Critical appraisal of quality of clinical practice guidelines for treatment of psoriasis vulgaris, 2006-2009

Barriers and suggestions for improving the implementation of guidelines in the systemic treatment of moderate to severe psoriasis: A literature review

BACKGROUND

Despite the availability of a wide range of therapies for the systemic treatment of moderate to severe psoriasis, many psoriasis patients do not receive adequate treatment, suggesting that guidelines may not be correctly applied by physicians.

OBJECTIVES

The aim of this study was to analyze data on physicians' implementation of, and reasons for noncompliance with, guidelines for the systemic treatment of moderate to severe psoriasis.

METHODS

We conducted a systematic literature review according to the Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the PubMed and Embase databases for studies on guideline adherence in the systemic treatment of moderate to severe psoriasis. All eligible articles were retrieved in full text and the relevant references of retrieved articles were included.

RESULTS

A total of 20 studies were selected. Four studies investigated knowledge of the guidelines, six studies examined their application, and five studies focused on the various barriers to implementation. Finally, five studies discussed ways to improve implementation. Several studies on the quality of psoriasis care have revealed discrepancies between the reality and the optimal care described in national and international guidelines.

CONCLUSION

Various barriers to implementation of recommendations exist, such as economic barriers, lack of dermatologic orientation towards, lack of knowledge of recommendations by other specialists, lack of applicability, and country- and practice-specific features (e.g., different benefit/risk ratios, different reimbursement rates and conditions). This review can help the everyday practitioner to better understand these barriers, which will have a direct impact on improving the quality of life of psoriasis patients.

Selection of Quality Indicators for the Certification of Psoriasis Units: The CUDERMA Project Delphi Consensus Study

Defining quality indicators is a key strategy for ensuring the quality and standardization of health care. The CUDERMA project, an initiative of the Spanish Academy of Dermatology and Venerology (AEDV), was undertaken to define quality indicators for the certification of specialized units in dermatology; the first 2 areas selected were psoriasis and dermato-oncology. The aim of this study was to reach a consensus on what should be assessed by the indicators used to certify psoriasis units. The structured process used to do this comprised a literature review to identify potential indicators, the selection of an initial set of indicators to be evaluated by a multidisciplinary group of experts and, finally, a Delphi consensus study. A panel of 39 dermatologists evaluated the selected indicators and classified them as either "essential" or "of excellence". Consensus was finally reached on 67 indicators, which will be standardized and used to develop the certification standard for psoriasis units.

[Translated article] Selection of Quality Indicators for the Certification of Psoriasis Units: The CUDERMA Project Delphi Consensus Study

Defining quality indicators is a key strategy for ensuring the quality and standardization of health care. The CUDERMA project, an initiative of the Spanish Academy of Dermatology and Venerology (AEDV), was undertaken to define quality indicators for the certification of specialized units in dermatology; the first 2 areas selected were psoriasis and dermato-oncology. The aim of this study was to reach a consensus on what should be assessed by the indicators used to certify psoriasis units. The structured process used to do this comprised a literature review to identify potential indicators, the selection of an initial set of indicators to be evaluated by a multidisciplinary group of experts and, finally, a Delphi consensus study. A panel of 39 dermatologists evaluated the selected indicators and classified them as either "essential" or "of excellence". Consensus was finally reached on 67 indicators, which will be standardized and used to develop the certification standard for psoriasis units.

Biologics recommendations for patients with psoriasis: a critical appraisal of clinical practice guidelines for psoriasis

PURPOSE

This review article serves to assess the consistency of recommendations from guidelines on biologic agents for psoriasis, based on the quality evaluation of psoriasis Clinical Practice Guidelines (CPGs).

METHODS

We conducted a systematic literature search to identify CPGs that provide recommendations on diagnosis and treatment for psoriasis. Four reviewers performed a quality assessment of the included CPGs with the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument.

