A systematic review of 454 randomized controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries

BACKGROUND

Over 29 years of clinical application, the Dermatology Life Quality Index (DLQI) has remained the most used patient-reported outcome (PRO) in dermatology due to its robustness, simplicity and ease of use.

OBJECTIVES

To generate further evidence of the DLQI's utility in randomized controlled trials (RCTs) and to cover all diseases and interventions.

METHODS

The methodology followed PRISMA guidelines and included seven bibliographical databases, searching articles published from 1 January 1994 until 16 November 2021. Articles were reviewed independently by two assessors, and an adjudicator resolved any opinion differences.

RESULTS

Of 3220 screened publications, 454 articles meeting the eligibility criteria for inclusion, describing research on 198 190 patients, were analysed. DLQI scores were primary endpoints in 24 (5.3%) of studies. Most studies were of psoriasis (54.1%), although 69 different diseases were studied. Most study drugs were systemic (85.1%), with biologics comprising 55.9% of all pharmacological interventions. Topical treatments comprised 17.0% of total pharmacological interventions. Nonpharmacological interventions, mainly laser therapy and ultraviolet radiation treatment, comprised 12.2% of the total number of interventions. The majority of studies (63.7%) were multicentric, with trials conducted in at least 42 different countries; 40.2% were conducted in multiple countries. The minimal clinically importance difference (MCID) was reported in the analysis of 15.0% of studies, but only 1.3% considered full score meaning banding of the DLQI. Forty-seven (10.4%) of the studies investigated statistical correlation of the DLQI with clinical severity assessment or other PRO/quality of life tools; and 61-86% of studies had within-group scores differences greater than the MCID in 'active treatment arms'. The Jadad risk-of-bias scale showed that bias was generally low, as 91.8% of the studies had Jadad scores of ≥ 3; only 0.4% of studies showed a high risk of bias from randomization. Thirteen per cent had a high risk of bias from blinding and 10.1% had a high risk of bias from unknown outcomes of all participants in the studies. In 18.5% of the studies the authors declared that they followed an intention-to-treat protocol; imputation for missing DLQI data was used in 34.4% of studies.

CONCLUSIONS

This systematic review provides a wealth of evidence of the use of the DLQI in clinical trials to inform researchers' and -clinicians' decisions for its further use. Recommendations are also made for improving the reporting of data from future RCTs using the DLQI.

The impact of phototherapy on itch intensity and itch-related quality of life amongst different skin diseases, skin phototypes and genders - A prospective study with 102 patients

BACKGROUND

Phototherapy is a mainstay to treat itchy conditions. However, only little is known about differences in the antipruritic effect of phototherapy amongst different skin conditions, phototypes and genders.

METHODS

In this prospective, single-center study, we analyzed the effect of phototherapy on itch intensity and itch-related quality of life amongst these subgroups after a treatment duration of 4 weeks, while on-demand treatment with topical corticosteroids, topical calcineurin inhibitors and/or antihistamines was allowed.

RESULTS

Of 102 patients (age 53.0 ± 18.7, 56 females [54.9%]), 72 (78.3%) reported a significant reduction of itch intensity by Δ -2.76 on a 0-10 Numerical Rating Scale (NRS), p = <.001, 95% CI [2.2; 3.3] paralleled by a significant improvement of itch-related quality of life as measured by the German version of the ItchyQoL by Δ 7.3, p = <.001, 95% CI [4.4; 11.6]. The best improvement of itch intensity and itch-related QoL was reported by patients with pruritus on non-diseased skin (ΔNRS -3.5; Δ 9.7 Ger-ItchyQoL points), followed by patients with atopic dermatitis and psoriasis. We found no statistical differences in the response to phototherapy amongst Fitzpatrick phototypes I-VI. Women had higher itch intensities at baseline but itch-related quality of life impairment at baseline and phototherapy treatment response did not significantly differ between genders.

CONCLUSION

Phototherapy appears to induce a meaningful itch reduction in various itchy skin conditions, all phototypes and both genders within 4 weeks that directly translates into improvement of itch-related quality of life.

Phototherapy for atopic eczema

BACKGROUND

Atopic eczema (AE), also known as atopic dermatitis, is a chronic inflammatory skin condition that causes significant burden. Phototherapy is sometimes used to treat AE when topical treatments, such as corticosteroids, are insufficient or poorly tolerated.

OBJECTIVES

To assess the effects of phototherapy for treating AE.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov to January 2021.

SELECTION CRITERIA

We included randomised controlled trials in adults or children with any subtype or severity of clinically diagnosed AE. Eligible comparisons were any type of phototherapy versus other forms of phototherapy or any other treatment, including placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. For key findings, we used RoB 2.0 to assess bias, and GRADE to assess certainty of the evidence. Primary outcomes were physician-assessed signs and patient-reported symptoms. Secondary outcomes were Investigator Global Assessment (IGA), health-related quality of life (HRQoL), safety (measured as withdrawals due to adverse events), and long-term control.

