Long-term prognosis of vaccine-induced contact allergy to aluminium: Third patch-test with additional test preparations

BACKGROUND

A high incidence of local itching subcutaneous nodules and aluminium allergy was observed in clinical trials of a new aluminium adsorbed pertussis vaccine in Gothenburg, Sweden, in the 1990s. A total of 495 children with itching nodules were patch tested with aluminium chloride hexahydrate 2% and an empty Finn Chamber®, 377 (76%) with positive reactions. When 241 of them were re-tested some years later 186 (3 out of 4) had unexpectedly lost their patch test reactivity.

AIM

To investigate the long-term prognosis of vaccine-induced contact allergy to aluminium by a third patch test about 20 years after Patch test I.

METHODS

Twenty individuals with positive and 11 with negative results in Patch test II were tested a third time with the same sensitisers as in in the first two tests. Three additional aluminium preparations were also tested.

RESULTS

A total 15 out of 20 persons with positive results in the second test had lost their patch test reactivity. Two of 11 with negative tests had turned positive again. The addition of the preparations gave no conclusive results.

CONCLUSION

Contact allergy to aluminium caused by vaccination with aluminium-adsorbed vaccines in childhood seems to fade away with time as measured by loss of patch test reactivity.

Effects of brodalumab on psoriasis and depressive symptoms in patients with insufficient response to TNF-α inhibitors

The objective of this study was to evaluate emotions of depression and anxiety in psoriatic patients that due to insufficient response to tumor necrosis factor-alpha inhibition (TNF-α), underwent a treatment switch from TNF-α to interleukin 17 inhibition using brodalumab. The Self-rated Montgomery-Asberg Depression Rating Scale and the Hospital Anxiety and Depression Scale were used to assess depression and anxiety. A total of 20 patients with psoriasis were enrolled in the study. They were monitored for a period of 3 months following the transition to brodalumab treatment. The results showed a significant improvement in both the Psoriasis Area and Severity Index as well as symptoms of depression; anxiety symptoms showed a reduction, though not statistically significant. Perhaps of more interest, the positive effects on depression and anxiety seem to be independent of the reduction in skin related psoriatic lesions. These findings highlight the importance of addressing depressive and anxiety symptoms, together with psoriasis severity and quality of life, when managing patients with psoriasis.

Incidence and Prevalence of 73 Different Genodermatoses: A Nationwide Study in Sweden

This retrospective registry-based cohort study aimed to estimate the incidence and prevalence of genodermatoses in the Swedish population and to analyse associated healthcare usage. Patients diagnosed with genodermatoses were identified from the patient registry of Sahlgrenska University Hospital (Gothenburg, Sweden) between 2016 and 2020. Clinical data from medical records were used to verify diagnoses recorded in the National Patient Registry (NPR). The NPR was then searched for International Classification of Diseases, Tenth Revision (ICD-10) codes Q80-82 and Q84 from 2001 to 2020. The local cohort included 298 patients with 36 unique genodermatosis diagnoses. Verification of these diagnoses in the NPR showed positive predictive values of over 90%. The NPR search yielded 13,318 patients with 73 unique diagnoses, including ichthyoses (n = 3,341; 25%), porokeratosis (n = 2,277; 17%), palmoplantar keratodermas (n = 1,754; 13%), the epidermolysis bullosa group (n = 1011; 7%); Darier disease (n = 770; 6%), Hailey-Hailey disease (n = 477; 4%) and Gorlin syndrome (n = 402; 3%). The incidence and prevalence of each diagnosis were calculated based on the nationwide cohort and are reported. A total of 149,538 outpatient visits were registered, a mean of 4.6 visits per patient. This study provides a valuable resource for the epidemiology of genodermatoses by reporting on the incidence and prevalence of 73 different genodermatoses.

The Effect of Narrow-Band Ultraviolet B Phototherapy on Free and Total Vitamin D Serum Levels in Mild to Severe Plaque Psoriasis

Vitamin D plays an important role in skin inflammation in psoriasis. The beneficial effects of ultraviolet light B (UVB) phototherapy in psoriasis are partly attributed to UVB-induced increase of vitamin D levels. In clinical practice, total 25-hydroxy vitamin D (25(OH)D) levels are measured to assess sufficiency, but it might be more accurate to measure free 25(OH)D levels. The aim of this study was to measure free serum 25(OH)D levels in psoriasis patients before and after phototherapy and to investigate if free 25(OH)D correlates stronger to disease severity than total 25(OH)D. Twenty adults (>18 years) with psoriasis were included for treatment with narrow-band UVB (NB-UVB) phototherapy for 10-12 weeks. Psoriasis Area and Severity Index (PASI) and Visual Analogue Scale (VAS) were used to assess disease severity. Serum levels of total 25(OH)D, free 25(OH)D, and 1,25(OH)₂D were measured before and after NB-UVB. Total 25(OH)D, free 25(OH)D, 1,25(OH)₂D and the percentage of free 25(OH)D increased after NB-UVB, and PASI and VAS improved. The increase in total and free 25(OH)D remained significant when stratifying for vitamin D confounders. No correlations between disease severity and vitamin D levels were found. Total and free 25(OH)D levels were positively correlated before and after NB-UVB. NB-UVB is an effective treatment for mild to severe plaque psoriasis and increases not only total but also free 25(OH)D levels, as well as the percentage of free 25(OH)D, suggesting an increased bioavailability of skin-produced vitamin D.

How Does a Convolutional Neural Network Trained to Differentiate between Invasive Melanoma and Melanoma In situ Generalize when Assessing Dysplastic Naevi?

