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Singh S, Kirtschig G, Anchan VN, Chi CC, Taghipour K, Boyle RJ, Murrell DF. Interventions for bullous pemphigoid. Cochrane Database Syst Rev 2023; 8:CD002292. [PMID: 37572360 PMCID: PMC10421473 DOI: 10.1002/14651858.cd002292.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. OBJECTIVES To assess the effects of treatments for bullous pemphigoid. SEARCH METHODS We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA RCTs of treatments for immunofluorescence-confirmed bullous pemphigoid. DATA COLLECTION AND ANALYSIS At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. MAIN RESULTS We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti-inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo-controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate-certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low-certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low-certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate-certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low-certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low-certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high-certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate-certainty evidence). Mortality occurred in 2.4% (3/132) of participants with doxycycline and 9.7% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high-certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life-threatening treatment-related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate-certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low-certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low-certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low-certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. AUTHORS' CONCLUSIONS Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower-dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard-dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation.
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Affiliation(s)
- Sanjay Singh
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Vinayak N Anchan
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ching-Chi Chi
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Kathy Taghipour
- Department of Dermatology, Whittington Health NHS Trust, London, UK
| | - Robert J Boyle
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital & University of New South Wales, Sydney, Australia
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Asilian A, Safaei H, Iraji F, Fatemi Naeini F, Faghihi G, Mokhtari F. Interventions for bullous pemphigoid: An updated systematic review of randomized clinical trials. Med J Islam Repub Iran 2021; 35:111. [PMID: 34956957 PMCID: PMC8683802 DOI: 10.47176/mjiri.35.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Indexed: 11/12/2022] Open
Abstract
Background: Bullous pemphigoid (BP) is a widely recognized autoimmune blistering disease (AIBD) linked with a high incidence of morbidity and mortality. The aim of this study was to evaluate the available findings of randomized clinical trial studies to update interventions for Bullous pemphigoid.
Methods: This article provides an updated overview of interventions for BP. A literature search was performed using Cochrane Central Register of Clinical Trials, MEDLINE, Scopus, and Web of Science from August 2010 to December 2020. All randomized clinical trials (RCTs) were done on adults and investigated the effectiveness of administered topical or systemic medications versus placebos or controls included in the current systematic review. Three RCTs comprising 363 patients were included in the systematic review. One of the eligible studies was placebo-controlled. All of the included studies used various interventions including, methylprednisolone plus azathioprine versus methylprednisolone plus dapsone, doxycycline versus prednisolone, and intravenous immunoglobulin (IVIG).
Results: Following their potentials in disease control, no difference was observed between dapsone and azathioprine; although, dapsone had a higher corticosteroid-sparing potential. The evaluation of the effect of doxycycline in short-term blister control in comparison to corticosteroids showed that the medication was not inferior to prednisolone, although it had a higher long-term safety.
Conclusion: Therapeutic outcome of IVIG for steroid-resistant patients was satisfactory. Moreover, the effectiveness and reliability of various immunosuppressive drugs and tetracyclines are investigated by blinded RCTs for the treatment of BP.
