Sex‐ and age‐adjusted prevalence estimates of five chronic inflammatory skin diseases in France: results of the « OBJECTIFS PEAU » study

PNAd-expressing vessels characterize the dermis of CD3+ T-cell-mediated cutaneous diseases

T-cell recruitment to skin tissues is essential for inflammation in different cutaneous diseases; however, the mechanisms by which these T cells access the skin remain unclear. High endothelial venules expressing peripheral node address in (PNAd), an L-selectin ligand, are located in secondary lymphoid organs and are responsible for increasing T-cell influx into the lymphoid tissues. They are also found in non-lymphoid tissues during inflammation. However, their presence in different common inflammatory cutaneous diseases and their correlation with T-cell infiltration remain unclear. Herein, we explored the mechanisms underlying the access of T cells to the skin by investigating the presence of PNAd-expressing vessels in different cutaneous diseases, and its correlation with T cells' presence. Skin sections of 43 patients with different diseases were subjected to immunohistochemical and immunofluorescence staining to examine the presence of PNAd-expressing vessels in the dermis. The correlation of the percentage of these vessels in the dermis of these patients with the severity/grade of CD3+ T-cell infiltration was assessed. PNAd-expressing vessels were commonly found in the skin of patients with different inflammatory diseases. A high percentage of these vessels in the dermis was associated with increased severity of CD3+ T-cell infiltration (P < 0.05). Additionally, CD3+ T cells were found both around the PNAd-expressing vessels and within the vessel lumen. PNAd-expressing vessels in cutaneous inflammatory diseases, characterized by CD3+ T-cell infiltration, could be a crucial entry point for T cells into the skin. Thus, selective targeting of these vessels could be beneficial in cutaneous inflammatory disease treatment.

Vitiligo patient population and disease burden in France: VIOLIN study results from the CONSTANCES cohort

BACKGROUND

Vitiligo is a chronic autoimmune disease resulting in skin depigmentation.

OBJECTIVES

This study assessed the prevalence, disease burden and treatment of vitiligo in France.

METHODS

VIOLIN was a cross-sectional study nested in the national CONSTANCES cohort, which consists of randomly selected adults aged 18-69 years in France. In VIOLIN, longitudinal data were collected prospectively from 158,898 participants during 2012-2018 and linked to the National Health Data System (SNDS), a healthcare utilization database. Patients with physician-diagnosed vitiligo were matched (1:3) with control participants based on age, sex, geographic region, year of inclusion and skin phototype. Patients completed a questionnaire in 2022 to collect disease characteristics, disease burden and quality-of-life (QoL) data.

RESULTS

Vitiligo prevalence was 0.71% (681/95,597) in 2018. The mean age in the vitiligo population was 51.2 years; 51.4% were women. Most patients (63%) were diagnosed before age 30 years, mainly by dermatologists (83.5%). Most patients (81.1%) had visible lesions (i.e. on face, hands). Vitiligo was limited to <10% of the body surface area (BSA) in 85.8% of patients. Comorbidities including thyroid disease (18.0% vs. 9.0%), psoriasis (13.7% vs. 9.7%), atopic dermatitis (12.4% vs. 10.3%), depression (18.2% vs. 14.6%) and alopecia areata (4.3% vs. 2.4%) were significantly more common in patients with vitiligo versus matched controls (n = 2043). QoL was significantly impaired in patients with >5% BSA involvement or visible lesions, particularly with ≥10% facial involvement. Vitiligo-specific instruments (i.e. Vitiligo Impact Patient scale and Vitiligo-specific QoL instrument) were more sensitive to QoL differences among subgroups versus general skin instruments, and generic instruments were least sensitive. Most patients (83.8%) did not receive any prescribed treatment.

CONCLUSIONS

Patients with vitiligo in France have a high disease burden, particularly those with visible lesions or higher BSA involvement. Most patients are not receiving treatment, highlighting the need for new effective treatments and patient/physician education.

Impact of Baricitinib on Patients' Quality of Life after One Year of Treatment for Atopic Dermatitis in Real-World Practice: Results of the Observatory of Chronic Inflammatory Skin Diseases Registry

The efficacy and safety of baricitinib for treatment of atopic dermatitis have been demonstrated in clinical trials; however, very few real-life studies have been published to date. The Observatory of Chronic Inflammatory Skin Diseases (OMCCI) registry was initiated to prospectively determine the long-term impairment caused by chronic inflammatory dermatoses on patients' lives. The study included 88 patients starting baricitinib for treatment of atopic dermatitis. Clinical evaluation and patient-reported outcomes were recorded at baseline and after 6 and 12 months. After 6 months and 1 year of follow-up, 65 and 47 patients, respectively, were still being treated with baricitinib. Treatment failure was the main reason for discontinuation. Only 1 patient stopped baricitinib because of a side-effect. After 1 year of follow-up, the mean Eczema Area and Severity Index score decreased significantly from 20.7 to 6.4; the percentage of patients with severe atopic dermatitis decreased from 42.9% to 6.5% and a significant improvement in most patient-reported outcomes was noted. There was no difference in terms of efficacy whether or not patients were previously treated with dupilumab. The results remained stable after 6 and 12 months of treatment, which suggests a sustained efficacy of the treatment in patients who initially responded well.

Quality of life and stigmatization in people with skin diseases in Europe: A large survey from the 'burden of skin diseases' EADV project

BACKGROUND

Several large studies on the burden of skin diseases have been performed in patients recruited in hospitals or clinical centres, thus missing people with skin diseases who do not undergo a clinical consultation.

OBJECTIVES

To evaluate the burden of the most common dermatological diseases in adult patients across Europe, in terms of quality of life, work life, and stigmatization.

METHODS

Population-based survey on a representative sample of the European general population aged 18 years or older. Participants who declared to have had one or more skin problem or disease during the previous 12 months completed the Dermatology Life Quality Index questionnaire, and answered questions regarding the impact of their skin disease on daily and work life, anxiety/depression, and stigmatization.

RESULTS

The study population included 19,915 individuals, 44.7% of whom were men. Quality of life was particularly impaired in people with hidradenitis suppurativa (HS), and sexually transmitted diseases. About a half of participants with acne, alopecia, or chronic urticaria, and about 40% of those with atopic dermatitis (AD), skin cancers, or psoriasis reported a modest to extremely large effect of the disease on their quality of life. Overall, 88.1% of participants considered their skin disease as embarrassing in personal life and 83% in work life. About half of the respondents reported sleeping difficulty, feeling tired, and impact of the disease on taking care of themselves. Concerning stigmatization, 14.5% felt to have been rejected by others because of the skin disease, and 19.2% to have been looked at with disgust. Anxiety and depression were frequently reported by patients with all the diseases.

CONCLUSIONS

Skin diseases may heavily affect patients' daily and work life, and cause feelings of stigmatization. An early intervention is needed to avoid consequences on the patients' life course.

Public perception of dermatologists in Europe: Results from a population-based survey

BACKGROUND

The public perception of dermatology has been poorly investigated in Europe.

OBJECTIVE

To determine the general public's perception of dermatologists in Europe.

METHODS

This multinational, cross-sectional study was conducted within the framework of the EADV population-based survey on the 'Burden of skin diseases in Europe'. Data were collected using a web-based online survey on a representative sample of the general populations aged 18 years or more of 27 European countries. Proportional quota sampling with replacement design was used for each country.