Abstract is missing (Short communication)

Basal cell carcinoma: Epidemiological impact of clinical versus histopathological diagnosis

BACKGROUND

Low-risk basal cell carcinomas (BCCs) are to an increasing extent diagnosed by dermatologists through dermoscopic examination only and treated with non-surgical methods. Reports on increasing incidence as well as trends regarding subtypes, anatomical sites and differences related to gender are based solely on histopathologically verified tumours. How unreported clinically diagnosed BCCs affect the epidemiological data has not been sufficiently investigated.

OBJECTIVES

To analyse the tumour and patient characteristics of clinically diagnosed versus histopathologically confirmed primary BCCs and to make a gross estimate on how unreported BCCs could influence the total number of new cases.

METHODS

We retrospectively reviewed all primary BCCs diagnosed in 2016 at the Department of Dermatology, Sahlgrenska University Hospital in Gothenburg, Sweden. We also reviewed all histopathologically verified primary BCCs at the two largest pathology laboratories in Western Sweden during the same year to estimate the proportion of BCCs diagnosed by dermatologists.

RESULTS

In total, 2365 primary BCCs were diagnosed at our centre. More than half of these tumours were clinically diagnosed (55.8%). Superficial subtype (41.7%), location on the trunk (46.3%) and destructive treatment methods (60.0%) were most common. The reports from the two pathology laboratories showed that histopathologically verified BCCs (n = 5837) were more commonly of the infiltrative or nodular subtype and located in the head and neck area. Dermatologists managed 56.0% of them.

CONCLUSIONS

This study indicates that a substantial number of BCCs are not visualized in the official statistics which are solely based on reports from pathology laboratories. When taking clinically diagnosed tumours into account, truncal location and superficial subtype are more common than previously believed. Further, based on the regional calculations, the real burden of BCC in Sweden might be up to 70% higher than what is reported in official statistics.

Use of methotrexate and risk of skin cancer: a nationwide case-control study

BACKGROUND

Methotrexate (MTX) use has been suspected of increasing the risk of skin cancer. The aim of this investigation was to examine the association between the use of MTX and the risk of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC) and cutaneous malignant melanoma (CMM).

METHODS

In a nationwide Danish case-control study, we identified incident, histologically verified cases of BCC (n = 131,447), cSCC (n = 18,661) or CMM (26,068) from 2004 to 2018. We matched 10 controls to each case on sex and birth year using risk-set sampling and computed crude and adjusted odds ratios (ORs) using conditional logistic regression for the use of MTX (≥2.5 g) compared with never-use.

RESULTS

Use of MTX was associated with increased risk of BCC, cSCC and CMM with adjusted ORs of (95% confidence interval) 1.29 (1.20-1.38), 1.61 (1.37-1.89) and 1.35 (1.13-1.61), respectively. For BCC and cSCC, ORs increased with higher cumulative doses. When restricting the study population to patients with psoriasis, the ORs were 1.43 (1.23-1.67), 1.18 (0.80-1.74) and 1.15 (0.77-1.72), respectively.

CONCLUSIONS

We observed an increased risk of BCC and cSCC associated with the use of MTX with evidence of a dose-response pattern; however, the association was not consistent when restricting the study population to patients with psoriasis.

Porokeratosis is one of the most common genodermatoses and is associated with an increased risk of keratinocyte cancer and melanoma

BACKGROUND

Porokeratosis is a clinically heterogeneous group of keratinization disorders with a genetic background mainly affecting the mevalonate pathway, which is involved in the synthesis of cholesterol, an essential component for the formation of the extracellular lipid lamellae in the stratum corneum. Porokeratosis is reportedly associated with an increased risk of keratinocyte cancer, but to date, no large epidemiological studies have been conducted to further address this association.

OBJECTIVES

The first objective was to characterize a cohort of patients diagnosed with porokeratosis at the Department of Dermatology and Venereology, Sahlgrenska University Hospital (SU), Gothenburg, Sweden. The second objective was to conduct a nationwide registry-based cohort study to investigate the association, if any, between porokeratosis and the cutaneous malignancies squamous cell carcinoma (SCC), basal cell carcinoma (BCC) and melanoma.

METHODS

For the SU cohort, the hospital registry was searched for patients with a diagnosis of porokeratosis recorded between 2016 and 2020. Clinical data were extracted from the records of the identified patients. For the nationwide cohort, national registries were searched to identify patients with a diagnosis of porokeratosis between 2001 and 2020. A tenfold control cohort was formed by Statistics Sweden. The data was cross-referenced with the Swedish Cancer Register to study the associations between porokeratosis and SCC, BCC and melanoma.

RESULTS

Disseminated superficial actinic porokeratosis was the most common clinical type among the 108 patients in the SU cohort. In the nationwide search, 2277 patients with porokeratosis were identified (prevalence 1/4132). Porokeratosis was associated with an increased risk for SCC, BCC and melanoma with hazard ratios (95% CI) of 4.3 (3.4-5.4), 2.42 (1.97-2.98) and 1.83 (1.18-2.82), respectively, in the patient cohort, compared to the matched control group.

CONCLUSION

Porokeratosis is a common genodermatosis, and it is associated with an enhanced risk of skin cancer.

Assessment of melanoma thickness based on dermoscopy images: an open, web-based, international, diagnostic study

BACKGROUND

Preoperative assessment of whether a melanoma is invasive or in situ (MIS) is a common task that might have important implications for triage, prognosis and the selection of surgical margins. Several dermoscopic features suggestive of melanoma have been described, but only a few of these are useful in differentiating MIS from invasive melanoma.