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Affiliation(s)
- Ali Asilian
- Department of Dermatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hoda Safaei
- Department of Dermatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fariba Iraji
- Department of Dermatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farahnaz Fatemi Naeini
- Department of Dermatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gita Faghihi
- Department of Dermatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Mokhtari
- Department of Dermatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Gehring M, Wieczorek D, Kapp A, Wedi B. Potent Anti-Inflammatory Effects of Tetracyclines on Human Eosinophils. FRONTIERS IN ALLERGY 2021; 2:754501. [PMID: 35386966 PMCID: PMC8974775 DOI: 10.3389/falgy.2021.754501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/10/2021] [Indexed: 11/13/2022] Open
Abstract
Eosinophils are potent pro-inflammatory cells. Not only in allergic diseases but also in other diseases there is a need for treatment strategies to induce resolution of eosinophil-mediated inflammation. During the last years beneficial non-antibiotic activities of tetracyclines (TCNs) have been shown in different diseases in which eosinophils play a role, for example, asthma and bullous pemphigoid. The working mechanism of these effects remains to be clarified. Aim of the present study was to investigate the effects of TCNs on eosinophils. Flow cytometry analysis of apoptosis, mitochondrial membrane potential, activation of caspases, intracellular H2O2 and calcium, surface expression of eosinophil activation markers was performed in highly purified peripheral blood eosinophils of non-atopic donors. Tetracycline hydrochloride, minocycline and doxycycline significantly induced eosinophil apoptosis. All TCNs were able to significantly overcome the strong survival enhancing effects of pro-eosinophilic cytokines and staphylococcus aureus enterotoxins. Tetracycline hydrochloride induced eosinophil apoptosis was accompanied by intracellular production of hydrogen peroxide, loss of mitochondrial membrane potential and activation of caspases. Moreover, tetracycline hydrochloride significantly down regulated eosinophil surface expression of CD9 and CD45, and of the activation markers CD11b and CD69, but not of CD54, CD63, or CD95. Our data, propably for the first time, point to a potent anti-inflammatory role of TCNs on eosinophils.
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Fagundes PPS, Santi CG, Maruta CW, Miyamoto D, Aoki V. Autoimmune bullous diseases in pregnancy: clinical and epidemiological characteristics and therapeutic approach. An Bras Dermatol 2021; 96:581-590. [PMID: 34304937 PMCID: PMC8441454 DOI: 10.1016/j.abd.2020.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/09/2020] [Accepted: 10/17/2020] [Indexed: 01/11/2023] Open
Abstract
Autoimmune bullous dermatoses are a heterogeneous group of diseases with autoantibodies against structural skin proteins. Although the occurrence of autoimmune bullous dermatoses during pregnancy is low, this topic deserves attention, since the immunological and hormonal alterations that occur during this period can produce alterations during the expected course of these dermatoses. The authors review the several aspects of autoimmune bullous dermatoses that affect pregnant women, including the therapeutic approach during pregnancy and breastfeeding. Gestational pemphigoid, a pregnancy-specific bullous disease, was not studied in this review.
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Affiliation(s)
| | - Claudia Giuli Santi
- Department of Dermatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Celina Wakisaka Maruta
- Department of Dermatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Denise Miyamoto
- Department of Dermatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Valeria Aoki
- Department of Dermatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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A Review of Acquired Autoimmune Blistering Diseases in Inherited Epidermolysis Bullosa: Implications for the Future of Gene Therapy. Antibodies (Basel) 2021; 10:antib10020019. [PMID: 34067512 PMCID: PMC8161452 DOI: 10.3390/antib10020019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/24/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
Gene therapy serves as a promising therapy in the pipeline for treatment of epidermolysis bullosa (EB). However, with great promise, the risk of autoimmunity must be considered. While EB is a group of inherited blistering disorders caused by mutations in various skin proteins, autoimmune blistering diseases (AIBD) have a similar clinical phenotype and are caused by autoantibodies targeting skin antigens. Often, AIBD and EB have the same protein targeted through antibody or mutation, respectively. Moreover, EB patients are also reported to carry anti-skin antibodies of questionable pathogenicity. It has been speculated that activation of autoimmunity is both a consequence and cause of further skin deterioration in EB due to a state of chronic inflammation. Herein, we review the factors that facilitate the initiation of autoimmune and inflammatory responses to help understand the pathogenesis and therapeutic implications of the overlap between EB and AIBD. These may also help explain whether corrections of highly immunogenic portions of protein through gene therapy confers a greater risk towards developing AIBD.