RESULTS

A total of 44,689 adult participants responded to the questionnaire, of whom 18,004 visited a dermatologist in the preceding 3 years. The dermatologist was the second most often visited specialist among all medical specialties, with 69.7%, 72.1%, 42.1% and 78.1% of participants in Western Europe (WE), Eastern Europe (EE), Northern Europe (NE) and Southern Europe (SE), respectively, having consulted a dermatologist over the past 24 months. Most participants across all regions agreed that the dermatologist was the first healthcare provider for chronic skin diseases (61.9% in WE, 69.8% in EE, 45.7% in NE and 60.4% in SE) and for skin cancers (65.5% in WE, 67.6% in EE, 42.4% in NE and 63.0% in SE). The five most common reasons for visiting a dermatologist among all participants were: naevi check-up or skin cancer screening (20.2%), chronic skin diseases (16.5%), acute skin diseases (12.4%), cosmetic advice or procedure (10.2%), hyperpigmentation or congenital lesions (9.1%) and hair or nail disorder (7.7%). Most participants (84.6% in WE, 82.5% in EE, 78.3% in NE and 82.8% in SE) were very swatisfied/somewhat satisfied with the service provided.

CONCLUSION

Our study findings underscore the central role of dermatologists in skin health and highlights them as valued and trusted care providers across Europe. Understanding the perceived position of the dermatologist is the first step in improving health policy development and implementation. Notably, access to a dermatologist was lowest in NE, probably reflecting differences in healthcare organizational structures or possibly cultural differences in healthcare seeking behaviour.

Burden of visible [face and hands] skin diseases: Results from a large international survey

BACKGROUND

While numerous surveys over the last decade have evaluated the burden of skin diseases, none have focused on the specific impact of disease-location on the hands and face.

AIM

The purpose of our study was to evaluate the burden of 8 skin diseases on the multidimensional aspects of subjects' daily lives in respect to their location on visible body areas (face or hands) versus non-visible areas.

METHODS

This was a population-based study in a representative sample of the Canadian, Chinese, Italian, Spanish, German and French populations, aged over 18 years using the proportional quota sampling method. All participants were asked (i) to complete a specific questionnaire including socio-demographic characteristics, (ii) to declare if they had a skin disease. All respondents with a skin disease were asked (iii) to specify the respective disease locations (hands, face, body) and (iv) to complete the DLQI questionnaire. Respondents with 8 selected skin diseases were asked (v) to complete a questionnaire evaluating the impact of the skin disease on their daily life, including their professional activity, social relations, emotional and intimate life, leisure, sports activities and perceived stigma.

RESULTS

A total of 13,138 adult participants responded to the questionnaire, of whom 26.2 % (n = 3,450) had skin diseases, and 23.4 % (n = 3,072) reported having one of the 8 selected skin diseases. Fifty-three percent were women and the mean age was 39.6 ± 15.5 years. The QoL was mostly impaired when the visible localization was solely on the hands as compared with the face (38 % had a DLQI > 10 versus 22 % respectively). More subjects with a visible localization on the hands reported felt-stigma, having difficulty falling asleep and felt that their sex life had been affected.

CONCLUSION

Special attention should be given to patients with skin disease on the hands and face as they are at higher risk of social exclusion and lower quality of life.

Switches between biologics in patients with moderate-to-severe psoriasis: results from the French cohort PSOBIOTEQ

BACKGROUND

Biologics are the cornerstone of treatment of patients with moderate-to-severe plaque psoriasis and switches between biologics are frequently needed to maintain clinical improvement over time.

OBJECTIVES

The main purpose of this study was to describe precisely switches between biologics and how their pattern changed over time with the recent availability of new biologic agents.

METHODS

We included patients receiving a first biologic agent in the Psobioteq multicenter cohort of adults with moderate-to-severe psoriasis receiving systemic treatment. We described switches between biologics with chronograms, Sankey and Sunburst diagrams, assessed cumulative incidence of first switch by competing risks survival analysis and reasons for switching. We assessed the factors associated with the type of switch (intra-class - i.e. within the same therapeutic class - vs. inter-class) in patients switching from a TNF-alpha inhibitor using multivariate logistic regression.

RESULTS

A total of 2153 patients was included. The cumulative incidence of switches from first biologic was 34% at 3 years. Adalimumab and ustekinumab were the most prescribed biologic agents as first and second lines of treatment. The main reason for switching was loss of efficacy (72%), followed by adverse events (11%). Patients receiving a TNF-alpha inhibitor before 2016 mostly switched to ustekinumab, whereas those switching in 2016 or after mostly switched to an IL-17 inhibitor. Patients switching from a first-line TNF-alpha inhibitor before 2016 were more likely to switch to another TNF-alpha inhibitor compared with patients switching since 2018. Patients switching from etanercept were more likely to receive another TNF-alpha inhibitor rather than another therapeutic class of bDMARD compared with patients switching from adalimumab.

CONCLUSION

This study described the switching patterns of biologic treatments and showed how they changed over time, due to the availability of the new biologic agents primarily IL-17 inhibitors.

Vitiligo Prevalence and Quality of Life Among Adults in Europe, Japan, and the United States

Background

Vitiligo, an autoimmune disorder characterised by skin depigmentation, is associated with reduced quality of life (QoL). Vitiligo may be under‐reported, in part because of misconceptions that it is a cosmetic disease.

Objectives

This survey sought to characterise vitiligo prevalence and explore the relationship between sociodemographic and clinical characteristics with QoL in a population‐based, multinational study.

Methods

Participants aged ≥18 years were recruited via an online panel in Europe, Japan and the USA to answer questions regarding skin disorders they may have experienced. Those reporting vitiligo (diagnosed or undiagnosed) or vitiligo signs (experiencing loss of skin colour but unaware of vitiligo and not diagnosed) were included in the analyses of vitiligo prevalence. Participants who self‐reported physician‐diagnosed vitiligo were given a broader survey to characterise disease progression, management and QoL (as measured with the Vitiligo‐specific QoL [VitiQoL] instrument).

Results

The total estimated vitiligo prevalence among 35 694 survey participants (Europe, n = 18 785; USA, n = 8517; Japan, n = 8392) was 1.3% (diagnosed, 0.6%; undiagnosed, 0.4%; vitiligo signs, 0.3%). Among 219 patients formally diagnosed with vitiligo (Europe, n = 150; USA, n = 48; Japan, n = 21), total VitiQoL scores were associated with age (P = 0.00017), disease extent (P < 0.0001), disease progression (P < 0.0001), disease management (P < 0.0001) and time since diagnosis (P = 0.0015). Behaviour scores varied based on skin phototype (P = 0.024) and ethnicity (P = 0.048). Higher total VitiQoL scores were reported in patients with head lesions (P = 0.027) and those with head and hand and/or wrist lesions (P = 0.018). Substantial high concern (rated 8–10 on an 11‐point Likert scale) for lesions was found across all body areas and varied with geographical region.

Conclusions

The vitiligo prevalence rate may be higher than previously reported, with a substantial proportion attributed to people who have not received a formal diagnosis. Among formally diagnosed patients with vitiligo, QoL was most severely impacted by more progressive and higher extent of disease.

Long-term Persistence of First-line Biologics for Patients With Psoriasis and Psoriatic Arthritis in the French Health Insurance Database

Importance

Treatment options for psoriasis (PsO) and psoriatic arthritis (PsA) have evolved significantly throughout the era of biologics. Clinical trials are inadequate to assess the relative long-term efficacy of biologics and are often insufficient regarding safety.

Objectives

To assess the long-term persistence of different biologic classes to treat PsO and PsA.

Design, Setting, and Participants

This nationwide cohort study involved the administrative health care database of the French health insurance scheme linked to the hospital discharge database. All adults with PsO and PsA who were new users of biologics (not in the year before the index date) from January 1, 2015, to May 31, 2019, were included and followed up through December 31, 2019. Patients hospitalized for PsA in the PsO cohort and for PsO in the PsA cohort in the year before the index date were excluded. Data were analyzed from June 1 to October 31, 2021.