RESULTS

A total of 51 sets of CPGs from 22 medical societies or separate working groups fulfilled the inclusion criteria. The overall quality of the eligible sets of guidelines was moderate to high, with an overall average score of 55%The highest domain scores were Score and Purpose (70%) and Clarity of Presentation (68%). A total of 95 biologic agent recommendations were extracted from the 18 recommended CPGs.Three biologic agents (Etanercept, Adalimumab, Ustekinumab) were recommended for pediatric patients. Three biologic agents (Adalimumab, Ustekinumab, Secukinumab) were recommended as first-line biologic agents for adults with psoriasis.

CONCLUSION

The overall methodological quality of CPGs for psoriasis is medium to high. More attention should be paid to applicability in guideline development. The recommendations and the basis for them among various sets guidelines were almost consistent.

Comparison of Management Guidelines for Moderate-to-Severe Plaque Psoriasis: A Review of Phototherapy, Systemic Therapies, and Biologic Agents

INTRODUCTION:

Many international guidelines for management of psoriasis exist and most have variations in grading evidence quality, strength of recommendations, and dosing. The objective of our review is to compare international guidelines published in the United Kingdom, Canada, Europe, and the United States for the management of moderate-to-severe plaque psoriasis.

METHODS:

We conducted a literature review on systemic therapies and phototherapy for moderate-to-severe plaque psoriasis in adult patients. The British, Canadian, European, and American guidelines served as the key comparators in our review. To identify relevant supporting clinical trials not referenced in the guidelines, we conducted literature searches in PubMed and EMBASE. Two authors independently extracted data on indications, dosing, efficacy, evidence grade, and strength of clinical recommendation for each therapy.

RESULTS:

Monoclonal antibodies directed toward tumour necrosis factor and interleukin (IL)-12/23 received the strongest recommendations for treatment of moderate-to-severe plaque psoriasis, supported by robust, high-quality randomized controlled trials (RCTs). Newer agents such as IL-17 and IL-23 inhibitors are not referenced in most guidelines. There are fewer RCTs for conventional therapies and few head-to-head comparisons with biologics, making it difficult to draw direct comparisons. Among older agents, methotrexate is most strongly recommended for long-term maintenance and cyclosporine is recommended for short-term control of flares.

CONCLUSION:

Physicians should individualize psoriasis-management strategies based on medication tolerance, efficacy, safety, patient comorbidities, availability of the medication, and patient preference.

Quality assessment of atopic dermatitis clinical practice guidelines in ≤ 18 years

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects the patients' quality of life greatly often from a very young age. Its worldwide incidence in children and adults varies, but it is usually among the first ten causes of dermatological consultation worldwide. There is a wide variety of treatment options for this condition including topical and systemic regimes. The decision to choose a treatment option in dermatological diseases is greatly influenced by the personal experience of each specialist, which increases variability in the selection of available therapies. Clinical practice guidelines (CPGs) not only offer recommendations supported on the available scientific evidence, but also are intended to assist in making appropriate decisions in clinical scenarios. To standardize the way in which CPGs should be developed, an instrument called AGREE II (Appraisal of Guidelines for Research and Evaluation) is used. In this study, ten clinical practice guidelines in ≤ 18 years were evaluated. Six domains (scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence) were assessed for each guideline, by three reviewers. Most of the domains obtained high scores except in the applicability domain. It is suggested that future atopic dermatitis CPGs should emphasize in the facilitating factors and barriers that may influence the application of guideline recommendations.

Anti-TNF agents for paediatric psoriasis

BACKGROUND

Psoriasis is a chronic skin disease that may develop at any age. Estimates for the United States and Europe suggest that psoriasis accounts for 4% of skin diseases in children. In most cases, the condition is mild and can be treated with creams. However, a small percentage of children have moderate to severe disease that requires drugs, such as ciclosporin or methotrexate, and some will require injections with newer biological agents, such as anti-TNF (tumour necrosis factor) drugs. Anti-TNF drugs (among them etanercept, infliximab, and adalimumab) are designed to reduce inflammation in the body caused by tumour necrosis factor. Evidence for the safety and efficacy of these biological agents in paediatric psoriasis is lacking.