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Yoon J, Choi JW. Primary cicatricial alopecia in a single-race Asian population: A 10-year nationwide population-based study in South Korea. J Dermatol 2018; 45:1306-1311. [DOI: 10.1111/1346-8138.14625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/29/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Jisun Yoon
- Department of Dermatology; Ajou University School of Medicine; Suwon Korea
| | - Jee Woong Choi
- Department of Dermatology; Ajou University School of Medicine; Suwon Korea
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Zhang Y, Hwang BJ, Liu Z, Li N, Lough K, Williams SE, Chen J, Burette SW, Diaz LA, Su MA, Xiao S, Liu Z. BP180 dysfunction triggers spontaneous skin inflammation in mice. Proc Natl Acad Sci U S A 2018; 115:6434-6439. [PMID: 29866844 PMCID: PMC6016813 DOI: 10.1073/pnas.1721805115] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BP180, also known as collagen XVII, is a hemidesmosomal component and plays a key role in maintaining skin dermal/epidermal adhesion. Dysfunction of BP180, either through genetic mutations in junctional epidermolysis bullosa (JEB) or autoantibody insult in bullous pemphigoid (BP), leads to subepidermal blistering accompanied by skin inflammation. However, whether BP180 is involved in skin inflammation remains unknown. To address this question, we generated a BP180-dysfunctional mouse strain and found that mice lacking functional BP180 (termed ΔNC16A) developed spontaneous skin inflammatory disease, characterized by severe itch, defective skin barrier, infiltrating immune cells, elevated serum IgE levels, and increased expression of thymic stromal lymphopoietin (TSLP). Severe itch is independent of adaptive immunity and histamine, but dependent on increased expression of TSLP by keratinocytes. In addition, a high TSLP expression is detected in BP patients. Our data provide direct evidence showing that BP180 regulates skin inflammation independently of adaptive immunity, and BP180 dysfunction leads to a TSLP-mediated itch. The newly developed mouse strain could be a model for elucidation of disease mechanisms and development of novel therapeutic strategies for skin inflammation and BP180-related skin conditions.
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Affiliation(s)
- Yang Zhang
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, 710004 Shaanxi, China
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Bin-Jin Hwang
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Zhen Liu
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Guangdong Center for Adverse Drug Reactions of Monitoring, 510000 Guangzhou, China
| | - Ning Li
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Kendall Lough
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Scott E Williams
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Jinbo Chen
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Wuhan No. 1 Hospital, The Fourth Affiliated Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, China
| | - Susan W Burette
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Luis A Diaz
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Maureen A Su
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Shengxiang Xiao
- Department of Dermatology, The Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, 710004 Shaanxi, China;
| | - Zhi Liu
- Department of Dermatology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599;
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
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Abstract
Autoimmune bullous diseases (AIBD), including pemphigus, bullous pemphigoid, epidermolysis bullosa acquisita, mucous membrane pemphigoid, and pemphigoid gestationis, pose significant therapeutic challenges, especially in pregnant and post-partum breastfeeding patients or those planning to conceive. Data on the safety and efficacy of therapeutic interventions during the perinatal period are lacking because randomized controlled trials are typically not performed in this setting. However, many of the treatments for AIBD are also used in other diseases, so data can be extrapolated from studies or case reports in these other patient populations. It appears that many of the treatments for AIBD can adversely affect the fetus or neonate, and alterations in immune status caused by pregnancy-associated hormonal changes can negatively impact disease control. This article summarizes and weighs the risks and benefits of the various agents used to treat AIBD during pregnancy. We also present the available information on lactation as well as effects on male fertility.
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Affiliation(s)
- Carolyn J Kushner
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Josef Symon S Concha
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Section of Dermatology, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
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Mason JM, Chalmers JR, Godec T, Nunn AJ, Kirtschig G, Wojnarowska F, Childs M, Whitham D, Schmidt E, Harman K, Walton S, Chapman A, Williams HC. Doxycycline compared with prednisolone therapy for patients with bullous pemphigoid: cost-effectiveness analysis of the BLISTER trial. Br J Dermatol 2018; 178:415-423. [PMID: 28940316 DOI: 10.1111/bjd.16006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder associated with significant morbidity and mortality. Doxycycline and prednisolone to treat bullous pemphigoid were compared within a randomized controlled trial (RCT). OBJECTIVES To compare the cost-effectiveness of doxycycline-initiated and prednisolone-initiated treatment for patients with BP. METHODS Quality-of-life (EuroQoL-5D-3L) and resource data were collected as part of the BLISTER trial: a multicentre, parallel-group, investigator-blinded RCT. Within-trial analysis was performed using bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost-effectiveness from a health service perspective. RESULTS In the base case, there was no robust difference in costs or QALYs per patient at 1 year comparing doxycycline- with prednisolone-initiated therapy [net cost £959, 95% confidence interval (CI) -£24 to £1941; net QALYs -0·024, 95% CI -0·088 to 0·041]. However, the findings varied by baseline blister severity. For patients with mild or moderate blistering (≤ 30 blisters) net costs and outcomes were similar. For patients with severe blistering (> 30 blisters) net costs were higher (£2558, 95% CI -£82 to £5198) and quality of life poorer (-0·090 QALYs, 95% CI -0·22 to 0·042) for patients starting on doxycycline. The probability that doxycycline would be cost-effective for those with severe pemphigoid was 1·5% at a willingness to pay of £20 000 per QALY. CONCLUSIONS Consistently with the clinical findings of the BLISTER trial, patients with mild or moderate blistering should receive treatment guided by the safety and effectiveness of the drugs and patient preference - neither strategy is clearly a preferred use of National Health Service resources. However, prednisolone-initiated treatment may be more cost-effective for patients with severe blistering.