Main Outcomes and Measures

Persistence was defined as the time from biologic therapy initiation to discontinuation and was estimated using the Kaplan-Meier method. Comparison of persistence by biologic class involved using propensity score-weighted Cox proportional hazards regression models and adjustment on specific systemic nonbiologics (time-dependent variables).

Results

A total of 16 892 patients with PsO were included in the analysis (mean [SD] age, 48.5 [13.8] years; 9152 men [54.2%] men). Of these, 10 199 patients (60.4%) started therapy with a tumor necrosis factor (TNF) inhibitor; 3982 (23.6%), with an interleukin 12 and interleukin 23 (IL-12/23) inhibitor; and 2711 (16.0%), with an interleukin 17 (IL-17) inhibitor. An additional 6531 patients with PsA (mean [SD] age, 49.1 [12.8] years; 3565 [54.6%] women) were included; of these, 4974 (76.2%) started therapy with a TNF inhibitor; 803 (12.3%), with an IL-12/23 inhibitor; and 754 (11.5%), with an IL-17 inhibitor. Overall 3-year persistence rates were 40.9% and 36.2% for PsO and PsA, respectively. After inverse probability of treatment weighting and adjustment, the IL-17 inhibitor was associated with higher persistence compared with the TNF inhibitor for PsO (weighted hazard ratio [HR], 0.78 [95% CI, 0.73-0.83]) and PsA (weighted HR, 0.70 [95% CI, 0.58-0.85]) and compared with the IL-12/23 inhibitor for PsA (weighted HR, 0.69 [95% CI, 0.55-0.87]). No difference between the IL-17 inhibitor and IL-12/23 inhibitor for PsO was noted. The IL-12/23 inhibitor was associated with higher persistence than the TNF inhibitor for PsO (weighted HR, 0.76 [95% CI, 0.72-0.80]), with no difference observed for PsA.

Conclusions and Relevance

The findings of this cohort study suggest that IL-17 inhibitors are associated with higher treatment persistence than the TNF inhibitor for PsO and PsA. Interleukin 17 inhibitors were also associated with higher persistence than the IL-12/23 inhibitor for PsA, with no difference for PsO. However, the persistence rates of all biologics remained globally low at 3 years.

Prevalence of most common skin diseases in Europe: a population-based study

BACKGROUND

The assessment of the prevalence of diseases is of primary importance in planning health policies. No complete data on the prevalence of skin diseases across European countries are available.

OBJECTIVE

To estimate the prevalence of the most frequent skin conditions or diseases in 27 European countries (24 EU countries, plus Norway, Switzerland, and UK).

METHODS

We conducted a population-based study on representative and extrapolable samples of the general population aged 18 years or more in each of the 27 countries surveyed. Participants were selected using a stratified, proportional sampling with replacement design. Data were collected using a web-based online survey. All participants were asked to fill in a questionnaire with sociodemographic data and to declare if they have had one or more skin conditions or diseases during the previous 12 months.

RESULTS

A total of 44,689 participants from 27 countries responded to the questionnaire, 21,887 (48.98%) men and 22,802 (51.02%) women. The proportion of participants who reported having suffered from at least one dermatological condition or disease during the previous 12 months was 43.35% [95% CI 42.89%, 43.81%)]. The projection in the total population of the 27 countries included in the study resulted in 185,103,774 individuals affected by at least one dermatological condition or disease. Accordingly, we can estimate that more 94 million Europeans complain of uncomfortable skin sensations like itch, burning, or dryness. The most frequent conditions were fungal skin infections (8.9%), acne (5.4%), and atopic dermatitis or eczema (5.5%). Alopecia, acne, eczema and rosacea were more common in women, whereas men were more likely to suffer from psoriasis and sexually transmitted infections.

CONCLUSION

Skin diseases are an important public health concern. Their high prevalence has to be taken into account in planning access to dermatological care to address patient needs.

The epidemiology of alopecia areata: a population-based cohort study in UK primary care

BACKGROUND

There is a lack of population-based information on the disease burden and management of alopecia areata (AA).

OBJECTIVES

To describe the epidemiology of AA, focusing on incidence, demographics and patterns of healthcare utilization.

METHODS

Population-based cohort study of 4·16 million adults and children, using UK electronic primary care records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, 2009-2018. The incidence and point prevalence of AA were estimated. Variation in AA incidence by age, sex, deprivation, geographical distribution and ethnicity was examined. Patterns of healthcare utilization were evaluated in people with incident AA.

RESULTS

The AA incidence rate was 0·26 per 1000 person-years. AA point prevalence in 2018 was 0·58% in adults. AA onset peaked at age 25-29 years for both sexes, although the peak was broader in females. People of nonwhite ethnicity were more likely to present with AA, especially those of Asian ethnicity [incidence rate ratio (IRR) 3·32 (95% confidence interval 3·11-3·55)]. Higher AA incidence was associated with social deprivation [IRR most vs. least deprived quintile 1·47 (1·37-1·59)] and urban living [IRR 1·23 (1·14-1·32)]. People of higher social deprivation were less likely to be referred for specialist dermatology review.

CONCLUSIONS

By providing the first large-scale estimates of the incidence and point prevalence of AA, our study helps to understand the burden of AA on the population. Understanding the variation in AA onset between different population groups may give insight into the pathogenesis of AA and its management.

The Atopic Dermatitis Control Tool: A High-Performance Tool for Optimal Support

The evaluation of global atopic dermatitis control is key to minimizing disease burden. The Atopic Dermatitis Control Tool (ADCT) has been developed for this purpose. Participants (diagnosed by a physician) were recruited to this observational cross-sectional study using real-life methodology and completed a questionnaire on sociodemographic and personal information. The ADCT algorithm, described by Pariser, was used to categorize patients as having controlled or uncontrolled atopic dermatitis. Data were collected for 1,606 patients. Median age of the patients was 40 years , and 1,023 (63.7%) patients were women. A total of 1,146 (71.4%) patients had uncontrolled atopic dermatitis according to the ADCT score. Patients with uncontrolled disease were at significantly higher risk of a high stress level and were more likely to be absent from work than those with controlled disease. In conclusion, a key factor for predicting disease burden in atopic dermatitis is patient self-assessed disease control in terms of multiple dimensions: stress, sleep, quality of life, work absenteeism and loss of productivity.

Epidemiology, management and the associated burden of mental health illness, atopic and autoimmune conditions, and common infections in alopecia areata: protocol for an observational study series

INTRODUCTION

Alopecia areata (AA) is a common cause of immune-mediated non-scarring hair loss. Links between AA and common mental health, autoimmune and atopic conditions, and common infections have previously been described but remain incompletely elucidated and contemporary descriptions of the epidemiology of AA in the UK are lacking.

METHODS AND ANALYSIS

Retrospective study series using a large population-based cohort (5.2 million) from the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database, exploring four themes: AA epidemiology, mental health comorbidities, autoimmune/atopic associations and common infections.In the epidemiology theme, we will describe the incidence and point prevalence of AA overall and by age, sex and sociodemographic factors. Healthcare utilisation (primary care visits and secondary care referrals) and treatments for AA will also be assessed. In the mental health theme, we will explore the prevalence and incidence of mental health conditions (anxiety, depressive episodes, recurrent depressive disorder, adjustment disorder, agoraphobia, self-harm and parasuicide) in people with AA compared with matched controls. We will also explore the mental health treatment patterns (medication and psychological interventions), time off work and unemployment rates. Within the autoimmune/atopic associations theme, we will examine the prevalence of atopic (atopic dermatitis, allergic rhinitis, asthma) and autoimmune conditions (Crohn's disease, ulcerative colitis, coeliac disease, type 1 diabetes, Hashimoto's thyroiditis, Graves' disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE), polymyalgia rheumatica, Sjögren's syndrome, psoriasis, vitiligo, multiple sclerosis, pernicious anaemia) in people with AA compared with matched controls. We will also estimate the incidence of new-onset atopic and autoimmune conditions after AA diagnosis. Within the common infections theme, we will examine the incidence of common infections (respiratory tract infection, pneumonia, acute bronchitis, influenza, skin infection, urinary tract infection, genital infections, gastrointestinal infection, herpes simplex, herpes zoster, meningitis, COVID-19) in people with AA compared with matched controls.