OBJECTIVES

To assess the efficacy and safety of anti-TNF agents for the treatment of paediatric psoriasis.

SEARCH METHODS

We searched the following databases up to July 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 6), MEDLINE (from 1946), Embase (from 1974), and LILACS (from 1982). We also searched 13 trials registers and checked the reference lists of included studies and key review articles for further references to relevant randomised controlled trials (RCTs). We handsearched conference proceedings and attempted to contact trial authors and relevant pharmaceutical manufacturers. We searched the US Food and Drug Administration's and European Medicines Agency's adverse effects databases.

SELECTION CRITERIA

All relevant RCTs that evaluated the efficacy and safety of anti-TNF agents for the treatment of chronic plaque psoriasis in individuals less than 18 years of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked titles and abstracts and performed data extraction and 'Risk of bias' assessment of the included studies. One review author entered data into Review Manager (RevMan), and a second review author checked the data. We also attempted to obtain unclear data from the trial authors where possible.Our primary outcomes were investigator-assessed number of participants achieving a 75% improvement in Psoriasis Area and Severity Index-75 (PASI 75) compared to baseline, improvement in quality of life using an instrument such as Children's Dermatology Life Quality Index (CDLQI), and adverse effects. Our secondary outcomes included the proportion of participants achieving PASI 50 and the Physician's Global Assessment (PGA).

MAIN RESULTS

We included one study with 211 participants (median age 13 years), in which etanercept (dosage ranged from 0.8 to 50 mg per kilogram of body weight) was compared to placebo. Follow-up was over a 48-week period.At week 12, 57% versus 11% who received etanercept or placebo, respectively, achieved the PASI 75 (risk ratio 4.95, 95% confidence interval (CI) 2.83 to 8.65; high-quality evidence). Absolute risk reduction and the number needed to treat to obtain a benefit with etanercept was 45% (95% CI 33.95 to 56.40) and 2 (95% CI 1.77 to 2.95), respectively.The percentage improvement from baseline of the CDLQI scores at week 12 was better in the etanercept group than the placebo group (52.3% versus 17.5%, respectively (P = 0.0001)). Analysis between the groups showed an effect size that was clinically important (mean difference 2.30, 95% CI 0.85 to 3.75; high-quality evidence). However, means, medians, and minimal important difference results and results of the Pediatric Quality of Life Inventory, Stein Impact on Family Scale, and Harter Self-Perception Profile for Children scores must be interpreted with caution, as they were not prespecified outcomes.Three serious adverse events were reported, but they were resolved without sequelae. Deaths or other events such as malignant tumours, opportunistic infections, tuberculosis, or demyelination were not reported in the included study.Also, 13% of participants in the placebo group and 53% in the etanercept group had a PGA of clear or almost clear (risk ratio 3.96, 95% CI 2.36 to 6.66; high-quality evidence) at week 12.

AUTHORS' CONCLUSIONS

This review found only one RCT evaluating the use of this type of biological therapy. Although the risk of publication bias was high, as we included only one industry-sponsored RCT, the risk of allocation, selection, performance, attrition, and selective reporting biases for all outcomes (except for CDLQI) was low, and no short-term serious adverse events were found.We can conclude, based on this single included study, that etanercept seems to be efficacious and safe (at least in the short term) for the treatment of paediatric psoriasis. However, as the GRADE approach refers not to individual studies but to a body of evidence, we shall wait for the results of the ongoing studies in a future update of this review. In addition, future studies should evaluate quality-of-life endpoints established a priori and standardise primary outcome measures such as PASI 75, and should include the PGA as a secondary endpoint. Also, collating and reporting adverse events uniformly is required to better evaluate safety.