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Affiliation(s)
- J M Mason
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, U.K
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - T Godec
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - A J Nunn
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7BN, U.K
| | - M Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - D Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - K Harman
- Dermatology Department, Leicester Royal Infirmary, University Hospitals Leicester, Leicester, LE1 5WW, U.K
| | - S Walton
- Castle Hill Hospital, Castle Road, Cottingham, Hull, HU16 5JQ, U.K
| | - A Chapman
- Queen Elizabeth Hospital, Greenwich, London, SE18 4QH, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
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Batchelor JM, Chapman A, Craig FE, Harman KE, Kirtschig G, Martin-Clavijo A, Ormerod AD, Walton S, Williams HC. Generating new evidence, improving clinical practice and developing research capacity: the benefits of recruiting to the U.K. Dermatology Clinical Trials Network's STOP GAP and BLISTER trials. Br J Dermatol 2017; 177:e228-e234. [PMID: 29124728 DOI: 10.1111/bjd.15959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2017] [Indexed: 10/18/2022]
Abstract
Clinical trials may benefit clinical practice in three ways: firstly, clinicians may change their practice according to the new trial evidence; secondly, clinical processes can improve when working on a trial; and thirdly, research capacity is increased. We held a meeting to present and discuss the results of two large multicentre randomized controlled trials delivered through the U.K. Dermatology Clinical Trials Network. Investigators gave reflections on how the trials had changed their clinical practice. The STOP GAP trial showed that prednisolone and ciclosporin are equally effective as first-line systemic treatment for pyoderma gangrenosum. The final decision of which treatment to use should be based on the different adverse event profiles of the two drugs in relation to comorbidities, along with age, disease severity and patient preference. The BLISTER trial showed that starting people with pemphigoid on doxycycline produces acceptable short-term effectiveness and a superior safety profile to oral corticosteroids. Recruiting to these trials has led to the development of new specialist clinics with improved documentation. It has increased the profile of participating departments and embedded research in the department's activities. Helping to design and run these trials has also allowed trial staff to develop new skills in research design, which has been beneficial for career development. These and other benefits of recruiting to the trials are summarized here. We hope that these reflections will inspire wider involvement in clinical research.
