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Foley P, Mahar PD, Smith SD, Gupta M, Manuelpillai N, Orchard D, Wong LC, Su JC, James A, Fischer G, Marshman G, Rawlin M, Turner M, King E, Kennedy R, Baker C. Australian consensus: Treatment goals for moderate to severe psoriasis in the era of targeted therapies - Considerations for paediatric patients. Australas J Dermatol 2024. [PMID: 38741474 DOI: 10.1111/ajd.14303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/14/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Treatment goals have been established in Australia to facilitate the management of adults with moderate to severe psoriasis. The Australasian College of Dermatologists sought to determine if and how these adult treatment goals could be modified to accommodate the needs of paediatric and adolescent patients. METHODS A modified Delphi approach was used. Comprehensive literature review and guideline evaluation resulted in the development of statements and other questions to establish current clinical practices. Two rounds of anonymous voting were undertaken, with a collaborative meeting held in between to discuss areas of discordance. Overall, consensus was defined as achievement of ≥75% agreement in the range 7-9 on a 9-point scale (1 strongly disagree; 9 strongly agree). RESULTS Consensus was achieved on 23/29 statements in round 1 and 17/18 statements in round 2. There was a high level of concordance with treatment criteria in the adult setting. The limitations of applying assessment tools developed for use in adult patients to the paediatric setting were highlighted. Treatment targets in the paediatric setting should include objective metrics for disease severity and psychological impact on the patients and their family, and be based on validated, age-appropriate tools. CONCLUSION While the assessment, classification and management of moderate to severe psoriasis in paediatric patients aligns with metrics established for adults, it is vital that nuances in the transition from childhood to adolescence be taken into account. Future research should focus on psoriasis severity assessment scales specific to the paediatric setting.
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Affiliation(s)
- Peter Foley
- Skin Health Institute, Carlton, Victoria, Australia
- Department of Dermatology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick D Mahar
- Skin Health Institute, Carlton, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
- Department of Dermatology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Saxon D Smith
- Sydney Adventist Hospital Clinical School, ANU College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia
- The Dermatology and Skin Cancer Centre, St Leonards, New South Wales, Australia
| | - Monisha Gupta
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- The Skin Hospital, Westmead, New South Wales, Australia
- The University of New South Wales, Sydney, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
| | - Nicholas Manuelpillai
- Department of Dermatology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - David Orchard
- Department of Dermatology, The Royal Children's Hospital, Parkville, Victoria, Australia
- Barkers Road Dermatology, Kew, Victoria, Australia
| | - Li-Chuen Wong
- Royal Prince Alfred Hospital Medical Centre, Newtown, New South Wales, Australia
- Department of Dermatology, Children's Hospital, Westmead, New South Wales, Australia
- The University of Sydney, Camperdown, New South Wales, Australia
| | - John C Su
- The University of Melbourne, Melbourne, Victoria, Australia
- Department of Dermatology, The Royal Children's Hospital, Parkville, Victoria, Australia
- Eastern Health, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Amelia James
- Department of Dermatology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Gayle Fischer
- The University of Sydney, Camperdown, New South Wales, Australia
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Gillian Marshman
- Dermatology Clinic, Flinders Medical Centre, Adelaide, South Australia, Australia
- Willan House Dermatology, Brighton, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Morton Rawlin
- Macedon Medical Centre, Templestowe Lower, Victoria, Australia
| | | | - Emma King
- Department of Dermatology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Robyn Kennedy
- Department of Dermatology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Christopher Baker
- Skin Health Institute, Carlton, Victoria, Australia
- Department of Dermatology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
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2
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Wang J, Zhang CS, Zhang AL, Yu J, Deng H, Chen H, Xue CC, Lu C. Add-on effects of Chinese herbal medicine external application (FZHFZY) to topical urea for mild-to-moderate psoriasis vulgaris: Protocol for a double-blinded randomized controlled pilot trial embedded with a qualitative study. PLoS One 2024; 19:e0297834. [PMID: 38512933 PMCID: PMC10956750 DOI: 10.1371/journal.pone.0297834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 01/01/2024] [Indexed: 03/23/2024] Open
Abstract