ETHICS AND DISSEMINATION

The Health Research Authority decision tool classed this a study of usual practice, ethics approval was not required. Study approval was granted by the RCGP RSC Study Approval Committee. Results will be disseminated through peer-reviewed publications.

OBSERVATIONAL STUDY REGISTRATION NUMBER

NCT04239521.

General Burden of Adult Atopic Dermatitis: An Observational Study of Disease Perceptions among Patients and Dermatologists in France

It is important to understand patients’ and dermatologists’ perceptions of various aspects of atopic dermatitis, but there is a lack of studies on quality of life and stakeholder viewpoints in this therapy area. The aim of this study was to compare patients’ and dermatologists’ viewpoints regarding the impact of atopic dermatitis that is uncontrolled by topical corticosteroids. Data were collected from 348 adult patients who responded to self-administered questionnaires, and 150 telephone interviews with the dermatologists who selected them. Patients and dermatologists reported both convergent and divergent assessments of the impact of atopic dermatitis and its treatment. Notable areas of agreement were regarding the safety of emollients, the time required and difficulty of applying topical corticosteroids, especially to certain parts of the body. Divergent views involved the perceived efficacy of available treatments and the impact of atopic dermatitis on professional life. A greater understanding of these differences would help dermatologists to optimize patient care.

Interest in Micellar Solution to Reduce Unpleasant Skin Sensations

Introduction

The results from the “Objectifs Peau” project showed that approximately 30% of the French population complains of an unpleasant skin sensation at least once a day. Itching was the most frequent complaint (32%), followed by tingling (18.9%) and burning sensation (5.6%), which impact an individual’s daily life. These sensations could be identified, as they were either isolated or associated with each other. The aim of this study was to evaluate the use of micellar solution to reduce these sensations, especially on sensitive skin.

Methodology

A questionnaire was administered at Day 0 (D0), D2, D14, and D28 using a mobile phone application to individuals applying micellar solution (Sensibio H2O, Laboratoire Bioderma, NAOS) who spontaneously used micellar solution for sensitive skin and/or spontaneously consulted a health professional. Itching, tightness, tingling and burning sensations were evaluated by means of frequencies (never, rarely, sometimes, often or constantly) at D0, D2, D14 and D28. Responses from the questionnaire were rated (never=0, rarely=1, sometimes=2, often=3 or constantly=4) and allowed us to obtain an overall “unpleasant sensations” score, where a higher score corresponded to a higher degree of unpleasant sensations.

Results

In total, 400 evaluable individuals participated in the study (97% female, average age 38.5±13 years, 82% reported sensitive skin). The “unpleasant sensations” score improved from D2 and continued significantly on D14 and D28. The improvement rates were 47.7%, 57.9% and 62.7% at D2, D14 and D28, respectively, compared to D0. The percentages of improvement at D2, D14 and D28 were 83.2% (95% CI: 79.26; 87.21), 87.54% (95% CI: 84.01; 91.06) and 90% (95% CI: 87.06; 92.94), respectively, compared to D0.

Conclusion

The improvement in the reduction of unpleasant sensations was observed as early as 2 days after using micellar solution and increased over time. The use of this type of micellar solution, especially on sensitive skin, and the guidance of health professionals (dermatologists and pharmacists) may help to reduce the impact of unpleasant skin sensations.

Development and Validation of the Fingertip Unit for Assessing Facial Vitiligo Area Scoring Index (F-VASI)

BACKGROUND

Facial involvement of vitiligo is an important factor in patient's life and has often been evaluated separately from body surface area in clinical trials. However, no reliable measurement tools to measure facial vitiligo specifically are available thus far.

OBJECTIVE

To develop and validate a practical instrument for assessing facial vitiligo METHODS: The ratios of a hand to a fingertip unit (FTU) of 98 healthy volunteers (age range: 2-69 years) were calculated to define the FTU. Facial Vitiligo Area Scoring Index (F-VASI) was measured as the sum of all FTUs of each vitiligo lesion on the face (range: 0-112 FTU). In the validation study, 6 raters evaluated 11 patients with facial vitiligo twice at an interval of 2 weeks.

RESULTS

One hand was measured at 32.1±1.3 FTU, and it was highly consistent among subjects across different age groups, genders, and races. F-VASI showed remarkably high accuracy (concordance correlation coefficient: 0.946, smallest detectable change: 2.2 FTU) as well as high intra-rater reliability (intraclass correlation coefficient: 0.903) and inter-rater reliability (0.903).

LIMITATIONS

Lack of dynamic validation of responsiveness CONCLUSION: F-VASI using the FTU is an intuitive, precise, and reliable instrument for assessing the extent of facial involvement in vitiligo patients.

Epidemiology of Vitiligo - A Dual Population-Based Approach

Background

Most epidemiological data on vitiligo refer to selected environments or focus on the prevalence of comorbidity unrelated to the population.

Objective

Aim of the study was to gain robust representative prevalence data on vitiligo and on associated dermatologic comorbidity in the German adult population.

Methods

A dual population-based approach was applied with 1) primary data obtained between 2004 and 2014 from dermatological exams in the general working population; 2) claims data from a large German statutory health insurance, reference year 2010.

Results

In the working cohort (N = 121,783; 57% male; mean age 43 years), the prevalence of vitiligo was 0.77% (0.84% in men; 0.67% in women). In the claims data (N = 1,619,678; 38% male; mean age 46 years), prevalence was 0.17% (0.14% in men; 0.18% in women). In the working cohort, vitiligo was significantly more common in people with fair skin type, ephelides and port-wine stains and less common in people with acne and solar lentigines. In the claims data, vitiligo was associated with a variety of skin conditions, eg, atopic dermatitis, psoriasis and alopecia areata.

Conclusion

The resulting discrepancy of claims vs primary data between 0.17% and 0.77% indicates the most probable spectrum of vitiligo prevalence in Germany. It is more frequently observed in clinical exams than recorded in claims data, indicating a marked proportion of people seeking no medical help. Such nonattendance may result from the fact that many treatment options do not provide satisfying benefits to the patients.

Use of Methotrexate in the Treatment of Moderate to Severe Plaque Psoriasis in France: A Practice Survey

Purpose

To evaluate the modalities of methotrexate prescription for moderate to severe psoriasis by dermatologists in France.

Patients and Methods

We performed a national online practice survey between October and December 2020.

Results

A total of 254 dermatologists responded, 237 reported prescribing methotrexate for moderate to severe psoriasis in adults, of which 57% as a first line systemic treatment. Nineteen percent reported performing a test dose at the initiation of treatment. Methotrexate was prescribed orally in 54.7% of cases, subcutaneously in 44.8% of cases and intramuscularly in 0.4% of cases. The initial weekly dose of methotrexate was <15 mg for 30% of the dermatologists and ≥15 mg for 70% of them. Two hundred and three dermatologists had already change the route of administration for methotrexate from the oral to injectable form due to poor tolerance (48.3%), lack of efficacy (35%) or lack of compliance (16.7%). Two hundred thirty-four dermatologists (98.7%) reported prescribing folic acid with methotrexate, and 79.3% reported prescribing tests evaluating the risk of hepatic fibrosis. Forty-three percent of dermatologists have not initiated or have reduced their prescriptions since the beginning of the pandemic of COVID-19. Prescribing patterns were different according to the type of practice (private practice versus hospital/mixed practice).