MAIN RESULTS

We included 32 trials with 1219 randomised participants, aged 5 to 83 years (mean: 28 years), with an equal number of males and females. Participants were recruited mainly from secondary care dermatology clinics, and study duration was, on average, 13 weeks (range: 10 days to one year). We assessed risk of bias for all key outcomes as having some concerns or high risk, due to missing data, inappropriate analysis, or insufficient information to assess selective reporting. Assessed interventions included: narrowband ultraviolet B (NB-UVB; 13 trials), ultraviolet A1 (UVA1; 6 trials), broadband ultraviolet B (BB-UVB; 5 trials), ultraviolet AB (UVAB; 2 trials), psoralen plus ultraviolet A (PUVA; 2 trials), ultraviolet A (UVA; 1 trial), unspecified ultraviolet B (UVB; 1 trial), full spectrum light (1 trial), Saalmann selective ultraviolet phototherapy (SUP) cabin (1 trial), saltwater bath plus UVB (balneophototherapy; 1 trial), and excimer laser (1 trial). Comparators included placebo, no treatment, another phototherapy, topical treatment, or alternative doses of the same treatment. Results for key comparisons are summarised (for scales, lower scores are better): NB-UVB versus placebo/no treatment There may be a larger reduction in physician-assessed signs with NB-UVB compared to placebo after 12 weeks of treatment (mean difference (MD) -9.4, 95% confidence interval (CI) -3.62 to -15.18; 1 trial, 41 participants; scale: 0 to 90). Two trials reported little difference between NB-UVB and no treatment (37 participants, four to six weeks of treatment); another reported improved signs with NB-UVB versus no treatment (11 participants, nine weeks of treatment). NB-UVB may increase the number of people reporting reduced itch after 12 weeks of treatment compared to placebo (risk ratio (RR) 1.72, 95% CI 1.10 to 2.69; 1 trial, 40 participants). Another trial reported very little difference in itch severity with NB-UVB (25 participants, four weeks of treatment). The number of participants with moderate to greater global improvement may be higher with NB-UVB than placebo after 12 weeks of treatment (RR 2.81, 95% CI 1.10 to 7.17; 1 trial, 41 participants). NB-UVB may not affect rates of withdrawal due to adverse events. No withdrawals were reported in one trial of NB-UVB versus placebo (18 participants, nine weeks of treatment). In two trials of NB-UVB versus no treatment, each reported one withdrawal per group (71 participants, 8 to 12 weeks of treatment). We judged that all reported outcomes were supported with low-certainty evidence, due to risk of bias and imprecision. No trials reported HRQoL. NB-UVB versus UVA1 We judged the evidence for NB-UVB compared to UVA1 to be very low certainty for all outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (MD -2.00, 95% CI -8.41 to 4.41; 1 trial, 46 participants; scale: 0 to 108), or patient-reported itch after six weeks (MD 0.3, 95% CI -1.07 to 1.67; 1 trial, 46 participants; scale: 0 to 10). Two split-body trials (20 participants, 40 sides) also measured these outcomes, using different scales at seven to eight weeks; they reported lower scores with NB-UVB. One trial reported HRQoL at six weeks (MD 2.9, 95% CI -9.57 to 15.37; 1 trial, 46 participants; scale: 30 to 150). One split-body trial reported no withdrawals due to adverse events over 12 weeks (13 participants). No trials reported IGA. NB-UVB versus PUVA We judged the evidence for NB-UVB compared to PUVA (8-methoxypsoralen in bath plus UVA) to be very low certainty for all reported outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (64.1% reduction with NB-UVB versus 65.7% reduction with PUVA; 1 trial, 10 participants, 20 sides). There was no evidence of a difference in marked improvement or complete remission after six weeks (odds ratio (OR) 1.00, 95% CI 0.13 to 7.89; 1 trial, 9/10 participants with both treatments). One split-body trial reported no withdrawals due to adverse events in 10 participants over six weeks. The trials did not report patient-reported symptoms or HRQoL. UVA1 versus PUVA There was very low-certainty evidence, due to serious risk of bias and imprecision, that PUVA (oral 5-methoxypsoralen plus UVA) reduced physician-assessed signs more than UVA1 after three weeks (MD 11.3, 95% CI -0.21 to 22.81; 1 trial, 40 participants; scale: 0 to 103). The trial did not report patient-reported symptoms, IGA, HRQoL, or withdrawals due to adverse events. There were no eligible trials for the key comparisons of UVA1 or PUVA compared with no treatment. Adverse events Reported adverse events included low rates of phototoxic reaction, severe irritation, UV burn, bacterial superinfection, disease exacerbation, and eczema herpeticum.