OBJECTIVE

The primary aim of this study was to evaluate how accurately a large number of international readers, individually as well as collectively, were able to discriminate between MIS and invasive melanomas as well as estimate the Breslow thickness of invasive melanomas based on dermoscopy images. The secondary aim was to compare the accuracy of two machine learning convolutional neural networks (CNNs) and the collective reader response.

METHODS

We conducted an open, web-based, international, diagnostic reader study using an online platform. The online challenge opened on 10 May 2021 and closed on 19 July 2021 (71 days) and was advertised through several social media channels. The investigation included, 1456 dermoscopy images of melanomas (788 MIS; 474 melanomas ≤1.0 mm and 194 >1.0 mm). A test set comprising 277 MIS and 246 invasive melanomas was used to compare readers and CNNs.

RESULTS

We analysed 22 314 readings by 438 international readers. The overall accuracy (95% confidence interval) for melanoma thickness was 56.4% (55.7%-57.0%), 63.4% (62.5%-64.2%) for MIS and 71.0% (70.3%-72.1%) for invasive melanoma. Readers accurately predicted the thickness in 85.9% (85.4%-86.4%) of melanomas ≤1.0 mm (including MIS) and in 70.8% (69.2%-72.5%) of melanomas >1.0 mm. The reader collective outperformed a de novo CNN but not a pretrained CNN in differentiating MIS from invasive melanoma.

CONCLUSIONS

Using dermoscopy images, readers and CNNs predict melanoma thickness with fair to moderate accuracy. Readers most accurately discriminated between thin (≤1.0 mm including MIS) and thick melanomas (>1.0 mm).

Evaluation of Melanoma Thickness with Clinical Close-up and Dermoscopic Images Using a Convolutional Neural Network

Convolutional neural networks (CNNs) have shown promise in discriminating between invasive and in situ melanomas. The aim of this study was to analyse how a CNN model, integrating both clinical close-up and dermoscopic images, performed compared with 6 independent dermatologists. The secondary aim was to address which clinical and dermoscopic features dermatologists found to be suggestive of invasive and in situ melanomas, respectively. A retrospective investigation was conducted including 1,578 cases of paired images of invasive (n = 728, 46.1%) and in situ melanomas (n = 850, 53.9%). All images were obtained from the Department of Dermatology and Venereology at Sahlgrenska University Hospital and were randomized to a training set (n = 1,078), a validation set (n = 200) and a test set (n = 300). The area under the receiver operating characteristics curve (AUC) among the dermatologists ranged from 0.75 (95% confidence interval 0.70–0.81) to 0.80 (95% confidence interval 0.75–0.85). The combined dermatologists’ AUC was 0.80 (95% confidence interval 0.77–0.86), which was significantly higher than the CNN model (0.73, 95% confidence interval 0.67–0.78, p = 0.001). Three of the dermatologists significantly outperformed the CNN. Shiny white lines, atypical blue-white structures and polymorphous vessels displayed a moderate interobserver agreement, and these features also correlated with invasive melanoma. Prospective trials are needed to address the clinical usefulness of CNN models in this setting.

Diagnostic Outcomes and Treatment Modalities in Patients with Mycosis Fungoides in West Sweden—A Retrospective Register-Based Study

Simple Summary

Mycosis fungoides (MF) is a rare and incurable disease, but there are a wide variety of treatment options. Since the condition is rare, only a few studies have been performed on this topic in Sweden. This study contributes to the knowledge of the epidemiological and clinical features and diagnostic findings in addition to the treatment modalities and responses in patients with diagnosed MF and/or followed up for a long period of time in Sweden. The results of this study can be used to improve clinical practice and stimulate future research.

Abstract

(1) Background: Mycosis fungoides (MF) is a variant of primary cutaneous T-cell lymphoma. The aim of this study was to describe the clinical features and epidemiological and diagnostic findings in addition to the treatment modalities and responses in patients with MF. Furthermore, comparisons between patients in the early stage and the advanced stage were evaluated. (2) Methods: A retrospective register-based study based on data collected from the primary cutaneous lymphoma register and medical records was performed at the Department of Dermatology and Venerology at Sahlgrenska University Hospital, Gothenburg, Sweden. (3) Results: Eighty-four patients with a median age of 55 years with MF were included. Most of the patients (n = 73) were diagnosed at the early stage of the disease (IA–IIA). Overall disease progression was seen in 12.5% (n = 9) of the patients. Nine (10.7%) patients were deceased, out of which four (4.8%) deaths were associated with MF-related causes. (4) Conclusions: This study contributes to the knowledge of the epidemiological and clinical features in addition to the diagnostic findings and treatment responses in patients with MF in Sweden.

Long-term clinical course and prognosis of vaccine-related persistent itching nodules (1997-2019): An observational study

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Vaccine-induced itching nodules almost always resolve over time.

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The symptoms may last up to six years though diminishing with time.

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Contact allergy to aluminium is not a cause to refrain from further vaccination.

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Vaccination can continue once the nodule has vanished and the itching has resolved.

Background

Vaccines adsorbed to aluminium can induce long-lasting intensely itching subcutaneous nodules (granulomas) at the injection site as well as contact allergy to aluminium. In clinical trials of a new acellular pertussis vaccine performed in the 1990s (Gothenburg, Sweden) with 76 000 participants, itching nodules were reported in 745 children. A positive patch test to aluminium was verified in 77% of the tested children with itchy nodules.

Aim

To describe the long-term clinical course and prognosis of vaccine-related itching nodules caused by aluminium-containing pediatric vaccines and to estimate the risk for new symptoms after future vaccination with aluminium-containing vaccines.

Methods

745 children with vaccine-related itching nodules were followed by regular interviews/questionnaires for more than 20 years. 723 of them received a booster dose of diphtheria/tetanus vaccine either with or without aluminium adjuvant during the follow-up time.