Conclusion

Methotrexate is used by the majority of dermatologists interviewed for moderate to severe psoriasis in adults, with heterogeneity of practices.

Use of Systemic Medications for Treating Adult Atopic Dermatitis in France: Results of a Practice Survey

Purpose

Recent studies have illustrated that systemic medications are underused for treating adult atopic dermatitis (AD) and that dermatologists have concerns regarding the safety profile of cyclosporine in AD.

Patients and Methods

We performed a national online practice survey between March and April 2020.

Results

A total of 305 dermatologists responded, 57% with hospital-based activity and 43% with private practice. Overall, 46.9% prescribed cyclosporine for adult AD. Before initiating treatment, 56.9% did not perform evaluation scoring. Reasons for not prescribing cyclosporine were no eligible patients (24.7%), lack of information (52.6%), need for hospital prescription (31.2%), and lack of experience (79.2%). Fifty-four percent of the dermatologists prescribed methotrexate for adult AD. Before initiating treatment, 50.5% did not perform evaluation scoring. Reasons for not prescribing methotrexate were no eligible patients (46.7%), lack of information (39.3%), lack of experience (25.2%), and not approved for AD (47.4%). A total of 2.1% dermatologists prescribed other systemic treatments for adult AD, 9.8% prescribed corticosteroids and 56.4% prescribed dupilumab.

Conclusion

Systemic treatments for AD are used by half of dermatologists, although cyclosporine and dupilumab must be initiated in hospitals in France. Methotrexate is more frequently used than cyclosporine, although it is not approved for this indication in France. A vast majority of dermatologists do not perform any evaluation scoring before initiating systemic treatment for adult AD.

Demographic and Clinical Features of 1,641 Patients with Alopecia Areata, Alopecia Totalis, and Alopecia Universalis: A Single-Center Retrospective Study

Background/Aim

Alopecia areata (AA) is a common autoimmune hair disorder which is characterized by noncicatricial hair loss. AA commonly presents with localized patches on the scalp and face but may affect any hair-bearing region of the body leading to even more generalized involvement. AA may affect any age group, gender, and race. The current study investigates the demographic characteristics of the patients with AA and subgroups of AA including alopecia totalis (AT) and alopecia universalis (AU) and the prevalence of disease, sex, and age distribution and seasonal variation retrospectively in a tertiary dermatology clinic in Turkey.

Materials and Methods

In this retrospective, cross-sectional study, 1,641 patients diagnosed with AA, AT, and AU in the dermatology clinic of a public university hospital were included. The dermatology outpatient database was reviewed retrospectively. The diagnosis of AA was based on patient history, clinical examinations, and histopathologic findings.

Results

Fifty-four thousand one hundred sixty-eight patients were admitted to our outpatient clinic in 4 years time, and 1,641 were diagnosed as having AA, AT, and AU. One thousand three hundred ninety-two patients (84.8%) had AA, 81 (4.9%) had AT, and 168 (10.2%) had AU. Among the 1,641 patients included in the study, 877 were females (53.4%) and 764 were males (46.6%). The mean age was 29.86 ± 14.48 years in AA, 29.50 ± 16.18 in AT, and 32.81 ± 14.48 in AU; 77.4, 72.8, and 68.5% of patients were aged under 40 years in AA, AT, and AU. There was no statistically significant difference in seasonal presentation times.

Conclusion

AA is affecting approximately 2% of the general population without any sex, race, or age group predilection. In this study, we found a lower prevalence of AA in the pediatric age group in comparison with adults. This finding may support the hypothesis of the increasing prevalence of AA over time. The higher ratio of AA regarding this study may support that the frequency of AA and subtypes varies between regions.

Atopic Dermatitis: A Patient and Dermatologist's Perspective

This article has been co-authored by a patient with atopic dermatitis (AD) and her consulting dermatologist who is based at the University Hospital in Angers, France. Here they discuss the patient’s experiences and difficulties with AD, as well as strategies that can help a patient in this situation. The patient describes the history of her illness and the difficulties encountered, particularly in terms of quality of life. She describes the various treatments she has received, mainly based on topical corticosteroids, and tells of her satisfaction at being treated today at the University Hospital. The healthcare team there is supportive and reassuring and she is receiving a systemic medication that has successfully reduced and controlled her AD symptoms. The physician describes the main characteristics of AD, and then reviews this case of chronic eczema with topographical localisations on the hands, head and neck and diffuse flares. Rapid resolution of the flares on the patient’s hands and face, which were having a strong impact on mood, was achieved by treatment with systemic ciclosporin and topical corticosteroids. In 6 months, treatment with dupilumab will be planned to avoid ciclosporin-induced adverse effects on kidney function. The pivotal roles of therapeutic education as an adjunct to conventional therapy, a good patient–physician relationship with consideration of the patient’s personal preferences, and treatment objectives are highlighted in this perspective piece.

This article has been co-authored by a French patient who has had atopic dermatitis (eczema, AD) since childhood and her dermatologist, a French healthcare professional based in a university hospital in Angers. AD is caused by a genetic variation that affects the skin’s ability to protect against bacteria, irritants and allergens. In people with AD, environmental factors make the skin red and itchy. AD can occur at any age; it most often begins before 5 years of age and may persist into adolescence and adulthood. AD signs and symptoms vary widely, and the disease may be accompanied by asthma and allergies. AD is long lasting (chronic) and, even if treatment is successful, signs and symptoms may return (flare) periodically. The patient describes her personal experience, including how the discomfort from the AD on her face and hands affected her daily activities and sleep. She talks about having to try various treatments, including home remedies, over the years to control AD and relates her frustration when experiencing symptoms. Now she is being monitored by a healthcare team in a French university hospital that gives her full care and support. As a result, she is now receiving a systemic medication that reduces and controls the AD symptoms and she is very satisfied with her care. The dermatologist notes that this patient’s experience is a common clinical picture of AD in adults, and discusses how the patient was treated and how the treatment will evolve over time. The dermatologist emphasises the importance of a good patient–physician relationship for successful AD management. This should be based on confidence and empathy, and consider the patient’s expectations, personal preferences and treatment objectives. Therapeutic education (educational programs, video training and workshops) is pivotal as an adjunct to conventional therapy.

At the Dawn of a Therapeutic Revolution for Atopic Dermatitis: An Interview with Dr Anne-Claire Fougerousse

Dr Anne-Claire Fougerousse is Head of Dermatology at the Bégin Hospital in Saint-Mandé, France, and scientific coordinator of a French network of dermatologists and allergists (ResoEczema). The focus of her work is to improve the care of adolescent and adult patients with atopic dermatitis (AD), a chronic, pruritic inflammatory skin disease that substantially impacts patient quality of life. In this interview, Dr Fougerousse provides an overview of the clinical presentation of adult patients with AD and describes available treatments. Today, topical agents like emollients and corticosteroids are the mainstay of AD therapy, and patients with lesions that are resistant to optimally administered topical treatment can also receive phototherapy or systemic therapy with ciclosporin. Dr Fougerousse discusses her hopes for the future of AD therapy with the recent development of biologicals like dupilumab, which may provide improvements in clinical outcomes and quality of life for patients with moderate-to-severe AD. In the next few years, the therapeutic arsenal for AD will likely expand to include more systemic therapies providing sustained symptom control. The real challenge will be to ensure that the maximum number of patients with AD achieve clinical benefits from these new treatments.

Impact of acne on the daily life of adult patients: building a self-administered patient questionnaire

BACKGROUND

Acne is a long-lasting disease in adolescents and adults impacting the patient's daily life. Currently, there is no specific questionnaire that assesses its impact in adult patients.

AIM

To build a self-administered questionnaire assessing the impact of acne on the daily life in adult patients.