AUTHORS' CONCLUSIONS

Compared to placebo or no treatment, NB-UVB may improve physician-rated signs, patient-reported symptoms, and IGA after 12 weeks, without a difference in withdrawal due to adverse events. Evidence for UVA1 compared to NB-UVB or PUVA, and NB-UVB compared to PUVA was very low certainty. More information is needed on the safety and effectiveness of all aspects of phototherapy for treating AE.

Differences in phototherapy among skin diseases and genders in real-life conditions-A retrospective analysis of the cumulative doses, numbers of sessions, side effects and costs in 561 patients

BACKGROUND

Phototherapy has been a mainstay therapy for dermatological diseases since more than a century. Although phototherapy is still extensively used and some recommendations exist, only scarce data are available addressing disease-specific differences in cumulative doses, treatment durations and costs. Knowledge of such differences could help to avoid over-/undertreatment, predict treatment duration and costs. Therefore, we sought to determine differences in cumulative doses, numbers of sessions, side effects and costs among different skin diseases and genders in real-life conditions.

METHODS

In this single-centre, retrospective study, patients treated with phototherapy between March 2014 and April 2019 were classified into seven diagnostic groups and analysed according to the study goals.

RESULTS

Out of 561 patients (age 53.9 ± 20.3 yrs; 52.9% females), 83.7% percent were treated with cabin NB-UVB (mean cumulative dose 17.79 ± 17.11 J/cm² ). Patients with vitiligo and psoriasis were treated with significantly higher cumulative NB-UVB doses (cabin, local) in comparison with the five other diagnostic groups as were males in comparison with females. Consequently, significantly higher UV-related costs resulted in patients with vitiligo, psoriasis and males. Patients with atopic dermatitis and pruritus were treated with significantly higher cumulative UVA1 doses compared to patients with non-atopic eczema. The complication rate (pooled from all UV modalities) in our population was 3.8% (erythema 3.4%, aggravated itch 0.4% and worsening of symptoms 0.2%).

CONCLUSIONS

Our results demonstrate that cumulative doses and phototherapy-related costs vary strongly among skin diseases-a fact not adequately considered in recommendations. A more disease-specific stratification of phototherapy could not only help to optimize outcomes, but also to facilitate comparability of clinical trials using phototherapy.

Intense Pulsed Light Treatment for Itch Associated with Allergic Keratoconjunctivitis: A Retrospective Study of 35 Cases

Objective: To conduct a preliminary assessment of intense pulsed light (IPL) treatment for allergic keratoconjunctivitis (AKC)-associated ocular itch. Background: Current control measures for AKC rely primarily on drugs. IPL is effective for dry eye disease (DED). Furthermore, phototherapy is effective for managing skin inflammation and pruritus, suggesting that eye itching could decrease in some patients having AKC complicated with DED following IPL treatment to control dry eye symptoms. Methods: Thirty-five patients having DED complicated with mid-to-severe AKC were administered three IPL treatments to the periorbital skin. The eye scores of subjective symptoms and signs of AKC and tear film breakup time (TBUT) were retrospectively assessed before and after each treatment. Results: The scores for AKC-related symptoms and signs were determined four times: on Day 1 (time 0), Day 15 (time 1), Day 45 (time 2), and Day 75 (time 3) before each treatment. The average symptom score significantly decreased with treatments (time 0: 30.97, time 1: 15.03, time 3: 10). The average sign score for both eyes decreased after the first IPL treatment (left eye: 7.97 vs. 11.38; right eye: 8.1 vs. 11.1). There were no further improvements in the signs after the last treatment. The TBUT value in the right eye increased from times 0 to 3 (2.31 vs. 4.66 vs. 7.71 vs. 7.74). The TBUT value in the left eye increased from times 0 to 3 (2.50 vs. 6.97 vs. 7.57 vs. 8.24). Conclusions: Symptoms and signs improved after IPL treatment in patients with AKC. Eye itching was gradually controlled and rarely recurred. IPL may be effective for AKC treatment.

Individual variation in the transmission of UVB radiation in the young adult eye

Objectives

Data obtained mostly from animal models and ex vivo samples show that a small portion of ultraviolet light (UV, 300–400 nm) penetrates the cornea and crystalline lens and impinges on the human retina. UV transmission to the retina appears to be unique to the young and some older pseudophakes. In this study, we determine the variation in UV transmission in a relatively homogenous sample of young adults.

Methods

42 subjects were tested (M = 19 ± 1.3 years). Absolute thresholds to UV radiation were collected (λmax = 315 nm, 305–325). Macular pigment optical density (MPOD, measured using heterochromatic flicker photometry) and iris color (using a standardized color scale) were also assessed as potential covariates.

Results

All of the subjects could detect UV radiation at 315 nm but individual variation was large (over a factor of 30). Higher MPOD and darker iridies were not related to UV sensitivity in this young sample. Males, however, were more sensitive to UV than the females (p<0.05).

Conclusions

The large individual differences in UV reaching the retina of younger individuals suggests equally significant vulnerability to the actinic effects of this highly energetic light.