Results

Most study participants (86%) reported a full recovery from their itching nodules after a median duration of 6.6 years. Only a few of the diphtheria/tetanus-booster-vaccinated children (3%) reported mild transient itching and swelling at the new injection site.

Conclusion

Vaccine-induced itching granulomas caused by an aluminium-adsorbed acellular pertussis toxoid vaccine seem to disappear over time. Future vaccinations with aluminium-adsorbed vaccines can be performed with little risk for new itching nodules later in life.

Ability to Predict Melanoma Within 5 Years Using Registry Data and a Convolutional Neural Network: A Proof of Concept Study

Research relating to machine learning algorithms, including convolutional neural networks, has increased during the past 5 years. The aim of this pilot study was to investigate how accurately a convolutional neural network, trained on Swedish registry data, could perform in predicting cutaneous invasive and in situ melanoma (CMM) within 5 years. A cohort of 1,208,393 individuals was used. Registry data ranged from 4 July 2005 to 31 December 2011, predicting CMM between 1 January 2012 and 31 December 2016. A convolutional neural network with one-dimensional convolutions with respect to time was trained using healthcare databases and registers. The algorithm was trained on 23,886 individuals. Validation was performed on a holdout validation set including 6,000 individuals. After training and validation, the convolutional neural network was evaluated on a test set (1,000 individuals with an CMM occurring within 5 years and 5,000 without). The area under the receiver-operating characteristic curve was 0.59 (95% confidence interval (95% CI) 0.57–0.61). The point on the receiver-operating characteristic curve where sensitivity equalled specificity had a value of 56% (sensitivity 95% CI 53–60% and specificity 95% CI 55–58%). Albeit at an early stage, this pilot investigation demonstrates potential usefulness for machine learning algorithms in predicting melanoma risk.

Curettage versus cryosurgery for superficial basal cell carcinoma: a prospective, randomised and controlled trial

Background

Basal cell carcinoma (BCC) is the most common cancer in the world and has a rising incidence. Current guidelines for low‐risk BCC including superficial BCC (sBCC) recommend several treatment options including destructive treatment methods, such as cryosurgery with or without prior curettage or curettage and electrodesiccation. Curettage only (i.e. without subsequent cryosurgery or electrodesiccation) is a simple and quick destructive treatment method used for many benign skin lesions but has not been sufficiently evaluated for the treatment of sBCCs.

Objectives

The objective was to compare the effectiveness of curettage vs. cryosurgery for sBCCs in terms of overall clinical clearance rates after 1 year as well as wound healing times.

Methods

A single‐centre non‐inferiority clinical trial was conducted. Non‐facial sBCCs with a diameter of 5–20 mm were randomised to either cryosurgery using one freeze–thaw cycle or curettage. At follow‐up visits, treatment areas were evaluated regarding the presence of residual tumour after 3–6 months and recurrence after 1 year. Further, wound healing times were assessed.

Results

In total, 228 sBCCs in 97 patients were included in the analysis. At 3–6 months, no residual tumours were seen in any of the treated areas. After 1 year, the clinical clearance rates for curettage and cryosurgery were 95.7% and 100%, respectively (P = 0.060). However, the non‐inferiority analysis was inconclusive. Wound healing times were shorter for curettage (4 weeks) compared to cryosurgery (5 weeks; P < 0.0001). Overall, patient satisfaction at 1 year was high.

Conclusions

Both treatment methods showed high clinical clearance rates after 1 year, whilst curettage reduced the wound healing time.

Impact of Etanercept on Vitamin D Status and Vitamin D-binding Protein in Bio-naïve Patients with Psoriasis

High levels of serum vitamin D-binding protein have been shown previously in patients with psoriasis compared with healthy controls; a possible role in inflammation is implied. The primary objective of this study was to investigate the impact of 24-week etanercept treatment on vitamin D status and vitamin D-binding protein in patients with psoriasis. The secondary aim was to explore whether pre-treatment vitamin D levels could predict the treatment effect. A prospective observational study was performed, including 20 patients with psoriasis and 15 controls. Serum samples were analyzed for, among others, vitamin D metabolites, vitamin D-binding protein and highly sensitive Creactive protein. Baseline levels of vitamin D-binding protein were higher in patients with self-reported arthropathy than in those without. After 24 weeks’ treatment, an improvement in psoriasis was noted, as was a decrease in highly sensitive C-reactive protein. Vitamin D-binding protein decreased in those with self-reported arthropathy. Higher baseline levels of vitamin D were associated with faster and greater improvement in psoriasis. Vitamin D-binding protein may have an inflammatory biomarker role.

Interobserver Agreement on Dermoscopic Features and their Associations with In Situ and Invasive Cutaneous Melanomas

Several melanoma-specific dermoscopic features have been described, some of which have been reported as indicative of in situ or invasive melanomas. To assess the usefulness of these features to differentiate between these 2 categories, a retrospective, single-centre investigation was conducted. Dermoscopic images of melanomas were reviewed by 7 independent dermatologists. Fleiss' kappa (κ) was used to analyse interobserver agreement of predefined features. Logistic regression and odds ratios were used to assess whether specific features correlated with melanoma in situ or invasive melanoma. Overall, 182 melanomas (101 melanoma in situ and 81 invasive melanomas) were included. The interobserver agreement for melanoma-specific features ranged from slight to substantial. Atypical blue-white structures (κ=0.62, 95% confidence interval 0.59-0.65) and shiny white lines (κ=0.61, 95% confidence interval 0.58-0.64) had a substantial interobserver agreement. These 2 features were also indicative of invasive melanomas >1.0 mm in Breslow thickness. Furthermore, regression/peppering correlated with thin invasive melanomas. The overall agreement for classification of the lesions as invasive or melanoma in situ was moderate (κ=0.52, 95% confidence interval 0.49-0.56).