The quality of European dermatological guidelines: critical appraisal of the quality of EDF guidelines using the AGREE II instrument

Clinical practice guidelines are systematically developed tools to assist clinicians and health policy makers in decision making for clearly defined clinical situations. In the light of the demand for evidence-based medicine and quality in health care and the increasing methodological requirements concerning guidelines development, it is important to evaluate existing practice guidelines to systematically identify strengths and weaknesses. Currently, the most accepted tool for the methodological evaluation of guidelines is the Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. Intention of this assessment is to identify and critically appraise clinical practice guidelines commissioned by the European Dermatology Forum (EDF). A quality assessment of a predefined set of guidelines, including all available clinical practice guidelines published on the EDF guidelines internet site, was performed using the AGREE II instrument. To assure an objective assessment, four independent assessments were performed by evaluators situated in different European countries. Twenty-five EDF guidelines covering different dermatological topics were identified and evaluated. The assessment included seven guidelines developed on the highest methodological standard (systematic literature search and structured consensus conference, S3). Eighteen guidelines were identified that were based on either a structured consensus process (S2k), a systematic literature assessment (S2e) or on informal consensus only (S1). The methodological and reporting quality among the evaluated guidelines was heterogeneous. S3 guidelines generally received the highest scores. The domains 'clarity of presentation' and 'scope and purpose' achieved the highest mean ratings within the different domains of assessment, whereas the domains of 'applicability', 'stakeholder involvement' and 'editorial independence' scored poorly. Considering the large variations in the achieved scores, there is need for methodological harmonization within the EDF guidelines to achieve comparable methodological standards.

Do guidelines offer implementation advice to target users? A systematic review of guideline applicability

OBJECTIVE

Providers and patients are most likely to use and benefit from guidelines accompanied by implementation support. Guidelines published in 2007 and earlier assessed with the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument scored poorly for applicability, which reflects the inclusion of implementation instructions or tools. The purpose of this study was to examine the applicability of guidelines published in 2008 or later and identify factors associated with applicability.

DESIGN

Systematic review of studies that used AGREE to assess guidelines published in 2008 or later.

DATA SOURCES

MEDLINE and EMBASE were searched from 2008 to July 2014, and the reference lists of eligible items. Two individuals independently screened results for English language studies that reviewed guidelines using AGREE and reported all domain scores, and extracted data. Descriptive statistics were calculated across all domains. Multilevel regression analysis with a mixed effects model identified factors associated with applicability.

RESULTS

Of 245 search results, 53 were retrieved as potentially relevant and 20 studies were eligible for review. The mean and median domain scores for applicability across 137 guidelines published in 2008 or later were 43.6% and 42.0% (IQR 21.8-63.0%), respectively. Applicability scored lower than all other domains, and did not markedly improve compared with guidelines published in 2007 or earlier. Country (UK) and type of developer (disease-specific foundation, non-profit healthcare system) appeared to be associated with applicability when assessed with AGREE II (not original AGREE).

CONCLUSIONS

Despite increasing recognition of the need for implementation tools, guidelines continue to lack such resources. To improve healthcare delivery and associated outcomes, further research is needed to establish the type of implementation tools needed and desired by healthcare providers and consumers, and methods for developing high-quality tools.

Patient satisfaction with treatments for moderate-to-severe plaque psoriasis in clinical practice

BACKGROUND

Treatment satisfaction among patients with moderate-to-severe psoriasis has not been studied and compared across treatments using a validated instrument.

OBJECTIVES

To assess patient-reported satisfaction with systemic and phototherapy treatments for moderate-to-severe psoriasis in clinical practice and to correlate satisfaction with disease severity and quality-of-life measures.

METHODS

This was a cross-sectional study of 1182 patients with moderate-to-severe psoriasis in the Dermatology Clinical Effectiveness Research Network in the U.S.A. Patients receiving either topical therapies only; monotherapy with oral systemic therapies, biologics or narrowband ultraviolet B phototherapy; or combination therapy with biologics and methotrexate completed the Treatment Satisfaction Questionnaire for Medication version II.