Psoriasis vulgaris is a chronic dermatological disease with a high global prevalence. It significantly reduces patients' quality of life and is associated with a substantial economic burden. Conventional therapies for mild-to-moderate psoriasis are often associated with insufficient long-term symptomatic relief and side effects. Chinese herbal medicine (CHM) is commonly used for psoriasis management. A CHM formula, namely Fu zheng he fu zhi yang (FZHFZY), has shown promising treatment effects in clinical practice when used as a bath therapy. However, its efficacy and safety has not been evaluated by a rigorous randomized controlled trial (RCT). Therefore, we designed a double-blinded pilot RCT embedded with a qualitative study on CHM formula FZHFZY plus topical urea for mild-to-moderate psoriasis vulgaris to advance the evidence development and practice of CHM external application for psoriasis. This will be a mixed-method design consisting of a pilot RCT and a qualitative study. The pilot RCT is a two-arm, parallel, placebo-controlled, double-blinded trial. Sixty eligible participants will be randomized at a 1:1 ratio to receive eight weeks' treatment of either FZHFZY plus 10% urea cream, or placebo plus 10% urea cream, with 12-week follow-up visits after the treatment phase. The CHM or placebo will be administered externally as a bath therapy. Outcome measures include trial feasibility, efficacy and safety. The primary efficacy outcome will be Psoriasis Area Severity Index (PASI). Secondary efficacy outcomes include Physician Global Assessment, PASI-75, PASI-50, Body Surface Area, Dermatology Life Quality Index, Skindex-16, itch visual analogue scale and relapse. The qualitative study will be conducted to collect participants' feedback on CHM external application and their experience with the pilot RCT. This study will advance the evidence-based clinical practice of using CHM for psoriasis vulgaris and then to support translation of findings into clinical practice in the future. Trial registration number: ChiCTR2200064092.
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Affiliation(s)
- Junyue Wang
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Claire Shuiqing Zhang
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Anthony Lin Zhang
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Jingjie Yu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Hao Deng
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Haiming Chen
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Charlie Changli Xue
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Chuanjian Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine and Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macau Joint Lab on Chinese Medicine and Immune Disease Research, Guangzhou University of Chinese Medicine, Guangzhou, China
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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3
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Leung AKC, Barankin B, Lam JM, Leong KF. Childhood guttate psoriasis: an updated review. Drugs Context 2023; 12:2023-8-2. [PMID: 37908643 PMCID: PMC10615329 DOI: 10.7573/dic.2023-8-2] [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: 08/20/2023] [Accepted: 09/25/2023] [Indexed: 11/02/2023] Open
Abstract
Background Guttate psoriasis is common and affects 0.5-2% of individuals in the paediatric age group. This review aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis and proper management of guttate psoriasis. Methods A search was conducted in July 2023 in PubMed Clinical Queries using the key term "guttate psoriasis". The search strategy included all observational studies, clinical trials and reviews published within the past 10 years. The information retrieved from the search was used in the compilation of the present article. Results Guttate psoriasis typically presents with an abrupt onset of numerous, small, scattered, tear-drop-shaped, scaly, erythematous, pruritic papules and plaques. Sites of predilection include the trunk and proximal extremities. There may be a history of preceding streptococcal infection. Koebner phenomenon is characteristic. Guttate psoriasis may spontaneously remit within 3-4 months with no residual scarring, may intermittently recur and, in 40-50% of cases, may persist and progress to chronic plaque psoriasis. Given the possibility for spontaneous remission within several months, active treatment may not be necessary except for cosmetic purposes or because of pruritus. On the other hand, given the high rates of persistence of guttate psoriasis and progression to chronic plaque psoriasis, some authors suggest active treatment of this condition. Conclusion Various treatment options are available for guttate psoriasis. Triggering and exacerbating factors should be avoided if possible. Topical corticosteroids alone or in combination with other topical agents (e.g. tazarotene and vitamin D analogues) are the most rapid and efficient treatment for guttate psoriasis and are therefore the first-line treatment for mild cases. Other topical therapies include vitamin D analogues, calcineurin inhibitors, anthralin, coal tar and tazarotene. Ultraviolet phototherapy is the first-line therapy for moderate-to-severe guttate psoriasis, as it is more practical than topical therapy when treating widespread or numerous small lesions. Systemic immunosuppressive and immunomodulatory therapies (e.g. methotrexate, cyclosporine, retinoids, fumaric acid esters and biologics) may be considered for patients with moderate-to-severe guttate psoriasis who fail to respond to phototherapy and topical therapies.