Discrimination Between Invasive and In Situ Melanomas Using Clinical Close-Up Images and a De Novo Convolutional Neural Network

Background: Melanomas are often easy to recognize clinically but determining whether a melanoma is in situ (MIS) or invasive is often more challenging even with the aid of dermoscopy. Recently, convolutional neural networks (CNNs) have made significant and rapid advances within dermatology image analysis. The aims of this investigation were to create a de novo CNN for differentiating between MIS and invasive melanomas based on clinical close-up images and to compare its performance on a test set to seven dermatologists.

Methods: A retrospective study including clinical images of MIS and invasive melanomas obtained from our department during a five-year time period (2016–2020) was conducted. Overall, 1,551 images [819 MIS (52.8%) and 732 invasive melanomas (47.2%)] were available. The images were randomized into three groups: training set (n = 1,051), validation set (n = 200), and test set (n = 300). A de novo CNN model with seven convolutional layers and a single dense layer was developed.

Results: The area under the curve was 0.72 for the CNN (95% CI 0.66–0.78) and 0.81 for dermatologists (95% CI 0.76–0.86) (P < 0.001). The CNN correctly classified 208 out of 300 lesions (69.3%) whereas the corresponding number for dermatologists was 216 (72.0%). When comparing the CNN performance to each individual reader, three dermatologists significantly outperformed the CNN.

Conclusions: For this classification problem, the CNN was outperformed by the dermatologist. However, since the algorithm was only trained and validated on 1,251 images, future refinement and development could make it useful for dermatologists in a real-world setting.

Optimizing treatment of acne with photodynamic therapy (PDT) to achieve long-term remission and reduce side effects. A prospective randomized controlled trial

Photodynamic therapy with methyl aminolevulinate (MAL-PDT) is an effective treatment of acne vulgaris, but is associated with side effects. We performed a prospective randomized split-face study aimed at optimizing MAL-PDT treatment. Patients (n = 33) were randomized to two or four treatments of PDT with MAL on one cheek and placebo vehicle on the other cheek, 1-2 weeks apart. A 1.5-h pre-treatment with the MAL cream was followed by illumination with red light (20 J/cm²). Assessments were performed before treatment and 4, 10, and 20 weeks after the last treatment. In comparison to baseline, the number of inflammatory lesions at 20 weeks on cheeks treated with MAL-PDT showed a relative decrease of 74% in the group with two treatments and 85% in the group with four treatments. This new treatment regimen for both MAL-PDT and red-light-only PDT, with shortened pre-treatment and reduced light dose, could be an effective modality.

Sun protection behaviour in organ transplant recipients and non-transplant patients attending a dermatology outpatient clinic in Sweden: A questionnaire survey

BACKGROUND/PURPOSE

Organ transplant recipients (OTRs) are at high risk of developing skin cancer and are therefore advised to protect their skin against ultraviolet radiation from the sun. Specialized OTR clinics with dermatological follow-up may improve sun habits among OTRs. In this study, we compared self-reported sun exposure and sun protection behaviour between OTRs and non-transplant patients (non-TPs) and between OTRs with and without special dermatological follow-up.

METHODS

Patients from Sahlgrenska University Hospital, Gothenburg, Sweden, completed a sun exposure questionnaire. Between 2011 and 2015, 282 OTRs transplanted in the period 1976-2014 and 414 non-TPs were recruited among dermatological outpatients. Participants were stratified into five groups by their status as OTRs or non-TPs and by attendance to dermatological follow-up.

RESULTS

More non-TPs than OTRs reported one or more sunburns in the past year, 46% vs. 20%, P < .0001). More OTRs with than OTRs without dermatological follow-up reported frequent use of sunscreens (63% vs 44%, P = .006). More OTRs with follow-up used one or more sun protection measure such as covering clothes, than other OTRs (54% vs 34%, P = .016).

CONCLUSION

In this study, OTRs reported less sun exposure than non-TPs. Specialized dermatological follow-up seems to improve sun protection behaviour among OTRs. We suggest that specialized OTR clinics should be more broadly implemented.

High levels of serum vitamin D-binding protein in patients with psoriasis: A case-control study and effects of ultraviolet B phototherapy

The role of vitamin D in psoriasis remains contradictory despite the fact that vitamin D analogues constitute an established treatment for psoriasis. It has been proposed that the ability of vitamin D to exert anti-inflammatory effects might not depend solely on the concentration of serum 25(OH)D but also on the concentration of vitamin D-binding protein (DBP). High concentrations of DBP might diminish vitamin D's biologic action. The aims of this study were (i) to analyze the serum levels of DBP, total and calculated free 25(OH)D in patients with psoriasis and compare the results with healthy controls and (ii) to study the effect of ultraviolet B (UVB) phototherapy on DBP levels. Caucasian subjects (n = 68) with active plaque psoriasis were compared with a population-based sample of men and women (n = 105), matched for age and sex. Season of enrollment was taken into consideration. The patients were also studied before and after UVB phototherapy. The severity of the disease was calculated as Psoriasis Area Severity Index (PASI). DBP, free 25(OH)D index and total 25(OH)D were higher in patients with psoriasis compared with controls (P= 0.004, P = 0.045 and P < 0.0001, respectively). DBP did not change after phototherapy, whereas 25(OH)D increased and intact parathyroid hormone (iPTH) decreased (P < 0.001 for both). Psoriasis improved and PASI decreased after phototherapy (P < 0.001). There was no correlation between DBP and 25(OH)D or between DBP and PASI. Measurement of DBP is recommended when evaluating vitamin D status in patients with psoriasis. High DBP levels in psoriasis imply a disturbed vitamin D pathway that warrants further investigation. Direct measurement of free 25(OH)D, instead of total 25(OH)D that circumvents abnormally high levels of DBP, could be considered.