RESULTS

Median unadjusted overall satisfaction scores were highest for patients receiving biologic monotherapies, biologic-methotrexate combinations, or phototherapy (83.3); scores were lowest for those receiving topical therapies only or acitretin (66.7). In fully adjusted models, compared with patients receiving methotrexate monotherapy, those receiving adalimumab, etanercept, ustekinumab, phototherapy or adalimumab with methotrexate had significantly higher median overall satisfaction scores by 7.2-8.3 points, while those receiving topical therapies only had significantly lower overall satisfaction by 8.9 points. Adjusted convenience scores were lowest for patients receiving topical therapies only or infliximab. Modest but significant correlations were found between the overall satisfaction subscale and both the Psoriasis Area and Severity Index (ρ = -0.36, P < 0.001) and the Dermatology Life Quality Index (ρ = -0.47, P < 0.001).

CONCLUSIONS

Discernible differences were found in treatment satisfaction among therapies, particularly regarding treatment effectiveness and convenience. Further application of treatment satisfaction measures may inform treatment decisions and guideline development.

Does the pharmaceutical industry influence guidelines?: two examples from Germany

BACKGROUND

The recommendations in clinical guidelines are based on clinical trial findings and expert opinion. The influence of drug companies on these two factors is illustrated with two examples.

METHODS

A judicially ordered expert review revealed that the market authorization holder (MAH) of gabapentin manipulated study data. Gabapentin was, therefore, chosen as an example for this article to analyze whether manipulated data serve as a basis for recommendations in German clinical guidelines. A search was carried out for manipulated publications on gabapentin that found their way into guidelines published by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). To analyze the possible effects of financial ties between guideline authors and drug companies, the S3 guideline on the treatment of psoriasis vulgaris with efalizumab was compared with guidelines whose authors had no conflicts of interest. One of the authors of this article had noted variable prescribing practices for psoriasis among dermatologists while carrying out an economic assessment for a German state Association of Statutory Health Insurance Physicians.

RESULTS

The data that had been manipulated by the MAH of gabapentin served as a basis for recommendations to prescribe gabapentin in guidelines that were published by the AWMF. Efalizumab was judged more favorably in the S3 guideline than in a guideline issued by the National Institute of Health and Care Excellence: for example, the evidence for it was judged as good, the use of efalizumab for induction and combination therapy in psoriasis vulgaris was recommended, and efalizumab was said to improve patients' health-related quality of life.

CONCLUSION

Public access to all trial data must be ensured so that independent evaluations are possible. We take the view that the responsibility for creating guidelines should be borne by authors and organizations that do not have any conflicts of interest.

Assessment of the quality of clinical practice guidelines in Korea using the AGREE Instrument

The objective of this study was to conduct the systematic evaluation of methodological quality of clinical practice guidelines (CPGs) in Korea. The authors conducted a very comprehensive literature search to identify potential CPGs for evaluation. CPGs were selected which were consistent with a predetermined criteria. Four reviewers evaluated the quality of the CPGs using the Appraisal of Guidelines, Research and Evaluation (AGREE) Instrument. AGREE item scores and standardized domain scores were calculated. The inter-rater reliability of each domain was evaluated using the intra-class correlation coefficient (ICC). Consequently, 66 CPGs were selected and their quality evaluated. ICCs for CPG appraisal using the AGREE Instrument ranged from 0.626 to 0.877. Except for the "Scope and Purpose" and "Clarity and Presentation domains", 80% of CPGs scored less than 40 in all other domains. This review shows that many Korean research groups and academic societies have made considerable efforts to develop CPGs, and the number of CPGs has increased over time. However, the quality of CPGs in Korea were not good according to the AGREE Instrument evaluation. Therefore, we should make more of an effort to ensure the high quality of CPGs.