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Affiliation(s)
- Alexander KC Leung
- Department of Pediatrics, The University of Calgary, Calgary, Alberta, Canada
- The Alberta Children’s Hospital, Calgary, Alberta, Canada
| | | | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Kin Fon Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
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4
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Nikolaishvili M, Di Lernia V. Biological therapies for the treatment of psoriasis in pediatrics. Expert Opin Biol Ther 2023; 23:1219-1226. [PMID: 37936485 DOI: 10.1080/14712598.2023.2281496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/06/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Psoriasis is a multifactorial, immune-mediated condition with predominant skin involvement. It may develop at any age. In one-third of patients, the first symptoms of psoriasis start during childhood or adolescence. A marked impairment of the quality of life of patients and their caregivers is often associated. AREAS COVERED Databases including PubMed and Clinicaltrials.gov were used to identify clinical studies involving pediatric patients with psoriasis. In the last few years, the implementation of therapy with drugs targeting cytokines like interleukin (IL)-12/23 and IL-17A has expanded the number of available therapeutic options in pediatric psoriasis. This review focuses on the latest evidence on the clinical efficacy and safety profile of drugs licensed for severe pediatric psoriasis. EXPERT OPINION Increasing knowledge about the pathogenetic mechanisms underlying pediatric psoriasis is leading to an improvement in disease management. Effective treatment is crucial in patients affected with moderate to severe disease to reduce the burden of the disease and avoid stigmatization. The treatment of pediatric psoriasis remains challenging for specific clinical subtypes, when difficult areas are involved, after resistance to multiple treatments, and when psoriatic arthritis is associated. A personalized approach and a thorough understanding of the disease are required to advance pediatric psoriasis care.
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Affiliation(s)
- Mariam Nikolaishvili
- Faculty of Medicine, Ivane Javakhishvili, Tbilisi State University, Tbilisi, Georgia
| | - Vito Di Lernia
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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5
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Ujiie H, Rosmarin D, Schön MP, Ständer S, Boch K, Metz M, Maurer M, Thaci D, Schmidt E, Cole C, Amber KT, Didona D, Hertl M, Recke A, Graßhoff H, Hackel A, Schumann A, Riemekasten G, Bieber K, Sprow G, Dan J, Zillikens D, Sezin T, Christiano AM, Wolk K, Sabat R, Kridin K, Werth VP, Ludwig RJ. Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases. Front Med (Lausanne) 2022; 9:875492. [PMID: 35755063 PMCID: PMC9218547 DOI: 10.3389/fmed.2022.875492] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022] Open
Abstract
An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.
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Affiliation(s)
- Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - David Rosmarin
- Department of Dermatology, Tufts Medical Center, Boston, MA, United States
| | - Michael P Schön
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany.,Lower Saxony Institute of Occupational Dermatology, University Medical Center Göttingen, Göttingen, Germany
| | - Sonja Ständer
- Center for Chronic Pruritus, Department of Dermatology, University Hospital Muenster, Muenster, Germany
| | - Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Martin Metz
- Institute for Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute for Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Diamant Thaci
- Institute and Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL, United States.,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Kyle T Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL, United States.,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Dario Didona
- Department of Dermatology and Allergology, Philipps-Universität, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-Universität, Marburg, Germany
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Hanna Graßhoff
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Alexander Hackel
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Anja Schumann
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Gant Sprow
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Joshua Dan
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Tanya Sezin
- Department of Dermatology, Columbia University Medical Center, New York, NY, United States
| | - Angela M Christiano
- Department of Dermatology, Columbia University Medical Center, New York, NY, United States
| | - Kerstin Wolk
- Psoriasis Research and Treatment Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Interdisciplinary Group Molecular Immunopathology, Dermatology/Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Sabat
- Psoriasis Research and Treatment Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Interdisciplinary Group Molecular Immunopathology, Dermatology/Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Victoria P Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Ralf J Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
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6
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Katakam BK, Munisamy M, Rao TN, Chiramel MJ, Panda M, Gupta S, PSS R, Seetharam KA. Recommendations for Management of Childhood Psoriasis. Indian Dermatol Online J 2021; 12:S71-S85. [PMID: 34976883 PMCID: PMC8664175 DOI: 10.4103/idoj.idoj_965_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/09/2021] [Accepted: 05/22/2021] [Indexed: 12/17/2022] Open
Abstract
Childhood psoriasis is recognized as a potential multisystem disorder and hence it is imperative to optimize disease management to arrest progression, minimize psychological burden and evolution of metabolic syndrome. Clinical practice recommendations are necessary to assist practitioners in appropriate decision making based on available evidence. Owing to the lack of Indian recommendations on childhood psoriasis, the SIG Pediatric Dermatology under IADVL Academy undertook an evidence-based approach based on published literature on the topic, between January 2000 and July 2020 to frame the recommendations.
