Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement

Importance

Inconsistent reporting of outcomes in clinical trials of rosacea is impeding and likely preventing accurate data pooling and meta-analyses. There is a need for standardization of outcomes assessed during intervention trials of rosacea.

Objective

To develop a rosacea core outcome set (COS) based on key domains that are globally relevant and applicable to all demographic groups to be used as a minimum list of outcomes for reporting by rosacea clinical trials, and when appropriate, in clinical practice.

Evidence Review

A systematic literature review of rosacea clinical trials was conducted. Discrete outcomes were extracted and augmented through discussions and focus groups with key stakeholders. The initial list of 192 outcomes was refined to identify 50 unique outcomes that were rated through the Delphi process Round 1 by 88 panelists (63 physicians from 17 countries and 25 patients with rosacea in the US) on 9-point Likert scale. Based on feedback, an additional 11 outcomes were added in Round 2. Outcomes deemed to be critical for inclusion (rated 7-9 by ≥70% of both groups) were discussed in consensus meetings. The outcomes deemed to be most important for inclusion by at least 85% of the participants were incorporated into the final core domain set.

Findings

The Delphi process and consensus-building meetings identified a final core set of 8 domains for rosacea clinical trials: ocular signs and symptoms; skin signs of disease; skin symptoms; overall severity; patient satisfaction; quality of life; degree of improvement; and presence and severity of treatment-related adverse events. Recommendations were also made for application in the clinical setting.

Conclusions and Relevance

This core domain set for rosacea research is now available; its adoption by researchers may improve the usefulness of future trials of rosacea therapies by enabling meta-analyses and other comparisons across studies. This core domain set may also be useful in clinical practice.

Tazarotene Lotion 0.045% for the Treatment of Acne

Topical retinoids are recommended as first line therapy for the treatment of acne. Despite this recommendation, topical retinoids are underutilized, in part because of their tendency to cause cutaneous irritation. Tazarotene 0.045% lotion was developed using polymeric emulsion technology to provide an effective, well tolerated topical retinoid for the treatment of acne.

Isotretinoin Laboratory Monitoring in Acne Treatment: A Delphi Consensus Study

Importance

Although isotretinoin may rarely be associated with laboratory abnormalities such as hypertriglyceridemia, the optimal approach to laboratory monitoring is uncertain, and there is wide variation in clinical practice.

Objective

To establish a consensus for isotretinoin laboratory monitoring among a diverse, international cohort of clinical and research experts in acne.

Design, Setting, and Participants

Using a modified electronic Delphi process, 4 rounds of anonymous electronic surveys were administered from 2021 to 2022. For laboratory tests reaching consensus (≥70% agreement) for inclusion, questions regarding more time-specific monitoring throughout isotretinoin therapy were asked in subsequent rounds. The participants were international board-certified dermatologist acne experts who were selected on a voluntary basis based on involvement in acne-related professional organizations and research.

Main Outcomes and Measures

The primary outcome measured was whether participants could reach consensus on key isotretinoin laboratory monitoring parameters.

Results

The 22 participants from 5 continents had a mean (SD) time in practice of 23.7 (11.6) years and represented a variety of practice settings. Throughout the 4-round study, participation rates ranged from 90% to 100%. Consensus was achieved for the following: check alanine aminotransferase within a month prior to initiation (89.5%) and at peak dose (89.5%) but not monthly (76.2%) or after treatment completion (73.7%); check triglycerides within a month prior to initiation (89.5%) and at peak dose (78.9%) but not monthly (84.2%) or after treatment completion (73.7%); do not check complete blood cell count or basic metabolic panel parameters at any point during isotretinoin treatment (all >70%); do not check gamma-glutamyl transferase (78.9%), bilirubin (81.0%), albumin (72.7%), total protein (72.7%), low-density lipoprotein (73.7%), high-density lipoprotein (73.7%), or C-reactive protein (77.3%).

Conclusions and Relevance

This Delphi study identified a core set of laboratory tests that should be evaluated prior to and during treatment with isotretinoin. These results provide valuable data to guide clinical practice and clinical guideline development to optimize laboratory monitoring in patients treated with isotretinoin.