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Affiliation(s)
- J M Batchelor
- Centre of Evidence Based Dermatology, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
| | - A Chapman
- Department of Dermatology, Lewisham and Greenwich NHS Trust, London, U.K
| | - F E Craig
- Division of Applied Medicine, Aberdeen University, Aberdeen, U.K
| | - K E Harman
- Department of Dermatology, University Hospitals Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, U.K
| | - G Kirtschig
- Institute of General Practice and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - A Martin-Clavijo
- Department of Dermatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, U.K
| | - A D Ormerod
- Division of Applied Medicine, Aberdeen University, Aberdeen, U.K
| | - S Walton
- Department of Dermatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
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Chalmers JR, Wojnarowska F, Kirtschig G, Mason J, Childs M, Whitham D, Harman K, Chapman A, Walton S, Schmidt E, Godec TR, Nunn AJ, Williams HC. A randomised controlled trial to compare the safety, effectiveness and cost-effectiveness of doxycycline (200 mg/day) with that of oral prednisolone (0.5 mg/kg/day) for initial treatment of bullous pemphigoid: the Bullous Pemphigoid Steroids and Tetracyclines (BLISTER) trial. Health Technol Assess 2017; 21:1-90. [PMID: 28406394 DOI: 10.3310/hta21100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder with increased morbidity and mortality in the elderly. OBJECTIVES To evaluate the effectiveness, safety and cost-effectiveness of a strategy of initiating BP treatment with oral doxycycline or oral prednisolone. We hypothesised that starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral prednisolone. DESIGN Pragmatic multicentre two-armed parallel-group randomised controlled trial with an economic evaluation. SETTING A total of 54 dermatology secondary care centres in the UK and seven in Germany. PARTICIPANTS Adults with BP [three or more blisters at two sites and positive direct and/or indirect immunofluorescence (immunoglobulin G and/or complement component 3 immunofluorescence at the dermal-epidermal junction)] and able to give informed consent. INTERVENTIONS Participants were allocated using online randomisation to initial doxycycline treatment (200 mg/day) or prednisolone (0.5 mg/kg/day). Up to 30 g/week of potent topical corticosteroids was permitted for weeks 1-3. After 6 weeks, clinicians could switch treatments or alter the prednisolone dose as per normal practice. MAIN OUTCOME MEASURES Primary outcomes: (1) the proportion of participants with three or fewer blisters at 6 weeks (investigator blinded) and (2) the proportion with severe, life-threatening and fatal treatment-related events at 52 weeks. A regression model was used in the analysis adjusting for baseline disease severity, age and Karnofsky score, with missing data imputed. Secondary outcomes included the effectiveness of blister control after 6 weeks, relapses, related adverse events and quality of life. The economic evaluation involved bivariate regression of costs and quality-adjusted life-years (QALYs) from a NHS perspective. RESULTS In total, 132 patients were randomised to doxycycline and 121 to prednisolone. The mean patient age was 77.7 years and baseline severity was as follows: mild 31.6% (three to nine blisters), moderate 39.1% (10-30 blisters) and severe 29.3% (> 30 blisters). For those starting on doxycycline, 83 out of 112 (74.1%) had three or fewer blisters at 6 weeks, whereas for those starting on prednisolone 92 out of 101 (91.1%) had three or fewer blisters at 6 weeks, an adjusted difference of 18.6% in favour of prednisolone [90% confidence interval (CI) 11.1% to 26.1%], using a modified intention-to-treat (mITT) analysis. Per-protocol analysis showed similar results: 74.4% compared with 92.3%, an adjusted difference of 18.7% (90% CI 9.8% to 27.6%). The rate of related severe, life-threatening and fatal events at 52 weeks was 18.2% for those started on doxycycline and 36.6% for those started on prednisolone (mITT analysis), an adjusted difference of 19.0% (95% CI 7.9% to 30.1%; p = 0.001) in favour of doxycycline. Secondary outcomes showed consistent findings. There was no significant difference in costs or QALYs per patient at 1 year between doxycycline-initiated therapy and prednisolone-initiated therapy (incremental cost of doxycycline-initiated therapy £959, 95% CI -£24 to £1941; incremental QALYs of doxycycline-initiated therapy -0.024, 95% CI -0.088 to 0.041). Using a willingness-to-pay criterion of < £20,000 per QALY gained, the net monetary benefit associated with doxycycline-initiated therapy was negative but imprecise (-£1432, 95% CI -£3094 to £230). CONCLUSIONS A strategy of starting BP patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control and considerably safer in the long term. The limitations of the trial were the wide non-inferiority margin, the moderate dropout rate and that serious adverse event collection was unblinded. Future work might include inducing remission with topical or oral corticosteroids and then randomising to doxycycline or prednisolone for maintenance. TRIAL REGISTRATION Current Controlled Trials ISRCTN13704604. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Gudula Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - James Mason