METHOD

A multidisciplinary working group was created, including 3 experts in healthcare questionnaires and dermatologists specialized in acne. A questionnaire using a standardized methodology for designing self-administered patient questionnaires according to conceptual, development and validation phases was developed. A cultural and linguistic validation into US English was conducted, based on the original French version.

RESULTS

A 14-item questionnaire demonstrating consistency, reproducibility and high reliability was build. The questionnaire significantly correlated with the SF-12 mental and SF-12 physical scores and CADI, indicating good external validity.

CONCLUSION

The present acne burden questionnaire AI-ADL allows the practioner to assess quickly and easily the burden of acne in patients during his daily clinical practice. Moreover, its short format allows patients to express easily and quickly their feelings and to initiate a conversation between the practioner and his patient. Thus, AI-ADL may help to better understand the multidimensional nature of acne, as well as the individual impact on the acne patient's daily life and moreover, it may play a key role in the decision-making process of treatment initiation and involvement of the patient in the management of his acne.

Topical medications for chronic plaque psoriasis: A 3-year longitudinal study in France

Topical treatments are first-line therapies, prescribed to most patients with chronic plaque psoriasis. This non-interventional, longitudinal study examined data regarding the treatment pathways of French patients with psoriasis vulgaris using a pharmacy database. From this database, patients with an initial prescription of a topical treatment of interest (ie, calcipotriol alone and/or calcipotriol/betamethasone) between March and October 2013 were included in the study. The primary objective was to capture the switch from a topical treatment, from treatment initiation to receipt of a systemic therapy over a period of 3 years. A total of 26 605 patients were included in the study. The mean age was 58.5 years. The majority of patients (94.7%) maintained topical treatment during the 3 years, receiving a mean of 1.1 different therapies. Of 1400 patients who switched to a systemic therapy, 93.1% switched to a non-biological (mean time to switching >400 days), maintaining this for the remainder of the follow-up period. The most commonly prescribed first non-biological systemic therapy was methotrexate (37%). Less than 1% of patients switched to a biological therapy during follow up. Cohort analyses suggest that patients progressing to use of a systemic therapy within 12 months were those with more severe disease. There was a low rate of transition from topical to systemic therapies in patients with chronic plaque psoriasis during the first 3 years of treatment, suggesting stability of disease severity over time with topical therapy alone, potentially due to good patient adherence.

Prevalence of comorbidities in atopic dermatitis and psoriasis in the French population

BACKGROUND

Atopic dermatitis (AD) and psoriasis (Pso) are highly prevalent chronic inflammatory skin diseases. They share similarities regarding severity and impact on quality of life but display differences regarding risk factors, comorbidities, and pathogenesis.

OBJECTIVE

This study sought to assess the prevalence of AD and Pso among the French population, along with associated comorbidities, and to compare these data with those of the age- and gender-adjusted French population with neither AD nor Pso.

METHODS

The survey was conducted by a polling institute between September 1 and November 30, 2016, with proportional quota sampling being applied to render the study population representative of the French population. In all, 20 012 individuals were selected from among 900,000 internet users aged≥15years.

RESULTS

Overall, 20,012 adults (48.8% men; 51.2% women) completed a digital questionnaire. The prevalence of AD was 4.65% [95% confidence interval (CI) 4.36%-4.94%] and that of Pso was 4.42% [95% CI: 4.14%-4.71%]. More AD patients presented≥1 comorbidity compared to subjects without AD (57.04% vs. 49.2%, P<0.0001) and more Pso patients presented≥1 comorbidity compared to subjects without Pso (60.68% vs. 49.05%, P<0.0001). After adjustment for gender and age, hypertension and dyslipidemia, a greater prevalence of osteoarticular, respiratory and psychiatric diseases was noted in both AD and Pso patients, whereas increased prevalence of obesity was seen only in Pso patients. The prevalence of components of metabolic syndrome was higher among Pso than AD patients.

CONCLUSION

Further studies are required to consolidate these findings, to better characterize the entire spectrum of AD and Pso comorbidities, and to better identify determinants and risk factors, along with targeted therapies.

Contraception, Sexuality and Pregnancy in Women with Psoriasis: Real-Life Experience of 235 Women

Background

Little is known about how women of childbearing age with psoriasis experience contraception, sexuality and pregnancies through the lens of their skin condition.

Objective

To evaluate the experiences and expectations in this group of patients.

Materials and Methods

In total, 235 women aged between 18 and 45 years old completed an online survey. We collected the characteristics of psoriasis, contraception and pregnancy history. Psoriasis severity was measured using the Simplified Psoriasis Index. Patient quality of life was assessed using the Dermatology Life Quality Index (DLQI) and the Short Form-12.

Results

Psoriasis was mild in 78% of cases. The mean DLQI score was 8.8, highlighting a moderate impact of psoriasis. In total, 28% of the women had no current follow-ups, while at least two distinct physicians followed 21% of these patients. In total, 31.5% of the women felt that they could discuss sexuality during their consultations. In addition, 63% of respondents had a contraceptive method, but more than half of the women reported that contraception was rarely or never discussed during the consultations. In total, 63% had at least one pregnancy, and 61.5% reported that the doctor managing their psoriasis did not discuss their pregnancy during consultations. Psoriasis worsened during pregnancy for 21% of the respondents but improved in 34%. Among women who were not pregnant, less than 15% reported that the doctor in charge of their psoriasis discussed family planning and pregnancy possibilities.

Conclusion

Our study shows that the management of women of childbearing age with psoriasis must be improved with respect to sexuality, contraception and pregnancy planning.

Out-of-pocket expenditures in France to manage psoriasis in adult patients: results from an observational, cross-sectional, non-comparative, multicentre study

BACKGROUND

In 2018 in France, overall mean health-related out-of-pocket (OOP) expenditures were 214.00€/year/patient.

AIM

To evaluate OOP expenditures for psoriasis patients in France.

METHODOLOGY

Observational, cross-sectional, non-comparative, multicentre study in 3000 patients with clinically confirmed psoriasis who responded to a specific digital questionnaire collecting demographic and socio-economic characteristics, assessing the 3 domains (severity, psychosocial impact and past history and interventions) of the patient's Simplified Psoriasis Index (sa-SPI) and expenditures to manage psoriasis, including OOP. Multivariate linear regression was conducted to search for factors associated with higher OOP.

RESULTS

In total, 2681 patients completed the questionnaire and, of those, 2562 provided clinically validated data. Overall, 60% were women; the mean age was 49.4 ± 14.8 years. 30% of the patients declared that they suffered from psoriatic arthritis. The final mean sa-SPI core was 10.86 ± 9.70. Of these 2562 patients, 243 (9.5%) had severe, 442 (17.3%) moderate and 1877 (73.3%) mild psoriasis. In addition, 932 (36.4%) patients reported facial involvement, 724 (28.25%) genital impairment and 1124 (43.8%) lesions on the limbs. Mean OOP expenditures to manage psoriasis per patient were 531.00€, 439.74€ ± 939.85€ for patients with mild, 791.06€ ± 1367.67€ with moderate and 1077.64€ ± 1680.14€ for patients with severe psoriasis. For patients with psoriasis in the genital area, the median amount of expenditures (251.17€; CI95% [138.35;363.99]) was significantly higher than that for the face (183.85€; CI95% [78.76;288.94]) or limbs (199.96€; CI95% [93.77;306.15); (P < 0.001). More than 90% of the patients had OOP expenditures for over-the-counter products (97.5%) and alternative care (92.0%), especially for emollients and/or hydrating products.

CONCLUSION

In France, in 2019, OOP expenditures to manage psoriasis were on average more than twice as high as the overall mean health-related OOP expenditures estimated by the French Health Agency in 2018. These results should lead health authorities to review certain standards of healthcare reimbursement.

Excimer laser/light treatment of alopecia areata: A systematic review and meta-analyses

BACKGROUND

The excimer laser/light (EL) has been reported to be effective for alopecia areata (AA), but its treatment response has not been systematically reviewed.