Skin care and hygiene among healthcare professionals during and after the SARS-CoV-2 pandemic

The severe acute respiratory syndrome coronavirus 2 pandemic has necessitated enhanced protection against viral transmission among healthcare professionals, particularly relating to handwashing and personal protective equipment. Some of these requirements may persist for years to come. They bring associated concerns around skin hygiene and general care, with damage to the face and hands now a well-documented consequence among healthcare professionals. This review assesses optimal skin care during the severe acute respiratory syndrome coronavirus 2 pandemic and in the "new normal" that will follow, identifies current knowledge gaps, and provides practical advice for the clinical setting. Regular, systematic hand cleaning with soap and water or an alcohol-based hand rub (containing 60%-90% ethanol or isopropyl alcohol) remains essential, although the optimal quantity and duration is unclear. Gloves are a useful additional barrier; further studies are needed on preferred materials. Moisturization is typically helpful and has proven benefits in mitigating damage from frequent handwashing. It may be best practiced using an alcohol-based hand rub with added moisturizer and could be particularly important among individuals with pre-existing hand dermatoses, such as psoriasis and eczema. Face moisturization immediately prior to donning a mask, and the use of dressings under the mask to reduce friction, can be helpful dermatologically, but more work is required to prove that these actions do not affect seal integrity. Nonetheless, such measures could play a role in institutional plans for mitigating the dermatologic impact of transmission control measures as we exit the pandemic.

What Is the Risk of Harm Associated With Topical Calcineurin Inhibitors?

The topical calcineurin inhibitors (TCIs), tacrolimus (Protopic) and pimecrolimus (Elidel), were approved in the early 2000s and were widely used as a nonsteroid treatment for atopic dermatitis (AD) in adult and pediatric populations. In 2005, the addition of a boxed warning was mandated for TCIs based on a potential risk of malignancy, and there was subsequently a substantial decline in their use. Since then, evidence has mounted to support the safety of this class of medications and suggests that the increased risk of malignancy remains theoretical. This review aims to dispel some of the common myths surrounding the safety of TCIs by evaluating the key evidence regarding their safety and tolerability in adult and pediatric populations. Four major themes are addressed in a practical question-and-answer format: the risk of harm associated with TCIs including common and serious adverse events; warnings and precautions for their use including the risk of systemic absorption, immunosuppression, and malignancy; the comparative safety of TCIs; and suggestions for counselling patients about the risk of harm with TCIs. Based on the available evidence, international professional dermatological organizations and regulatory authorities have concluded that the benefits of TCIs outweigh their potential risks when used in the appropriate patient populations for the recommended duration of time.

Skin Surface pH

The role of skin surface pH, also referred to as “acid mantle,” was described more than 90 years ago and due to developing insights has now returned into focus.1

Clinical Insights About the Role of pH in Acne

Acne vulgaris is the most common dermatological disorder globally.1,2 Psychological and emotional distress due to acne, including poor self-esteem, social anxiety, depression, and suicidal ideation have been reported in various studies.3,4, Acne is a complex multifactorial disease with its pathophysiology incompletely elucidated.

Acitretin Use in Dermatology

BACKGROUND

Acitretin has been used for the treatment of severe psoriasis for over 20 years.

OBJECTIVE

The current project was conceived to optimise patient care by recognising the role acitretin can play in the treatment of patients with psoriasis and those with other disorders of keratinisation.

METHODS

A literature review was conducted to explore the role of acitretin and to assess its value for dermatologic disorders other than severe psoriasis. A panel of Canadian dermatologists developed a clinical pathway using a case-based approach, focusing on specific patient features.

RESULTS

The clinical pathway covers plaque psoriasis with hyperkeratotic plantar disease, palmoplantar pustulosis, hyperkeratotic hand dermatitis, lichen planus, lamellar ichthyosis, and hidradenitis suppurativa.

CONCLUSION

The recommendations in our clinical pathway reflect the current use of acitretin in Canada for severe psoriasis and other disorders of keratinisation.

The Role of Skin Care in Optimizing Treatment of Acne and Rosacea

A triad approach to the treatment of acne and rosacea has been recommended. This integrated management approach includes patient education, selection of therapeutic agents, and initiation of an appropriate skin care regime. Proper skin care in patients undergoing treatment of both acne and rosacea includes use of products formulated for sensitive skin that cleanse, moisturize and photoprotect the skin. Both acne and rosacea are associated with epidermal barrier dysfunction, which can be mitigated by suitable skin care practices. Appropriate skin care recommendations for patients with acne and rosacea will be discussed.

Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel

Background:

Approximately 2% of people worldwide have psoriasis, with as many as 1 million people with psoriasis in Canada alone.1,2 The severity of psoriasis ranges from mild to severe. It can lead to substantial morbidity and psychological stress and have a profound negative impact on patient quality of life.3,4 Although available therapies reduce therapies reduce the extent and severity of the disease and improve quality of life,3 reports have indicated a patient preference for more aggressive therapy and a dissatisfaction with the effectiveness of current treatment options.5

Objective:

A Canadian Expert Panel, comprising Canadian dermatologists, convened in Toronto on 27 February 2004 to reach a consensus on unmet needs of patients treated with current therapies and how to include the pending biologic agents in and improve the current treatment algorithm for moderate-to-severe psoriasis. Current treatment recommendations suggest a stepwise strategy starting with topical agents followed by phototherapy and then systemic agents.3,6,7 The Panel evaluated the appropriate positioning of the biologic agents, once approved by Health Canada, for the treatment of moderate-to-severe psoriasis.

Methods:

The Panel reviewed available evidence and quality of these data on current therapies and from randomized, controlled clinical trials.8–14 Subsequently, consensus was achieved by small-group workshops followed by plenary discussion.

Results:

The Panel determined that biologic agents are an important addition to therapies currently available for moderate-to-severe psoriasis and proposed an alternative treatment algorithm to the current step wise paradigm.

Conclusion:

The Panel recommended a new treatment algorithm for moderate-to-severe psoriasis whereby all appropriate treatment options, including biologic agents, are considered together and patients' specific characteristics and needs are taken into account when selecting the most appropriate treatment option.

Mexoryl: Broad-Spectrum Ultraviolet a Photoprotection

The deleterious effects of long-wave (320–400 nm) ultraviolet (UV) radiation on human skin have been recognized for decades. Human exposure to UV radiation may induce skin pigmentation and sunburn, cutaneous connective tissue alterations (photoaging), immunosuppression, and the development of skin cancers. Public awareness campaigns on the need for photoprotection advocate the regular use of sunscreens. Consumer demand and an expanding knowledge of the adverse effects of UV exposure have fueled the continual development of novel sunscreen formulations. Two organic UV filters, terephthlylidene dicamphor sulphonic acid (Mexoryl SX, L'Oréal, Paris, France) and drometrizole trisiloxane (Mexoryl XL, L'Oréal), provide effective protection from UV irradiation and offer improved safety profiles in terms of protection from UVA radiation. This article details the photoprotective benefits of Mexoryl SX and Mexoryl XL.

Canadian Clinical Practice Guidelines for Rosacea

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.

The Skin Microbiome in Atopic Dermatitis and Its Relationship to Emollients

BACKGROUND

Human-associated bacterial communities on the skin, skin microbiome, likely play a central role in development of immunity and protection from pathogens. In atopic patients, the skin bacterial diversity is smaller than in healthy subjects.

OBJECTIVE

To review treatment strategies for atopic dermatitis in Canada, taking the skin microbiome concept into account.

METHODS

An expert panel of 8 Canadian dermatologists explored the role of skin microbiome in clinical dermatology, specifically looking at atopic dermatitis.

RESULTS

The panel reached consensus on the following: (1) In atopic patients, the skin microbiome of lesional atopic skin is different from nonlesional skin in adjacent areas. (2) Worsening atopic dermatitis and smaller bacterial diversity are strongly associated. (3) Application of emollients containing antioxidant and antibacterial components may increase microbiome diversity in atopic skin.

CONCLUSION

The skin microbiome may be the next frontier in preventive health and may impact the approach to atopic dermatitis treatment.

A Consensus on Acne Management Focused on Specific Patient Features

Background:

Most treatment guidelines for acne are based on clinical severity. Our objective was to expand that approach to one that also comprised individualized patient features: a case-based approach.

Methods:

An expert panel of Canadian dermatologists was established to develop demographic and clinical features considered to be particularly important in acne treatment selection. A nominal group consensus process was used for inclusion of features and corresponding appropriate treatments.