- Durham University, School of Medicine, Pharmacy and Health, Stockton-on-Tees, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Karen Harman
- University Hospitals Leicester, Dermatology Department, Leicester Royal Infirmary, Leicester, UK
| | | | | | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Thomas R Godec
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Abstract
Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease in Western countries, and typically affects the elderly. BP is immunologically characterized by tissue-bound and circulating autoantibodies directed against either the BP antigen 180 (BP180, or BPAG2) or the BP antigen 230 (BP230, or BPAG1e), or even both, which are components of hemidesmosomes involved in the dermal-epidermal cohesion. Risk factors for BP include old age, neurologic diseases (dementia, Parkinson's disease, cerebrovascular disease), and some particular drugs, including loop diuretics, spironolactone and neuroleptics. The spectrum of clinical presentations is extremely broad. Clinically, BP is an intensely pruritic erythematous eruption with widespread blister formation. In the early stages, or in atypical, non-bullous variants of the disease, only excoriated, eczematous or urticarial lesions (either localized or generalized) are present. The diagnosis of BP relies on immunopathologic findings, especially based on both direct and indirect immunofluorescence microscopy observations, as well as on anti-BP180/BP230 enzyme-linked immunosorbent assays (ELISAs). BP is usually a chronic disease, with spontaneous exacerbations and remissions, which may be accompanied by significant morbidity. In the past decade, potent topical corticosteroids have emerged as an effective and safe first-line treatment for BP, but their long-term feasibility is still controversial. Newer therapeutic agents targeting molecules involved in the inflammatory cascade associated with BP represent future alternatives to classical immunosuppressant drugs for maintenance therapy.
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Bağcı IS, Horváth ON, Ruzicka T, Sárdy M. Bullous pemphigoid. Autoimmun Rev 2017; 16:445-455. [DOI: 10.1016/j.autrev.2017.03.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 11/27/2022]
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Williams HC, Wojnarowska F, Kirtschig G, Mason J, Godec TR, Schmidt E, Chalmers JR, Childs M, Walton S, Harman K, Chapman A, Whitham D, Nunn AJ. Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic, non-inferiority, randomised controlled trial. Lancet 2017; 389:1630-1638. [PMID: 28279484 PMCID: PMC5400809 DOI: 10.1016/s0140-6736(17)30560-3] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 11/07/2016] [Accepted: 11/22/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Bullous pemphigoid is a blistering skin disorder with increased mortality. We tested whether a strategy of starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral corticosteroids. METHODS We did a pragmatic, multicentre, parallel-group randomised controlled trial of adults with bullous pemphigoid (three or more blisters at two or more sites and linear basement membrane IgG or C3). Participants were randomly assigned to doxycycline (200 mg per day) or prednisolone (0·5 mg/kg per day) using random permuted blocks of randomly varying size, and stratified by baseline severity (3-9, 10-30, and >30 blisters for mild, moderate, and severe disease, respectively). Localised adjuvant potent topical corticosteroids (<30 g per week) were permitted during weeks 1-3. The non-inferiority primary effectiveness outcome was the proportion of participants with three or fewer blisters at 6 weeks. We assumed that doxycycline would be 25% less effective than corticosteroids with a 37% acceptable margin of non-inferiority. The primary safety outcome was the proportion with severe, life-threatening, or fatal (grade 3-5) treatment-related adverse events by 52 weeks. Analysis (modified intention to treat [mITT] for the superiority safety analysis and mITT and per protocol for non-inferiority effectiveness analysis) used a regression model adjusting for baseline disease severity, age, and Karnofsky score, with missing data imputed. The trial is registered at ISRCTN, number ISRCTN13704604. FINDINGS Between March 1, 2009, and Oct 31, 2013, 132 patients were randomly assigned to doxycycline and 121 to prednisolone from 54 UK and seven German dermatology centres. Mean age was 77·7 years (SD 9·7) and 173 (68%) of 253 patients had moderate-to-severe baseline disease. For those starting doxycycline, 83 (74%) of 112 patients had three or fewer blisters at 6 weeks compared with 92 (91%) of 101 patients on prednisolone, an adjusted difference of 18·6% (90% CI 11·1-26·1) favouring prednisolone (upper limit of 90% CI, 26·1%, within the predefined 37% margin). Related severe, life-threatening, and fatal events at 52 weeks were 18% (22 of 121) for those starting doxycycline and 36% (41 of 113) for prednisolone (mITT), an adjusted difference of 19·0% (95% CI 7·9-30·1), p=0·001. INTERPRETATION Starting patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control in bullous pemphigoid and significantly safer in the long-term. FUNDING NIHR Health Technology Assessment Programme.