OBJECTIVE

To determine the treatment response and safety of EL treatment of AA.

METHODS

A comprehensive search of the Medline, EMBASE, Cochrane library, and Web of Science (from inception to December 31, 2018) was conducted to identify prospective clinical studies assessing the treatment response of EL for AA. The primary outcome was cosmetically acceptable hair regrowth (hair regrowth ≥75%); random-effects meta-analyses using generic inverse variance weighting were performed to estimate treatment responses. The study was registered with PROSPERO (CRD42019121092).

RESULTS

Of 52 records initially identified, 13 full-text articles were finally assessed in terms of eligibility. A total of 9 prospective clinical studies (129 AA patients) including 5 controlled clinical trials were identified. Cosmetically acceptable hair regrowth was achieved in 50.2% (95% confidence interval 31.5%-68.9%; 8 studies). EL treatment significantly improved hair regrowth compared with untreated controls (relative risk 7.83; 95% confidence interval 2.11-29.11; 5 controlled clinical trials). No serious adverse effect was noted.

CONCLUSIONS

EL treatment appeared to produce a favorable therapeutic response in AA patients. The use of EL should be encouraged for AA patients with the advantages of the non-invasiveness and no systemic effect.

Ki67 and CD31 Differential Expression in Cutaneous T-Cell Lymphoma and Its Mimickers: Association with Clinicopathological Criteria and Disease Advancement

BACKGROUND

Cell proliferation and angiogenesis are important in progression of cancerous processes. Differentiating cutaneous T-cell lymphoma (CTCL) from its mimicking dermatoses and prognosticating it are challenging.

AIM

This study assesses cell proliferation and angiogenesis in different CTCL subtypes using immunohistochemistry (IHC) for Ki67 and CD31 to testify their usability in differentiating CTCL from mimicking dermatoses and discriminating CTCL subtypes from each other with correlation to clinicopathological parameters and disease advancement.

PATIENTS AND METHODS

IHC for Ki67 and CD31 were applied to skin biopsies from 81 patients divided into CTCL (n=59) and dermatoses (n=22) groups. Hot-spot analysis was used to score Ki67 and CD31 microvascular density (MVD) semiquantitatively. Statistical analysis was performed to compare Ki67 index and MVD between CTCL and dermatoses. CTCL subgroups were compared to each other. Ki67 index and CD31 were compared to age, gender, skin and nodal involvement, blood tumor burden and TNMB stage.

RESULTS AND CONCLUSION

There were significant differences in proliferation index and MVD between dermatoses and CTCL, and between dermatoses and all CTCL subtypes with exception of Ki67 in early mycosis fungoides (MF) and CD31 in patch lesions. Increased cell proliferation and MVD were significantly associated with older age, T3 and 4 skin involvement, significant nodes (N1-3), positive blood tumor burden (B1,2) in CTCL and TNMB stage of MF. Both markers differentiated significantly late from early MF, classic MF from its variants and non-MF CTCL from total MF, but not from late MF. In conclusion, Ki67 and CD31 expression in skin biopsies using IHC reproduces the role of proliferation and angiogenesis in the differential diagnosis and prognostication of CTCL being expressed at higher levels in aggressive than indolent CTCL. Therapeutic targeting of cell proliferation and angiogenesis may improve patient's outcome in CTCL. Usability of these markers into patient's stratification should be considered in further studies.

Systematic review examining changes over time and variation in the incidence and prevalence of psoriasis by age and gender

BACKGROUND

There is a lack of any overview of changes over time and variation in the epidemiology of psoriasis with age and between genders.

OBJECTIVES

To perform a systematic review of published population-based studies on variations in psoriasis incidence and prevalence with age and between genders, and to explore trends in psoriasis epidemiology over time.

METHODS

Eleven electronic and regional databases were searched from their inception dates to October 2019. No language restrictions were applied. Studies were eligible if they reported on changes in psoriasis incidence and/or prevalence over time and/or by age group and gender.

RESULTS

In total 308 papers were critically appraised, from which 90 studies from 22 countries were included. Incidence data confirmed a clear bimodal age pattern in psoriasis onset, with the first and second peaks at around 30-39 and 60-69 years of age, respectively, and evidence suggesting that it presents slightly earlier in women than in men. Prevalence data showed an increasing trend with age until around 60 or 70 years, after which it decreases. Although there was lack of agreement on specific gender differences in psoriasis incidence and prevalence, a slight male predominance was reported in several studies. Studies worldwide suggested a stable or slightly decreasing trend in psoriasis incidence, while an increasing trend in psoriasis prevalence has been consistently reported. One particular challenge faced was the vastly different methodologies used in the included studies, which contributed to some of the heterogeneity of the results.

CONCLUSIONS

Studies on changes over time in the occurrence of psoriasis have contributed to a greater appreciation of the increasing burden of the disease. However, further research is required to determine the reasons driving the increase in psoriasis prevalence over time.

Skin seeding technique with 0.5-mm micropunch grafting for vitiligo irrespective of the epidermal-dermal orientation: Animal and clinical studies

Micropunch grafting is the simplest surgical intervention for refractory vitiligo but is tedious and time-consuming. Therefore, we aimed to verify the efficacy and safety of dermal orientation grafting using motorized 0.5-mm micropunch grafting for vitiligo. In a preliminary animal study, 12-week-old rats were used to observe the healing process after the transplantation of dermal orientation grafts with various punch sizes. In a clinical trial, a total of 100 vitiligo patches in 50 patients with stable vitiligo were randomly allocated to motorized 0.5-mm micropunch grafting in epidermal and dermal orientations, respectively. The grafts were implanted at intervals of 5 mm at the recipient site. Treatment success was defined as greater than 75% repigmentation. In the animal study, all grafts were shown to be well integrated into the recipient site within 3 weeks. In the clinical trial, treatment success was achieved in 72% and 76% of the epidermal and dermal orientation groups, respectively; a cobblestone appearance was observed in 4% and 2%, respectively. In conclusion, we demonstrated that this new grafting method irrespective of epidermal-dermal orientation using motorized 0.5-mm micropunch grafting was effective and safe. We have named this the "skin seeding technique" and it differs from traditional punch grafting in that it can be performed regardless of the graft orientation.

A safety evaluation of dimethyl fumarate in moderate-to-severe psoriasis

Introduction: Psoriasis is a chronic inflammatory disorder affecting skin, nails and joints. Systemic therapy of psoriasis is based upon several drugs which include fumaric acid esters (FAEs), initially introduced in 1959. Since 2017, one of the key substances among FAE spectrum (dimethyl fumarate; DMF) was registered by the European Medicines Agency (EMA) for the treatment of moderate-to-severe psoriasis vulgaris.Areas covered: This article covers the basic concepts underlying usefulness of DMF in psoriasis and extensively reviews the studies, which included its use in monotherapy of this dermatosis, with a particular emphasis on safety aspects and adverse events (AEs).Expert opinion: DMF monotherapy is a valuable systemic modality in the management of moderate-to-severe psoriasis as proved by a recent phase III study. AEs associated with DMF therapy are frequent, usually of mild severity, with a dose-independent manner. Occasionally they are burdensome and require drug discontinuation. The most common AEs comprise gastrointestinal symptoms, flushing and white blood cell count abnormalities. The latter require strict monitoring to prevent serious complications. Acknowledging the possibility of AEs, the use of DMF in moderate-to-severe psoriasis is encouraged while the need of further studies still remains.

[Monoclonal antibodies: also for dermatologists!]