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Affiliation(s)
- Bhumesh Kumar Katakam
- Dermatology, Venereology and Leprology, Gandhi Medical College, Secunderabad, Telangana, India
| | - Malathi Munisamy
- Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | | | | | - Maitreyee Panda
- Dermatology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Sandeep Gupta
- Consultant Dermatologist, Balaji Skin Clinic, New Delhi, India
| | - Ranugha PSS
- Dermatology, JSS Medical College and Hospital, JSSAHER, Mysore, Karnataka, India
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Otten M, Mrowietz U, von Kiedrowski RM, Otto R, Altenburg A, Aschoff R, Beissert S, Beiteke U, Bonnekoh B, Hoffmann M, Körber A, Maaßen D, Mössner R, Navarini A, Petering H, Ramaker-Brunke J, Rosenbach T, Schwichtenberg U, Sticherling M, Sondermann W, Thaci D, Timmel A, Tsianakas A, Werfel T, Wilsmann-Theis D, Augustin M. Dokumentation der Psoriasis in der Routineversorgung – Expertenkonsens zu einem deutschen Datensatz. J Dtsch Dermatol Ges 2021; 19:1463-1477. [PMID: 34661349 DOI: 10.1111/ddg.14547_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Marina Otten
- Competenzzentrum für Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
| | - Ulrich Mrowietz
- Psoriasis-Zentrum Kiel, Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | | | - Ramona Otto
- Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
| | - Andreas Altenburg
- Fachbereich für Haut- und Geschlechtskrankheiten, Städtisches Klinikum Dessau, Medizinische Hochschule Brandenburg Theodor Fontane und Fakultät für Gesundheitswissenschaften Brandenburg, Dessau
| | - Roland Aschoff
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Dresden
| | - Stefan Beissert
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | | | | | | | - Rotraut Mössner
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen
| | | | | | | | | | | | | | - Wiebke Sondermann
- Klinik für Dermatologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen
| | - Diamant Thaci
- Exzellenzzentrum für Entzündungsmedizin, Universitätsklinikum Schleswig- Holstein, Campus Lübeck
| | | | | | - Thomas Werfel
- Forschungsabteilung Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover (MHH)
| | | | - Matthias Augustin
- Competenzzentrum für Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
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8
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Otten M, Mrowietz U, von Kiedrowski RM, Otto R, Altenburg A, Aschoff R, Beissert S, Beiteke U, Bonnekoh B, Hoffmann M, Körber A, Maaßen D, Mössner R, Navarini A, Petering H, Ramaker-Brunke J, Rosenbach T, Schwichtenberg U, Sticherling M, Sondermann W, Thaci D, Timmel A, Tsianakas A, Werfel T, Wilsmann-Theis D, Augustin M. Documentation of psoriasis in routine care - expert consensus on a German data set. J Dtsch Dermatol Ges 2021; 19:1463-1475. [PMID: 34622544 DOI: 10.1111/ddg.14547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/20/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Documenting patient data in psoriasis clinical practice can improve care, but standardized and transparent documentation is rare. The current project aimed to develop a data set for the documentation of psoriasis in daily practice. MATERIAL AND METHODS In four online Delphi rounds and one in-person meeting, 27 psoriasis experts allocated variables to a standard, an optimal and an optional data set. Most of the questions were standardized. Open questions were included to allow for the provision of reasons and to enlarge the data sets. Furthermore, in the in-person meeting we considered a) patients' attitudes and b) dermatologists' information on the current usage and acceptability in Germany. RESULTS The consensus approach resulted in a data set with 69 variables. The standard data set includes 20, the optimal data set 31 and the optional data set 18 variables. In summary, the data set can mainly be grouped into master data, general status and medical history data, medical history of psoriasis, status of psoriasis, diagnostics and comorbidity, therapies and patient-reported outcomes. CONCLUSIONS The consensus recommendation of a standard, an optimal and an optional data set for routine care of psoriasis intends to be a decision-making aid and an orientation for both daily practice and further development of documentation systems.
