 2017. [DOI: 10.1016/j.jid.2017.07.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Jenei A, Gáspár K, Dajnoki Z, Béke G, Medgyesi B, Kinyó Á, Hendrik Z, Dinya T, Szegedi A, Kapitány A. 478 Immune status of healthy apocrine gland-rich skin regions and its alterations in Hidradenitis Suppurativa. J Invest Dermatol 2017. [DOI: 10.1016/j.jid.2017.07.674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Tamási B, Brodszky V, Hajdu K, Kárpáti S, Gulácsi L, Szegedi A, Bata-Csörgö Z, Kinyó Á, Péntek M, Rencz F. 015 The impact of pemphigus on health-related quality of life: First results with the EQ-5D questionnaire. J Invest Dermatol 2017. [DOI: 10.1016/j.jid.2017.07.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rencz F, Poór A, Péntek M, Holló P, Kárpáti S, Gulácsi L, Szegedi A, Remenyik É, Hidvégi B, Brodszky V. 017 Women, elderly and less educated psoriasis patients provide more ‘not relevant’ responses on the Dermatology Life Quality Index - is it a problem? J Invest Dermatol 2017. [DOI: 10.1016/j.jid.2017.07.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Khasawneh A, Baráth S, Medgyesi B, Béke G, Dajnoki Z, Gáspár K, Jenei A, Pázmándi K, Bácsi A, Szegedi A, Kapitány A. 365 Myeloid but not plasmacytoid blood DCs possess Th1 polarizing and Th1/Th17 recruiting capacity in psoriasis. J Invest Dermatol 2017. [DOI: 10.1016/j.jid.2017.07.560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hajdu K, Irinyi B, Gyimesi E, Kapitány A, Dajnoki Z, Bata‐Csörgő Z, Kinyó Á, Kiss F, Gáspár K, Szegedi A. A simple, combined test can improve the diagnosis of autoimmune urticaria. Br J Dermatol 2017; 177:864-866. [DOI: 10.1111/bjd.15175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Khasawneh A, Baráth S, Béke G, Dajnoki Z, Jenei A, Medgyesi B, Gáspár K, Szegedi A, Kapitány A. 374 Characterization of peripheral blood dendritic cells in psoriasis. J Invest Dermatol 2016. [DOI: 10.1016/j.jid.2016.06.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Janka E, Töröcsik D, Gáspár K, Bodnár E, Sawhney I, Csordás A, Kovács Z, Herédi E, Szegedi A, Remenyik É. 041 The association between early-onset and late-onset psoriasis and co-morbidities in a case-control study. J Invest Dermatol 2016. [DOI: 10.1016/j.jid.2016.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Herédi E, Végh J, Pogácsás L, Gáspár K, Varga J, Kincse G, Zeher M, Szegedi A, Gaál J. Subclinical cardiovascular disease and it's improvement after long-term TNF-α inhibitor therapy in severe psoriatic patients. J Eur Acad Dermatol Venereol 2016; 30:1531-6. [DOI: 10.1111/jdv.13649] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/04/2016] [Indexed: 11/29/2022]
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Szegedi A. Filaggrin mutations in early- and late-onset atopic dermatitis. Br J Dermatol 2015; 172:320-1. [PMID: 25660681 DOI: 10.1111/bjd.13534] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rencz F, Holló P, Kárpáti S, Péntek M, Remenyik É, Szegedi A, Balogh O, Herédi E, Herszényi K, Jókai H, Brodszky V, Gulácsi L. Moderate to severe psoriasis patients' subjective future expectations regarding health-related quality of life and longevity. J Eur Acad Dermatol Venereol 2014; 29:1398-405. [PMID: 25491660 DOI: 10.1111/jdv.12884] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 10/28/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Unrealistic expectations regarding treatments and clinical outcomes may lead to disappointment about therapy and sub-optimal compliance; nonetheless, these expectations have not been studied in psoriasis patients yet. OBJECTIVE To evaluate psoriasis patients' subjective future expectations regarding health-related quality of life (HRQOL) and life expectancy, and to explore clinical features associated with under- or overestimating behaviour. METHODS A cross-sectional questionnaire survey of consecutive adult patients with moderate to severe psoriasis was conducted. HRQOL expectations were recorded by applying the EQ-5D descriptive system for 6 months ahead and for future ages of 60, 70, 80 and 90 respectively. RESULTS In total, 167 patients (71% males) were included in the analysis with mean age of 50.4 ± 12.4 years and mean EQ-5D score of 0.71 ± 0.30. Overall 65% had chronic plaque psoriasis, 35% nail psoriasis, 35% scalp involvement, 29% psoriatic arthritis, 9% inverse psoriasis and 5% palmoplantar psoriasis respectively (combinations occurred). Participants expected 0.1 ± 0.23 mean improvement in EQ-5D within 6 months (P < 0.001) that achieves the minimum clinically important difference. Overall 37% expected improvement and 13% decline; however, 49% expected no changes in any of the five dimensions of EQ-5D within 6 months. Female gender, inverse or palmoplantar involvement and more severe psoriasis were likely associated with higher expectations. Patients at the initiation of their first biological at the time of the survey expected 0.18 ± 0.24 increase that seems to be realistic compared to the EQ-5D utility gain achieved in randomized controlled trials. Males expected by 2.7 ± 11.1 more, while females expected by 5.2 ± 9.3 less life years compared to the average statistical gender- and age-matched life expectancy (P < 0.05). Patients who expected to be alive at ages of 60, 70, 80 and 90 scored their future EQ-5D at ages of 60 to 90: 0.59 ± 0.46, 0.48 ± 0.41, 0.42 ± 0.41 and 0.22 ± 0.47 respectively. CONCLUSION Our findings highlight the importance of exploring expectations that might help to increase patients' compliance.
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Mócsai G, Gáspár K, Nagy G, Irinyi B, Kapitány A, Bíró T, Gyimesi E, Tóth B, Maródi L, Szegedi A. Severe skin inflammation and filaggrin mutation similarly alter the skin barrier in patients with atopic dermatitis. Br J Dermatol 2014; 170:617-24. [PMID: 24251354 DOI: 10.1111/bjd.12743] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Filaggrin (FLG) deficiency is a well-known predisposing factor for the development of atopic dermatitis (AD). Decreased FLG expression can be the result of haploinsufficiency or severe inflammation, which can cause acquired FLG alterations. FLG mutations are related to several clinical and laboratory parameters of AD; however, some recent data seem to contradict these associations. OBJECTIVES Our aim was to determine which clinical and biochemical parameters are connected to FLG haploinsufficiency and which ones are also associated with acquired FLG alterations due to severe skin symptoms in patients with AD. METHODS We introduced a novel classification of patients with AD, based on FLG mutations and SCORAD (SCORing Atopic Dermatitis). Based on these parameters, we created three groups of patients with AD: mild-to-moderate wild-type (A), severe wild-type (B) and severe mutant (C). In all groups, we assessed laboratory and clinical parameters and performed immunohistochemical analyses. RESULTS Groups B and C contained patients with equally severe symptoms based on the SCORAD. The two severe groups did not differ significantly with respect to barrier-specific parameters, whereas group A had significantly better results for the barrier function measurements. However, significant differences were detected between groups B and C with respect to the allergic sensitization-specific parameters. CONCLUSIONS These findings suggest that skin barrier function correlates with the severity of skin inflammation and can be equally impaired in patients with FLG mutant- and wild-type AD with severe symptoms. Nevertheless, our results also suggest that patients with FLG mutant-type AD may have a higher risk of allergic sensitization compared with patients with the wild-type.
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Mihály J, Sonntag D, Krebiehl G, Szegedi A, Töröcsik D, Rühl R. Steroid concentrations in patients with atopic dermatitis: reduced plasma dehydroepiandrosterone sulfate and increased cortisone levels. Br J Dermatol 2014; 172:285-8. [PMID: 24974914 DOI: 10.1111/bjd.13219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Rencz F, Gulacsi L, Remenyik É, Szegedi A, Holló P, Kárpáti S, Péntek M, Brodszky V. Subjective Expectations Regarding Life Expectancy And Health-Related Quality Of Life In Moderate To Severe Psoriasis Patients. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2014; 17:A611. [PMID: 27202132 DOI: 10.1016/j.jval.2014.08.2142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Yoncheva K, Popova M, Szegedi A, Mihaly J, Tzankov B, Lambov N, Konstantinov S, Tzankova V, Pessina F, Valoti M. Functionalized mesoporous silica nanoparticles for oral delivery of budesonide. J SOLID STATE CHEM 2014. [DOI: 10.1016/j.jssc.2013.12.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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