Can Dermoscopy Be Used to Predict if a Melanoma Is In Situ or Invasive?

Background

The preoperative prediction of whether melanomas are invasive or in situ can influence initial management.

Objectives

This study evaluated the accuracy rate, interobserver concordance, sensitivity and specificity in determining if a melanoma is invasive or in situ, as well as the ability to predict invasive melanoma thickness based on clinical and dermoscopic images.

Methods

In this retrospective, single-center investigation, 7 dermatologists independently reviewed clinical and dermoscopic images of melanomas to predict if they were invasive or in situ and, if invasive, their Breslow thickness. Fleiss' and Cohen's kappa (κ) were used for interobserver concordance and agreement with histopathological diagnosis.

Results

We included 184 melanomas (110 invasive and 74 in situ). Diagnostic accuracy ranged from 67.4% to 76.1%. Accuracy rates for in situ and invasive melanomas were 57.5% (95% confidence interval [CI], 53.1%-61.8%) and 81.7% (95% CI, 78.8%-84.4%), respectively. Interobserver concordance was moderate (κ = 0.47; 95% CI, 0.44-0.51). Sensitivity for predicting invasiveness ranged from 63.6% to 91.8% for 7 observers, while specificity was 32.4%-82.4%. For all correctly predicted invasive melanomas, agreement between predictions and correct thickness over or under 1.0 mm was moderate (κ = 0.52; 95% CI, 0.45-0.58). All invasive melanomas incorrectly predicted by any observer as in situ had a thickness <1.0 mm. All 32 melanomas >1.0 mm were correctly predicted to be invasive by all observers.

Conclusions

Accuracy rates for predicting thick melanomas were excellent, melanomas inaccurately predicted as in situ were all thin, and interobserver concordance for predicting in situ or invasive melanomas was moderate. Preoperative dermoscopy of suspected melanomas is recommended for choosing appropriate surgical margins.

Digital Quantification of Melanocytic Density in Resection Margins of Lentigo Maligna Using SOX10 Versus Hematoxylin-Eosin Staining

ABSTRACT

Lentigo maligna (LM) represents an overgrowth of atypical melanocytes at the dermal-epidermal junction of chronically sun-damaged skin. The presence of LM on sun-damaged skin poses a diagnostic challenge because the solar-induced melanocytic hyperplasia makes it difficult to assess the LM margins. Melanocytic density can be used to discriminate sun-damaged skin from LM. The aim of this study was to quantify the melanocytic density at the surgical margins of scanned whole-slide images of LM comparing sections stained with H&E and SOX10. Twenty-six surgically excised LM diagnosed at the Department of Pathology at Sahlgrenska University Hospital were collected. The slides that contained the closest surgical margin or harbored the highest density of melanocytes at the margin were selected for serial sectioning using H&E and SOX10. Whole-slide imaging at ×40 magnification was used, and a circular field with a diameter of 0.5 mm at the surgical margin was superimposed on the image. Five blinded pathologists reviewed the slides in a randomized order. In the majority of the cases (24/26), the pathologists identified more melanocytes on the SOX10 slides than those on the H&E slides. On average, 2.5 times more melanocytes were counted using SOX10 compared with H&E (P < 0.05). Furthermore, the average group SD on the H&E slides was 4.12 compared with 2.83 on the SOX10 slides (P = 0.004). Thus, the use of SOX10 staining leads to higher melanocytic density counts compared with H&E staining when assessing the surgical margins of LM. The use of SOX10 staining also significantly decreased the interobserver variability between pathologists.

Incomplete Excisions of Melanocytic Lesions: Rates and Risk Factors

Incomplete excisions of melanocytic lesions occur despite the intention of complete removal. The aim of this study was to determine the incomplete excision rates for benign and malignant melanocytic lesions and the associated risk factors. Demographic, clinical, and histopathological data possibly associated with incomplete excision were collected from 2,782 consecutive excisions between 2014 and 2015. Of these, 269 melanocytic lesions (9.7%) were incompletely excised. Multivariate analysis revealed the following risk factors for significantly higher incomplete excision rates: lesions located in the head and neck area (odds ratio (OR) 3.95, 95% confidence interval (95% CI) 2.35–6.65), surgery performed by general practitioners (OR 3.01, 95% CI 2.16–4.19), the use of a punch excision technique (OR 2.83, 95% CI 1.96–4.08), and excision of non-dysplastic naevi (OR 1.58, 95% CI 1.11–2.23). In conclusion, more caution should be taken when excising melanocytic lesions in the head and neck area, general practitioners require more surgical training, and punch excisions of melanocytic lesions should be avoided.

Methotrexate Use for Patients with Psoriasis and Risk of Cutaneous Squamous Cell Carcinoma: A Nested Case-control Study

An association between methotrexate use and risk of cutaneous squamous cell carcinoma has been reported in patients with rheumatoid and psoriatic arthritis. A nested case-control study was performed to investigate if methotrexate use among patients with psoriasis was associated with increased risk of cutaneous squamous cell carcinoma. Data were obtained from Swedish registers and included 623 patients with psoriasis and a first cutaneous squamous cell carcinoma from 2010 to 2016. Ten randomly selected patients with psoriasis were matched on age and sex to each case. Among cases, 160 (26%) were ever-users of metho-trexate. The corresponding number among the controls was 1,370 (22%), yielding an unadjusted odds ratio (OR) of 1.23 (95% confidence interval (95% CI) 1.02-1.49); p = 0.034. After adjusting for use of other immunosuppressive drugs the association was close to unity (OR 1.09; 95% CI 0.89-1.34); p = 0.39. The slightly increased risk of cutaneous squamous cell carcinoma associated with methotrexate-exposure in patients with psoriasis does not seem to be associated with metho-trexate, but rather with disease severity, other anti-psoriatic treatments, and ultraviolet exposure.