Results:

Consensus was achieved on the following statements: follicular epithelial dysfunction contributes to acne pathogenesis; inflammation from underlying disease(s) or prior treatment may impact further patient management; management focusing on specific patient features and on addressing psychosocial factors, including impact on quality of life, may improve treatment adherence and outcomes; and case-based scenarios are a practical approach to illustrate the effect of these factors. To address the latter, eight case profiles were developed.

Conclusions:

Management of acne should be based on multifactorial considerations beyond clinically determined acne severity and should include patient-reported impact, gender, skin sensitivity (including preexisting dermatoses), and phototype.

The impact of acne on quality of life

Optimal acne therapy must take into account not only acne type and severity, but also the impact of this skin disorder on the patients quality of life. Several validated instruments have been used to measure quality of life in acne patients. By using these instruments, acne patients have been shown to experience levels of social, psychological and emotional distress similar to those reported in patients with asthma, epilepsy and diabetes. Several studies have demonstrated that the disability caused by acne can be mitigated by effective therapy.

Recommendations for incorporating biologicals into management of moderate to severe plaque psoriasis: individualized patient approaches

Psoriasis is a T-cell mediated skin disease that affects approximately 2% of the population worldwide. Despite the prevalence of the disease and long-standing efforts to develop strategies to treat it, there is a need for safe and effective therapies to treat psoriasis, particularly the more severe forms. Biological agents such as alefacept, efalizumab, etanercept, and infliximab have been recognized as a class of treatment distinct from other forms of therapy in the treatment algorithm of psoriasis. Recent national and international consensus meetings have developed statements that position biological agents as an important addition to the treatment armamentarium for moderate to severe psoriasis, along with phototherapy and traditional systemic agents. There has been consensus that treatment should be individualized to each patient's needs and circumstances. Biological agents offer the hope of safe, effective, long-term management of moderate to severe psoriasis. As new agents receive approval from Health Canada, the available range of therapeutic options for treating this chronic disease will broaden. A Canadian Psoriasis Expert Panel recently convened in February 2005 to analyze, based on a series of clinical case scenarios, the indications, contraindications, and considerations for and against each of the four biological agents, derived from product labelling, where available, and from the efficacy and safety data from phase 3 and earlier clinical trials, as well as post-marketing reports. The Panel has formulated a set of recommendations for incorporating these biological agents into the current treatment paradigm of moderate to severe plaque psoriasis and has identified the preferred biological agents for each patient based on individual needs and circumstances.

A practical guide to dermatological drug use in pregnancy

Although the developing fetus was once considered protected from the outside world, we now know that it can potentially be affected by any medication given to the mother. Despite this knowledge, use of medications during pregnancy is common and pregnant women often present for treatment of dermatological disease. Therapeutic options available for these patients will be discussed.

Strategies for optimizing treatment with efalizumab in moderate to severe psoriasis

With the advent of biological therapies for the treatment of plaque psoriasis, guidance on the usage of these new agents has become necessary. One such agent, efalizumab, a humanized recombinant monoclonal IgG(1) antibody developed to target T-cell-mediated inflammation, provides rapid and sustained efficacy for many psoriasis patients. This article explores the pretreatment, initiation, and treatment phases with efalizumab therapy. In the pretreatment phase, physicians need to assess patients' disease state and educate them about the course of efalizumab treatment. Prior to initiation, physicians need to establish stable disease, ensure an adequate transition or washout of any prior psoriasis therapeutics, and obtain baseline platelet counts. After initiating treatment, both physician and patient must participate in disease monitoring. Patients responding favourably may receive continuous treatment. Those who do not respond to the drug or who experience adverse events should be managed appropriately in order to continue therapy or be transitioned onto another agent. A growing body of clinical evidence, as well as experience from clinical investigators, has provided much insight into the management strategies for patients undergoing treatment with efalizumab.

An update on the role of topical metronidazole in rosacea

Topical metronidazole (Noritate 1% Cream, Dermik; MetroCream 0.75% Cream, MetroLotion 0.75% Lotion, Metrogel 0.75% and 1% Topical Gel, Galderma) has been used for the treatment of rosacea for over 30 years. Several placebo-controlled trials have demonstrated its effectiveness in the treatment of moderate-to-severe rosacea. It is also effective in preventing relapses of disease and is well tolerated by most patients. A growing number of formulations are available.

Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel

BACKGROUND

Approximately 2% of people worldwide have psoriasis, with as many as 1 million people with psoriasis in Canada alone.1,2 The severity of psoriasis ranges from mild to severe. It can lead to substantial morbidity and psychological stress and have a profound negative impact on patient quality of life.3,4 Although available therapies reduce therapies reduce the extent and severity of the disease and improve quality of life,3 reports have indicated a patient preference for more aggressive therapy and a dissatisfaction with the effectiveness of current treatment options.5

OBJECTIVE

A Canadian Expert Panel, comprising Canadian dermatologists, convened in Toronto on 27 February 2004 to reach a consensus on unmet needs of patients treated with current therapies and how to include the pending biologic agents in and improve the current treatment algorithm for moderate-to-severe psoriasis. Current treatment recommendations suggest a stepwise strategy starting with topical agents followed by phototherapy and then systemic agents.3,6,7 The Panel evaluated the appropriate positioning of the biologic agents, once approved by Health Canada, for the treatment of moderate-to-severe psoriasis.

METHODS

The Panel reviewed available evidence and quality of these data on current therapies and from randomized, controlled clinical trials.8-14 Subsequently, consensus was achieved by small-group workshops followed by plenary discussion.

RESULTS

The Panel determined that biologic agents are an important addition to therapies currently available for moderate-to-severe psoriasis and proposed an alternative treatment algorithm to the current step wise paradigm.

CONCLUSION

The Panel recommended a new treatment algorithm for moderate-to-severe psoriasis whereby all appropriate treatment options, including biologic agents, are considered together and patients' specific characteristics and needs are taken into account when selecting the most appropriate treatment option.

Common sense dermatological drug suggestions for women who are breast-feeding

Use of medications by breast-feeding mothers is not uncommon. When prescribing a medication to a nursing mother, the physician must weigh the potential risk of exposing the infant to the medication or the risks of not breast-feeding against the benefits of the medication to the mother. Information regarding the safety of common dermatological medications during lactation will be reviewed. Based on this information, treatment recommendations will be made.

Histopathology in erythroderma: review of a series of cases by multiple observers

This study examines the utility of objective histopathological studies in the evaluation of adult patients with erythroderma. A series of 56 skin biopsies, from 40 erythrodermic patients, was reviewed sequentially by 4 Canadian dermatopathologists who were unaware of clinical details of the cases. The final diagnosis (gold standard), in each instance, had already been determined by others, based on clinicopathologic data and response to therapy. Direct comparison revealed that the mean accuracy of the histopathological diagnoses was 53% (range: 48-66%), a favorable result in view of the difficulty of the task at hand. Additional points of information which evolved from the study are as follows: (i) identification, by microscopy alone, of spongiotic dermatitis, cutaneous T-cell lymphoma and psoriasis, as underlying causes of erythroderma was more successful than that of drug eruptions and pityriasis rubra pilaris; (ii) the epidermotropism which characterizes cutaneous T-cell lymphoma may be mistaken for inflammatory interface changes seen in drug eruptions and vice versa, thus constituting a pitfall in diagnosis; (iii) finally, it appears that submission of multiple simultaneous biopsies, rather than a single specimen, from patients with erythroderma would be likely to enhance the accuracy of histopathological diagnosis.

The specificity of histopathology in erythroderma

Conflicting views about the diagnostic value of skin biopsy in the investigation of erythrodermic patients are extant. The objective of the present study was to establish the frequency with which a correct diagnosis can be based on histopathological assessment alone. This was achieved by comparison of the "blinded" microscopic diagnosis with the final diagnosis (based on combined clinico-pathologic parameters and response to therapy). In a retrospective review of 56 skin biopsies from 40 patients with erythroderma, we found a positive correlation between the pathological diagnosis and the final diagnosis in 66%; furthermore, when the microscopic characteristics observed in different diagnostic categories were assessed, these proved to simulate those seen in conventional manifestations of the various underlying diseases but tended to be subtle in the setting of erythroderma. We conclude that, despite the homogeneity of the clinical expression of erythroderma, diagnostic histopathological features of the underlying disease are retained in the majority of cases.