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Affiliation(s)
- Marina Otten
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Ulrich Mrowietz
- Psoriasis-Center Kiel, Department of Dermatology, Venerology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Ramona Otto
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Andreas Altenburg
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany
| | - Roland Aschoff
- Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Stefan Beissert
- Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ulrike Beiteke
- Department of Dermatology, Hospital of Dortmund, Dortmund, Germany
| | - Bernd Bonnekoh
- Department of Dermatology, University Hospital Magdeburg, Magdeburg, Germany
| | | | | | | | - Rotraut Mössner
- Department of Dermatology, Venerology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Alexander Navarini
- Department of Dermatology, University Hospital Zurich, Zürich, Switzerland
| | | | | | | | | | - Michael Sticherling
- Department of Dermatology, University Medical Center Erlangen, Erlangen, Germany
| | - Wiebke Sondermann
- Clinic for Dermatology, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Diamant Thaci
- Comprehensive Center for Inflammation Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | | | | | - Thomas Werfel
- Division of Immunodermatology and Allergy Reasearch, Department of Dermatology and Allergy, Hannover Medical School (MHH), Hannover, Germany
| | | | - Matthias Augustin
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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9
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Burden-Teh E, Murphy R, Gran S, Nijsten T, Hughes C, Abdul-Wahab A, Bewley A, Burrows N, Darne S, Gach JE, Katugampola R, Jury CS, Kuet K, Llewellyn J, McPherson T, Ravenscroft JC, Taibjee S, Wilkinson C, Thomas KS. Identifying the best predictive diagnostic criteria for psoriasis in children (< 18 years): a UK multicentre case-control diagnostic accuracy study (DIPSOC study). Br J Dermatol 2021; 186:341-351. [PMID: 34477218 PMCID: PMC9298773 DOI: 10.1111/bjd.20689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND In children, psoriasis can be challenging to diagnose. Difficulties arise from differences in the clinical presentation compared with adults. OBJECTIVES To test the diagnostic accuracy of previously agreed consensus criteria and to develop a shortlist of the best predictive diagnostic criteria for childhood psoriasis. METHODS A case-control diagnostic accuracy study in 12 UK dermatology departments (2017-2019) assessed 18 clinical criteria using blinded trained investigators. Children (< 18 years) with dermatologist-diagnosed psoriasis (cases, N = 170) or a different scaly inflammatory rash (controls, N = 160) were recruited. The best predictive criteria were identified using backward logistic regression, and internal validation was conducted using bootstrapping. RESULTS The sensitivity of the consensus-agreed criteria and consensus scoring algorithm was 84·6%, the specificity was 65·1% and the area under the curve (AUC) was 0·75. The seven diagnostic criteria that performed best were: (i) scale and erythema in the scalp involving the hairline, (ii) scaly erythema inside the external auditory meatus, (iii) persistent well-demarcated erythematous rash anywhere on the body, (iv) persistent erythema in the umbilicus, (v) scaly erythematous plaques on the extensor surfaces of the elbows and/or knees, (vi) well-demarcated erythematous rash in the napkin area involving the crural fold and (vii) family history of psoriasis. The sensitivity of the best predictive model was 76·8%, with specificity 72·7% and AUC 0·84. The c-statistic optimism-adjusted shrinkage factor was 0·012. CONCLUSIONS This study provides examination- and history-based data on the clinical features of psoriasis in children and proposes seven diagnostic criteria with good discriminatory ability in secondary-care patients. External validation is now needed.