Incidence of Kaposi Sarcoma in Sweden is Decreasing

Kaposi sarcoma is a rare skin cancer, and epidemiological research into Kaposi sarcoma is therefore scarce. The current epidemiological situation for Kaposi sarcoma in Sweden is unknown. The authors hypothesized that the incidence of Kaposi sarcoma should have decreased after the introduction of antiretroviral therapy in 1996. Using data from the Swedish Cancer Registry, this study aimed to determine the incidence rates and survival for Kaposi sarcoma in Sweden from 1993 to 2016. The results showed that a total of 657 patients (74.0% men, 26.0% women) were diagnosed with Kaposi sarcoma in Sweden during 1993 to 2016. The overall incidence per 100,000, age-standardized to the world population, decreased from 0.40 to 0.10 (p = 0.003) for both sexes combined, from 0.76 to 0.14 (p = 0.003) for men, and from 0.07 to 0.06 (p = 0.86) for women. The 10-year overall survival rate was significantly lower for the study population (30%) compared with the age- and sex-matched Swedish population (56%) (p < 0.00001). Over the study period, incidence rates of Kaposi sarcoma decreased significantly in men, especially during the late 1990s.

Attitudes Toward Artificial Intelligence Within Dermatopathology: An International Online Survey

Background: Artificial intelligence (AI) has recently surfaced as a research topic in dermatology and dermatopathology. In a recent survey, dermatologists were overall positive toward a development with an increased use of AI, but little is known about the corresponding attitudes among pathologists working with dermatopathology. The objective of this investigation was to make an inventory of these attitudes.

Participants and Methods: An anonymous and voluntary online survey was prepared and distributed to pathologists who regularly analyzed dermatopathology slides/images. The survey consisted of 39 question divided in five sections; (1) AI as a topic in pathology; (2) previous exposure to AI as a topic in general; (3) applications for AI in dermatopathology; (4) feelings and attitudes toward AI and (5) self-reported tech-savviness and demographics. The survey opened on March 13, 2020 and closed on May 5, 2020.

Results: Overall, 718 responders (64.1% females) representing 91 countries were analyzed. While 81.5% of responders were aware of AI as an emerging topic in pathology, only 18.8% had either good or excellent knowledge about AI. In terms of diagnosis classification, 42.6% saw strong or very strong potential for automated suggestion of skin tumor diagnoses. The corresponding figure for inflammatory skin diseases was 23.0% (P_adj < 0.0001). For specific applications, the highest potential was considered for automated detection of mitosis (79.2%), automated suggestion of tumor margins (62.1%) and immunostaining evaluation (62.7%). The potential for automated suggestion of immunostaining (37.6%) and genetic panels (48.3%) were lower. Age did not impact the overall attitudes toward AI. Only 6.0% of the responders agreed or strongly agreed that the human pathologist will be replaced by AI in the foreseeable future. For the entire group, 72.3% agreed or strongly agreed that AI will improve dermatopathology and 84.1% thought that AI should be a part of medical training.

Conclusions: Pathologists are generally optimistic about the impact and potential benefit of AI in dermatopathology. The highest potential is expected for narrow specified tasks rather than a global automated suggestion of diagnoses. There is a strong need for education about AI and its use within dermatopathology.

Evaluation of the Diagnostic Accuracy of an Online Artificial Intelligence Application for Skin Disease Diagnosis

Artificial intelligence (AI) algorithms for automated classification of skin diseases are available to the consumer market. Studies of their diagnostic accuracy are rare. We assessed the diagnostic accuracy of an open-access AI application (Skin Image Search™) for recognition of skin diseases. Clinical images including tumours, infective and inflammatory skin diseases were collected at the Department of Dermatology at the Sahlgrenska University Hospital and uploaded for classification by the online application. The AI algorithm classified the images giving 5 differential diagnoses, which were then compared to the diagnoses made clinically by the dermatologists and/or histologically. We included 521 images portraying 26 diagnoses. The diagnostic accuracy was 56.4% for the top 5 suggested diagnoses and 22.8% when only considering the most probable diagnosis. The level of diagnostic accuracy varied considerably for diagnostic groups. The online application demonstrated low diagnostic accuracy compared to a dermatologist evaluation and needs further development.