Comparison of international breast cancer guidelines: are we globally consistent? cancer guideline AGREEment

BACKGROUND

Evidence-based guidelines are used in health care systems throughout the world to aid in treatment decisions and to ensure quality and consistency in patient care. In breast oncology, guidelines for care are published by several internationally recognized organizations, including those from the United States, Canada, and the United Kingdom. The present study compared clinical breast cancer guidelines from the American Society of Clinical Oncology (ASCO, United States), Cancer Care Ontario (CCO, Canada), and the National Institute for Health and Clinical Excellence (NICE, United Kingdom) to determine the quality and consistency of content across international organizations.

METHODS

We searched for breast cancer guidelines published by ASCO, CCO, and NICE. Guidelines on the same theme were identified across organizations and appraised by 4 independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Content of each guideline was also scored for consistency in overall recommendations across organizations and for consistency in cited evidence.

RESULTS

The quality of breast cancer guidelines produced by the targeted organizations was consistently good in the areas of Scope and Purpose, Rigor of Development, and Clarity and Presentation, but variable in the domains of Stakeholder Involvement, Applicability, and Editorial Independence. The content of the guidelines varied slightly in the strength of their recommendations.

CONCLUSIONS

Our review demonstrated consistency in quality and content for breast cancer practice guidelines published by various organizations. Future guidelines developed by these organizations should focus on how to implement and measure uptake of a guideline.

Management of psoriasis in Africa and the Middle East: a review of current opinion, practice and opportunities for improvement

Psoriasis is a common, chronic, systemic, inflammatory disease of the skin that is often associated with inflammatory musculoskeletal disease. Psoriasis impacts on affected individuals and on society at many levels, being associated with considerable economic burden and impaired quality of life. This article aims to provide dermatologists and their allied healthcare professionals, particularly those practicing in Africa and the Middle East, with a review of the current understanding of psoriasis, its treatment and impact, as a backdrop for further discussion of the management of psoriasis in these regions. Insight into the real-life, day-to-day challenges and unmet needs currently facing dermatologists in Africa and the Middle East is provided by the authors, most of whom are experienced dermatologists practicing in this region.

Disclosure of potential conflicts of interest in dermatological guidelines in Germany - an analysis - status quo and quo vadis

BACKGROUND

In order to ensure the reliability of clinical practice guidelines it is essential to consider potential conflicts of interest with regard to its development.

METHODS

All valid dermatological practice guidelines, which were developed by the German Dermatologic Society (DDG) or the Professional Association of German Dermatologists (BVDD), were recorded. Details about financing and conflicts of interest were systematically evaluated by two independent appraisers according to Domain 6 of the guidelines evaluation instruments AGREE and AGREE II.

RESULTS

38 practice guidelines of the DDG/BVDD were identified. Data about financing of the guidelines are included in 12 of 38 guidelines (32 %) only. Conflicts of interest are stated in no more than 7 of the 38 guidelines (18 %). Wherever a connection with the pharmaceutical industry was stated, no further information on how possible conflicts of interests were dealt with was found.

CONCLUSIONS

In current guidelines details on the financing as well as the disclosures of potential conflicts of interest are stated insufficiently. Here an optimization is necessary. Furthermore strategies for handling conflicts of interest need to be developed. One possibility is a specific discussion on this issue at the beginning and during the process of the guidelines work. Furthermore in case of potential conflicts of interest a solution as e. g. abstention from voting on specific questions needs to be developed.

Support Needed to Involve Psoriasis Patients in Treatment Decisions: Survey of Dermatologists

Background:

Little is known about the interaction between dermatologists and their patients in facilitating treatment decisions for psoriasis.

Purpose:

Our objective was to determine dermatologists' perceptions of the needs of psoriasis patients in treatment decisions.

Methods:

Dermatologists were invited to complete an 18-item online survey on the treatment of psoriasis, including questions on decision-making roles, factors they considered important to patients in treatment decisions, and patients' needs for decision support.