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Affiliation(s)
- E Burden-Teh
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Dermatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R Murphy
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Dermatology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - S Gran
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - T Nijsten
- Department of Dermatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - C Hughes
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - A Abdul-Wahab
- Department of Dermatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Bewley
- Department of Dermatology, Barts Health NHS Trust, London, UK
| | - N Burrows
- Department of Dermatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Darne
- Department of Dermatology, The James Cook University Hospital, Middlesbrough, UK
| | - J E Gach
- Department of Dermatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - R Katugampola
- Department of Dermatology, Cardiff and Vale University Health Board, Cardiff, UK
| | - C S Jury
- Department of Dermatology, Royal Hospital for Children, Glasgow, UK
| | - K Kuet
- Department of Dermatology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - J Llewellyn
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Dermatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - T McPherson
- Department of Dermatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J C Ravenscroft
- Department of Paediatric Dermatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Taibjee
- Department of Dermatology, Dorset County Hospital NHS Foundation Trust, Dorchester, UK
| | - C Wilkinson
- Department of Dermatology, University Hospital Plymouth NHS Trust, Plymouth, UK
| | - K S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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10
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Volc-Platzer B. Fumaric acid esters for paediatric psoriasis. Br J Dermatol 2021; 185:5-6. [PMID: 34216014 DOI: 10.1111/bjd.20057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 11/27/2022]
Affiliation(s)
- B Volc-Platzer
- Karl Landsteiner Institute for Paediatric Dermatology, Vienna, Austria & Medical University of Vienna, Austria
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11
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Stephan B, Tittelbach J, Bühler S. Reisevorbereitungen für Patienten mit Psoriasis unter Immunsuppression. J Dtsch Dermatol Ges 2021; 19:197-208. [PMID: 33586903 DOI: 10.1111/ddg.14377_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Brigitte Stephan
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg
| | | | - Silja Bühler
- Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg
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12
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Haulrig MB, Zachariae C, Skov L. Off-Label Treatments for Pediatric Psoriasis: Lessons for the Clinic. PSORIASIS (AUCKLAND, N.Z.) 2021; 11:1-20. [PMID: 33604269 PMCID: PMC7886293 DOI: 10.2147/ptt.s268462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/14/2021] [Indexed: 11/23/2022]
Abstract
Psoriasis is a chronic inflammatory skin disease that affects up to 1.2% of children and adolescents. The treatment options for childhood psoriasis are often based on the same principles as in adults. However, most data on safety and efficacy derive from adult studies, and only a few of the frequently used treatments have achieved approval for use in children. The aim of this study was to review the current literature on off-label treatments for psoriasis in children and adolescents. We searched PubMed and identified 50 studies on off-label treatments. Of these, 23 studies were clinical trials (four randomized). There are only a small number of available studies on off-label treatments for children and adolescents with psoriasis, and many of these are retrospective reviews with few participants. Despite the current lack of studies, we still recommend the use of unapproved treatments since we have clinical experience with treatments such as topical corticosteroids, vitamin D analogs, and methotrexate that have shown promising effects. Regular clinical trials are needed to investigate the safety and efficacy of unapproved treatments. Due to The Pediatric Investigation Plans issued by The European Union, new drugs developed by pharmaceutical companies are required to undergo clinical trials in a pediatric population to get their application for marketing authorization processed. This will hopefully lead to much more data on the efficacy and safety of the new treatments, including treatments for children and adolescents with psoriasis.
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Affiliation(s)
- Morten B Haulrig
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, DK-2900, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, DK-2900, Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS), Hellerup, Denmark
| | - Lone Skov
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, DK-2900, Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS), Hellerup, Denmark
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13
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Stephan B, Tittelbach J, Bühler S. Considerations for patients with psoriasis travelling under immunosuppression. J Dtsch Dermatol Ges 2021; 19:197-207. [PMID: 33491922 DOI: 10.1111/ddg.14377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Abstract
With the establishment of modern systemic therapies for psoriasis, comprehensive consultation is required for travelling with immune modulation. Logistic aspects regarding transport and storage, climatic peculiarities of the country of travel and drug dependent risks regarding infections must be considered. Vaccinations and preventive measures are emphasized. Depending on the current national recommendations, special features of vaccinations while under immunosuppression must be taken into account.
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Affiliation(s)
- Brigitte Stephan
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Jörg Tittelbach
- Department of Dermatology, University Hospital of Jena, Jena, Germany
| | - Silja Bühler
- Bernhard Nocht Institute for Tropical Medicine (BNITM), Hamburg, Germany
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14
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Abstract
Subcutaneous secukinumab (Cosentyx®) is a recombinant, fully human, immunoglobulin (Ig) G1κ monoclonal antibody targeted against interleukin (IL)-17A, a proinflammatory cytokine involved in the pathogenesis of psoriasis. Secukinumab is approved in the EU and the USA for the treatment of moderate to severe plaque psoriasis in pediatric patients aged ≥ 6 years. In pivotal phase III trials in pediatric patients aged 6 to < 18 years, both low (75-150 mg) and high (75-300 mg) doses of secukinumab were significantly better than placebo and numerically better than etanercept at week 12 in terms of the proportion of patients achieving ≥ 75% improvement from baseline in Psoriasis Area and Severity Index and significantly better than placebo and etanercept in terms of the proportion of patients achieving an Investigator's Global Assessment score of 0 or 1. The clinical efficacy of secukinumab observed during the first 12 weeks of treatment was maintained over the longer term. Treatment with secukinumab improved health-related quality of life and was generally well tolerated. In conclusion, secukinumab represents a valuable new addition to the limited treatment options available for children and adolescents with moderate to severe plaque psoriasis.