Therapeutic monoclonal antibodies are henceforth commonly used in the management of psoriasis but have been also used more recently in chronic spontaneous urticaria and atopic dermatitis. Three examples are developed herein: dupilumab, omalizumab and lanadelumab. The specificity of their mechanism of action results from a better understanding of the inflammatory pathways in these chronic diseases, which previously shared either the same targeted topical or systemic treatments. However, their high costs should be put into perspective with the epidemiology, the precise evaluation of the severity, the optimization of first line treatments and the long-term benefit/risk ratio.

Global prevalence of hidradenitis suppurativa and geographical variation—systematic review and meta-analysis

Background

There is a significant variation in the reported prevalence of hidradenitis suppurativa (HS), ranging from 0.03–4%. We hypothesized that this significant variation may be due to different prevalence rates of HS according to geographical location as well as sex.

Objective

We aimed to perform a meta-analysis to determine pooled overall prevalence of HS, prevalence stratified according to geographical region and sex.

Materials and methods

A systematic review was performed by searching Ovid Medline, PubMed, Cochrane Library, DARE, and Embase, from inception to August 2018. A systematic review and meta-analysis was performed according to PRISMA guidelines. A meta-analysis of proportions was performed to determined pooled prevalence rates, with meta-regression based on geographic region. Prevalence in males versus females was also performed according to region.

Results

The overall pooled prevalence rate was 0.3% (0.2–0.6%) based on 118,760,093 HS cases available. Subgroup analysis demonstrated prevalence differences, with the highest being in Europe 0.8% (0.5–1.3%), compared to the USA 0.2% (0.1–0.4%), Asia-Pacific 0.2% (0.01–2.2%), and South America 0.2% (0.01–0.9%). Prevalence in males was lower compared to females in the USA (OR 0.403, 95% CI 0.37–0.439, P < 0.001) as well as in Europe (OR 0.635, 95% CI 0.397–1.015, P = 0.08) but not in the Asia-Pacific region (OR 0.936, 95% CI 0.319–2.751, P = 0.78).

Conclusion

Prevalence of HS varies significantly according to the geographical population. This variation is likely attributed to different ethnicity distributions amongst different continents.

Level of evidence

III

Epidemiology of atopic dermatitis in Europe

Atopic dermatitis (AD) is a chronic inflammatory disease persisting predominantly in the pediatric population. Its development is most presumably multifactorial and a derivative of interplay between genetic, immunologic, and environmental causes. To the authors’ knowledge, no multinational and systematic database of AD prevalence is established and maintained for Europe. Thus, epidemiologic data originating from the multinational studies was compiled to draw a picture of AD in both pediatric and adult populations in Europe. The outcomes of this exercise support the general observation that AD prevalence follows the latitudinal pattern with higher prevalence values in northern Europe and decreases progressively towards southern Europe. Noteworthy, the data shows significant differences on the country-level, with higher prevalence in municipal areas than rural. Finally, and unsurprisingly, the collected data reinforces the observation of AD prevalence being highest in pediatric populations in contrast to adults. Herein, data presented was additionally supplemented with the information on current standing on AD etiology.

T cell pathology in skin inflammation

Forming the outer body barrier, our skin is permanently exposed to pathogens and environmental hazards. Therefore, skin diseases are among the most common disorders. In many of them, the immune system plays a crucial pathogenetic role. For didactic and therapeutic reasons, classification of such immune-mediated skin diseases according to the underlying dominant immune mechanism rather than to their clinical manifestation appears to be reasonable. Immune-mediated skin diseases may be mediated mainly by T cells, by the humoral immune system, or by uncontrolled unspecific inflammation. According to the involved T cell subpopulation, T cell-mediated diseases may be further subdivided into T1 cell-dominated (e.g., vitiligo), T2 cell-dominated (e.g., acute atopic dermatitis), T17/T22 cell-dominated (e.g., psoriasis), and Treg cell-dominated (e.g., melanoma) responses. Moreover, T cell-dependent and -independent responses may occur simultaneously in selected diseases (e.g., hidradenitis suppurativa). The effector mechanisms of the respective T cell subpopulations determine the molecular changes in the local tissue cells, leading to specific microscopic and macroscopic skin alterations. In this article, we show how the increasing knowledge of the T cell biology has been comprehensively translated into the pathogenetic understanding of respective model skin diseases and, based thereon, has revolutionized their daily clinical management.

Acne relapses: impact on quality of life and productivity

BACKGROUND

Acne is a common skin disease that mostly affects teenagers, with a negative impact on quality of life. Recently, adult acne and acne relapses have increased in frequency, for yet unknown reasons.

OBJECTIVE

This non-interventional, real-life study sought to investigate the rate of acne relapses and their impact on quality of life and productivity (loss/absenteeism) among teenagers and adults.

METHODS

An online self-administered questionnaire was proposed to ≥15-year-olds suffering from acne who spontaneously consulted their dermatologist. To ensure homogeneous assessment of acne severity, the global acne severity scale was applied. Quality of life was assessed via Cardiff Acne Disability Index (CADI), SF12-physical score and SF12-mental score questionnaires. Productivity loss or absenteeism in middle/high school was estimated based on the number of days off work or school over the last 30 days.

RESULTS

Overall, 1048 questionnaires were considered assessable, with 448 (43%) mild acne, 434 (41%) moderate acne and 166 (16%) severe acne. Overall, 755 (72%) participants were in middle/high school, 267 (25%) employed and 26 (3%) with no professional activity. Considering the population by age groups, 68% (n = 716) were ≤20-year-olds and 32% (n = 332) >20-year-olds, with a mean age of 20.26 (SD: 7.43) years. Acne relapses were reported by 44% of respondents. Analyses revealed that poorer quality of life scores was observed in acne relapsers vs. non-relapsers, with a significant difference for CADI scores (P < 0.01) in >20-year-olds. Acne-related absenteeism was recorded in 5.7% of cases. On multivariate analyses, after adjusting for other variables, acne relapse was proven a significant determinant of absenteeism/productivity loss.

CONCLUSION

This real-life study first demonstrated acne relapse rates of 44%, which appeared to be generation-dependent, affecting 39.9% of ≤20-year-olds vs. 53.3% of >20-year-olds. Acne relapses were significantly associated with impaired quality of life and productivity loss/absenteeism.

Importance of out-of-pocket costs for adult patients with atopic dermatitis in France

BACKGROUND

Currently, few studies investigated the economic burden of atopic dermatitis (AD) in adult patients and specifically the estimation of out-of-pocket costs. Patients with skin disorders primarily use comfort care to ease dryness, itch or pain, and the costs of comfort care are not subject to any reimbursement from mandatory or complementary insurance.

OBJECTIVE

The purpose of this study was to measure the medical and non-medical expenses paid by the patient.

METHODS

Eczema Cohort Longitudinal Adults was a non-interventional study that aimed to assess the burden of AD in terms of quality of life and financial consequences. A self-assessment questionnaire was distributed to adult patients who were cared in four French hospitals. Patients were asked to list the resources consumed for the treatment of AD during the last 12 months and to estimate the corresponding amount of money they had to pay out of their own pockets. The severity of AD was subjected to a stratification based on the PO-SCORAD score.

RESULTS

A total of 1024 patients answered the questionnaire: 31.9% with severe AD, 40.4% with moderate AD and 27.6% with mild AD. The mean annual out-of-pocket cost was €462.1 for severe AD and €247.4 for moderate AD. Emollients were the most commonly used product: 74.4% for an average out-of-pocket cost of €151.4. The out-of-pocket costs increased significantly with the severity: 27% of patients with severe AD declared having bought specially textured clothes, while 19% of patients with moderate AD reported the same. The corresponding mean out-of-pocket costs were €162 and €91, respectively.

CONCLUSION

The amount of out-of-pocket costs for patients with AD for essential medical and non-medical expenses is relatively high, compared to the average out-of-pocket cost for French households. Integration of these essential resources into the list of reimbursed products and services appears necessary for a better coverage of AD.