Results:

Seventy dermatologists completed the survey (15% response rate). The highest rated factors in decision making were access to physicians for discussion (86%) and information about the risks and benefits (80%); the latter was more frequently reported by those ≥ 50 years ( p = .021). Treatment-specific factors of greatest importance were side-effect profile (87%) and cost (80%). Potential hindrances were patient misconceptions about disease, inadequate patient education materials, patient indecision, and inadequate physician time.

Conclusion:

Although dermatologists consider accessibility to dermatologists and information on treatment risk and benefits to be important in treatment decision making, they report time with patients and educational materials to be inadequate.

Limitations:

The small sample size may limit the generalizability of our findings.

[What's new in dermatological treatments?]

Although the isolated clinical cases published are sometimes helpful in individual situations in which the therapeutic options have been exhausted, this type of publication cannot be generalized. For this reason, the selection presented covering the period from November 2009 to October 2010 is to a very large extent based on controlled trials, either because they contribute important information or because they raise great hope for a significant number of patients. For the first time in cutaneous oncology, a treatment (ipilimumab) has significantly increased overall survival in patients with metastatic melanoma (phase III), although this gain remains modest (4-6 months) and adverse immunological effects are frequent (30-40%). A phase I trial with treatment specifically targeting the mutant BRAF protein has shown an objective response in 81% of the patients treated in the metastatic phase of melanoma, thus allowing its development to be pursued. Grouping two studies in a rare tumor such as dermatofibrosarcoma also gives hope with imatinib as a neoadjuvant treatment when the initial tumor is inoperable, with, however, an inconsistent response of approximately 50% and only if the tumor presents reorganization of chromosomes 17 and 22. Cutaneous inflammatory diseases are still dominated by dual therapies in psoriasis, with, notably, an effectiveness trial on etanercept at different doses not showing a difference in efficacy depending on dose for the joint component of psoriasis, but also by the publication of a direct comparison of two dual therapies, ustekinumab versus etanercept. In atopic dermatitis, a controversial article invites one to reflect upon the progress made in the management of children by clinical nurses, as in the Netherlands and in Great Britain, in an attempt to contend with the shortage of dermatologists. Since the use of biotherapies is not the prerogative of psoriasis, infliximab was assessed in a phase II trial in Verneuil disease without demonstrating significant efficacy on the main criterion, but it did show a tendency to reduce the score used. This trial suffered from a weakness both in methodology and statistical power, thus precluding any conclusion. The rarity of therapeutic trials on drug eruptions warrants their mention. A French phase II study gives a glimpse of a trend toward efficacy in terms of survival in the treatment of toxic epidermal necrolysis with cyclosporine. As for infectious dermatosis and sexually transmitted infections, a French multicenter study has shown significantly higher efficacy with ivermectin than with malathion in treating pediculosis without increasing the side effects. Today, however, this systemic treatment cannot be a first-line treatment outside of certain specific situations. A large cohort study (somewhat unsatisfactory in its methodology) has not demonstrated the teratogenicity of antiherpes treatments in 830,000 infants. In prevention of HIV transmission, no microbicidal gel had shown efficacy to date. This has now been accomplished in South Africa with a 1% tenofovir gel. The results of a preliminary trial on therapeutic vaccination against HPV16 proposed to women who are carriers of cervical intraepithelial neoplasia opens the way for wide vaccine therapy of cutaneous virus-induced neoplasia. In conclusion, several articles analyzing the dermatology literature provide an opportunity to reflect on the quality of such articles, Boutron's being absolutely in-dis-pen-sa-ble!

Evaluation of and perspectives on guidelines: what is important?

Tan et al. critically appraised the quality of eight guidelines for the treatment of psoriasis published by five working groups between 2006 and 2009, using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Four groups used the standards established by the AGREE instrument. All guidelines received high scores for "scope and purpose" and "clarity and presentation," but each of the guidelines was found to have important shortcomings in at least one item, including "stakeholder involvement," "development rigor," "applicability," and "editorial independence." The investigators conclude that, despite the use of predefined standards in their development, important deficiencies exist in the most recent clinical treatment guidelines for psoriasis.