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Affiliation(s)
- Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.
| | | | - Gudula Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK; Institute of General Medicine and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Thomas R Godec
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | | | - Karen Harman
- Dermatology Department, Leicester Royal Infirmary, Leicester, UK
| | - Anna Chapman
- Dermatology Department, Queen Elizabeth Hospital, Greenwich, London, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at University College London, London, UK
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Kim M, Borradori L, Murrell DF. Autoimmune Blistering Diseases in the Elderly: Clinical Presentations and Management. Drugs Aging 2016; 33:711-723. [DOI: 10.1007/s40266-016-0402-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Chen SC, Kim SY. A framework for analysis of research risks and benefits to participants in standard of care pragmatic clinical trials. Clin Trials 2016; 13:605-611. [PMID: 27365010 DOI: 10.1177/1740774516656945] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Standard of care pragmatic clinical trials that compare treatments already in use could improve care and reduce costs, but there is considerable debate about the research risks of standard of care pragmatic clinical trials and how to apply informed consent regulations to such trials. We sought to develop a framework integrating the insights from opposing sides of the debate. METHODS We developed a formal risk-benefit analysis framework for standard of care pragmatic clinical trials and then applied it to key provisions of the US federal regulations. RESULTS Our formal framework for standard of care pragmatic clinical trial risk-benefit analysis takes into account three key considerations: the ex ante estimates of risks and benefits of the treatments to be compared in a standard of care pragmatic clinical trial, the allocation ratios of treatments inside and outside such a trial, and the significance of some participants receiving a different treatment inside a trial than outside the trial. The framework provides practical guidance on how the research ethics regulations on informed consent should be applied to standard of care pragmatic clinical trials. CONCLUSION Our proposed formal model makes explicit the relationship between the concepts used by opposing sides of the debate about the research risks of standard of care pragmatic clinical trials and can be used to clarify the implications for informed consent.
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Affiliation(s)
- Stephanie C Chen
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Scott Yh Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Hofmann SC. Doxycycline in the treatment of bullous pemphigoid: as good as systemic corticosteroids? Br J Dermatol 2016; 173:17-8. [PMID: 26174646 DOI: 10.1111/bjd.13844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- S C Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios Hospital Wuppertal, University Witten/Herdecke, Heusnerstr. 40, 42283, Wuppertal, Germany.
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Meijer JM, Jonkman MF, Wojnarowska F, Wiliams HC, Kirtschig G. Current practice in treatment approach for bullous pemphigoid: comparison between national surveys from the Netherlands and the UK. Clin Exp Dermatol 2016; 41:506-9. [PMID: 26940484 DOI: 10.1111/ced.12831] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 11/30/2022]
Abstract
Treatment approaches for bullous pemphigoid (BP), the most common autoimmune skin blistering disease, are largely based on national and international guidelines. We conducted a national survey among dermatologists in the Netherlands to explore the current treatment of BP, and compared the results with those of a previously published survey from the UK. Almost all responders in the Netherlands (n = 175) used very potent topical corticosteroids, both as monotherapy and as adjunctive therapy. In contrast to UK dermatologists, the majority recommended whole-body application rather than local application to lesions. Systemic antibiotics were used by > 70% of responders. Half of the responders in the Netherlands considered systemic steroids the first-choice treatment, with the majority also using adjunctive therapy as a routine. Despite many similarities in treatment approach between the two countries, these surveys provide an important insight into the gap between actual and recommended practice at a country level in relation to the best external evidence.
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Affiliation(s)
- J M Meijer
- Department of Dermatology, Center for Skin Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - M F Jonkman
- Department of Dermatology, Center for Skin Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - H C Wiliams
- Center of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - G Kirtschig
- Institute of General Practice and Professional Care, University Hospital Tübingen, Tübingen, Germany
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