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Affiliation(s)
- Hannah A. Blair
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754 New Zealand
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15
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Lauffer F, Eyerich K, Boehncke WH, Asadullah K, Beissert S, Ghoreschi K, Schön MP. Zytokine der IL‐17‐Familie bei der Psoriasis. J Dtsch Dermatol Ges 2020; 18:675-681. [PMID: 32713148 DOI: 10.1111/ddg.14124_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/26/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Felix Lauffer
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Kilian Eyerich
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Wolf-Henning Boehncke
- Division of Dermatology and Venereology and Department of Pathology and Immunology, Hôpitaux Universitaires de Genève, University of Geneva, Schweiz
| | | | - Stefan Beissert
- Universitätsklinikum Carl Gustav Carus, Klinik und Poliklinik für Dermatologie, Dresden
| | - Kamran Ghoreschi
- Klinik für Dermatologie, Venerologie und Allergologie, Charité, Universitätsmedizin Berlin
| | - Michael P Schön
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen.,Niedersächsisches Institut für Berufsdermatologie, Universitätsmedizin Göttingen
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16
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Lauffer F, Eyerich K, Boehncke WH, Asadullah K, Beissert S, Ghoreschi K, Schön MP. Cytokines of the IL-17 family in psoriasis. J Dtsch Dermatol Ges 2020; 18:675-681. [PMID: 32447845 DOI: 10.1111/ddg.14124] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/26/2020] [Indexed: 12/14/2022]
Abstract
Various immune cells and their messenger substances influence the development of psoriasis. Cytokines of the IL-17 family are of particular importance. In addition to IL-17A, which plays a central role in the pathogenesis of psoriasis, other subtypes of the IL-17 family also have a proinflammatory effect. This review provides an up-to-date overview of the immunopathogenesis of psoriasis with regard to the six IL-17 subtypes, in particular their physiological and pathogenic properties, as well as their significance for psoriasis therapy.
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Affiliation(s)
- Felix Lauffer
- Department of Dermatology and Allergy Biederstein, University hospital of the Technical University Munich (TUM), Munich, Germany
| | - Kilian Eyerich
- Department of Dermatology and Allergy Biederstein, University hospital of the Technical University Munich (TUM), Munich, Germany
| | - Wolf-Henning Boehncke
- Division of Dermatology and Venereology and Department of Pathology and Immunology, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | | | - Stefan Beissert
- Department of Dermatology, Carl Gustav Carus University Medical Center, Dresden Technical University, Dresden, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael P Schön
- Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen University, Göttingen, Germany.,Lower Saxony Institute of Occupational Dermatology, Göttingen, Germany
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17
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Frantz T, Wright EG, Balogh EA, Cline A, Adler-Neal AL, Feldman SR. Topical and Oral Therapies for Childhood Atopic Dermatitis and Plaque Psoriasis. CHILDREN (BASEL, SWITZERLAND) 2019; 6:E125. [PMID: 31694234 PMCID: PMC6915686 DOI: 10.3390/children6110125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment of atopic dermatitis and psoriasis in children is difficult due to lack of standardized treatment guidelines and few FDA-approved treatment options. Treatments approved for adults may be used off-label in pediatric patients. OBJECTIVE This review evaluates the topical and oral treatment options available, including off-label uses, and provides a basic therapeutic guideline for pediatric atopic dermatitis and psoriasis. METHODS A PubMed review of topical and systemic treatments for pediatric psoriasis and atopic dermatitis with information regarding age, efficacy, dosing, contra-indications, adverse events, and off-label treatments. RESULTS The search identified seven topical and five systemic treatments that are routinely employed to treat pediatric atopic dermatitis and psoriasis. LIMITATIONS Standardized guidelines regarding treatment choice, dosing, and long-term safety are scarce. Reviews may be subject to ascertainment bias. CONCLUSIONS Current treatment guidelines are based on clinical experience and expert advice with few treatments officially approved for atopic dermatitis and psoriasis in children.
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Affiliation(s)
- Travis Frantz
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Ellen G Wright
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Esther A Balogh
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Abigail Cline
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Adrienne L Adler-Neal
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
- Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
- Department of Dermatology, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
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