Comorbidity and health-related quality of life in Somali women living in Sweden

Objective: To explore the relationship between low serum vitamin D levels and comorbidity in Somali women, immigrants to Sweden. Design and setting: Cohort study in a Primary Health Care Center and a University Hospital. Subjects: Somali women skin type V, n = 114, aged 18-56 years, from latitude 0-10○ N, living in Sweden, latitude 57○ N > 2 years were compared with women from a population sample, skin type II-III, n = 69, aged 38-56 years, the WHO MONICA study, Gothenburg, Sweden. Main outcome measures: Serum (S)-25(OH)D, S-parathyroid hormone (PTH), comorbidity and Health-Related Quality of Life (HRQoL) using the Short Form-36 (SF-36) and part of the EQ-5D questionnaires. All calculations were corrected for age. Results: Vitamin D deficiency (S-25(OH)D < 25 nmol/l) was found in 73% of the Somali women and in 1% of the controls (p < .0001). S-PTH was elevated (>6.9 pmol/l) in 26% and 9%, respectively (p < .004). Somali women used less medication, 16% vs. 55%, p < .0001) but more allergy medication, 11% vs. 7% (p = .006), had fewer fractures, 2% vs. 28% (p < .0001) and lower HRQoL in 7 out of 9 scales (p < .05-.001), than native controls. There were no differences in the prevalence of diabetes mellitus, hypothyroidism, positive thyroid peroxidase antibodies, vitamin B12 deficiency, celiac disease or hypertension. Conclusions: Vitamin D deficiency was common in Somali women living in Sweden, 73%, but comorbidity was low. Both mental, and especially physical HRQoL scores were lower in the Somali women. The effects of long-lasting deficiency are unknown. Key points The aim was to explore the relationship between vitamin D deficiency (S-25(OH)D < 25 nmol/l) and comorbidity in immigrants. Vitamin D deficiency was common in Somali women living in Sweden, 73%, but comorbidity of hypothyroidism, diabetes mellitus, hypertension, fractures and use of medications was low. Both mental, and especially physical, Health-Related Quality of Life were lower in the Somali women than in native Swedish women. The effects of long-lasting deficiency are unknown.

Degree of differentiation of cutaneous squamous cell carcinoma: a comparison between a Swedish cohort of organ transplant recipients and immunocompetent patients

Background

Organ transplant recipients (OTRs) have a very high risk of developing cutaneous squamous cell carcinoma (cSCC). Immunosuppressed OTRs may have a higher proportion of poorly differentiated cSCC than non-OTRs.

Objectives

The aim of this study was to investigate the degree of differentiation of cSCCs in OTRs compared with immunocompetent individuals.

Patients/Methods

Data from the Swedish Cancer Registry were crosschecked with data from the Transplant registry of the Transplant Institute at Sahlgrenska University Hospital in Gothenburg, Sweden. All OTRs with a diagnosis of cSCC, basosquamous carcinoma, and/or cSCC in situ established at the Department of Dermatology, Sahlgrenska University Hospital, during 2002–2015 were included. The control group consisted of non-OTRs with the same diagnoses during the same time period.

Results

During 2002–2015, 82 OTRs diagnosed with 515 tumors and 883 non-OTRs with 1,247 tumors were included. OTRs developed 0.47 tumors/year vs 0.10 tumors/year for non-OTRs, but no significant differences were observed in the degree of tumor differentiation of invasive cSCCs between OTRs and non-OTRs (P = 0.4). The distribution of poorly, moderately, and well-differentiated invasive cSCCs among OTRs and non-OTRs were 8.5% vs 12.5%, 22.1% vs 29.9%, and 69.4% vs 57.6%, respectively.

Conclusions

OTRs do not develop a higher proportion of poorly differentiated cSCCs than non-OTRs.

Methotrexate Exposure and Risk of Cutaneous Malignant Melanoma: No Evidence of a Dose-response Relationship

Methotrexate treatment has been linked with an increased risk of melanoma. However, a possible dose-response relationship with respect to methotrexate exposure and melanoma has not been addressed. The aim of the present study was to investigate whether higher accumulated doses of methotrexate correlate with an increased risk of melanoma, which would further support a possible association. A nationwide retrospective cohort study was conducted. All Swedish patients over 18 years of age who were dispensed methotrexate in the period 2005 to 2014 were registered (n = 101,966) and matched to the cancer registry. A Cox proportional hazards model, testing risk of melanoma vs. total accumulated methotrexate dose, controlled for sex, age group, and time from first to last dispensed prescription of methotrexate, yielded no significant risk dependence on dose, and a hazard ratio of 1.02 (95% CI 0.97-1.08). Overall, no conclusive dose-response relationship was observed between methotrexate exposure and risk of melanoma.

A prospective, randomized, within-subject study of ALA-PDT for actinic keratoses using different irradiation regimes

BACKGROUND

Photodynamic therapy (PDT) can be used to treat large fields of actinic keratoses (AKs) with high clearance rates. A notable downside is the amount of pain that accompany the treatment. This study aimed to optimize the illumination protocol during conventional PDT in order to reduce pain without compromising treatment effectiveness.

METHODS

In this prospective, randomized study with a split-face design, patients with, symmetrically distributed AKs were included. All patients were treated using a ALA 78 mg/g gel. One side was illuminated with the Aktilite^® CL-128 lamp and the other side with the RhodoLED^® lamp in which the light intensity gradually increased to a maximum of 60%. Both sides received a total light dose of 37 J/cm² . Pain during the treatment was measured using a visual analogue scale. The clinical effectiveness of the 2 treated sides was assessed after 12 weeks.

RESULTS

Twenty-nine patients with 399 AKs were included. Illumination with the gradually increasing light intensity resulted in a decrease in the median visual analogue scale score by 1.1 points. Clearance rates were similar between the 2 lamps.

CONCLUSION

Minimizing the light intensity during the illumination phase of PDT reduces pain, while still preserving a high clearance rate of AKs.

Lethal Melanomas: A Population-based Registry Study in Western Sweden from 1990 to 2014

The incidence rates of thin melanomas (≤1 mm Breslow thickness) have increased in many fair-skinned populations, prompting a need to better identify patients with thin melanomas who will eventually die from the disease. This study aimed to describe the clinicopathological characteristics of lethal melanomas in Western Sweden, with a focus on thin lesions. Population-based data on invasive melanomas diagnosed during the years 1990 to 2014 were extracted from the Swedish Melanoma Registry, and linked to the Swedish Cause of Death Registry. The age-standardized incidence (US population 2000) of thin melanomas increased from 9.1×10-5 (95% confidence interval (95% CI) 8.5-9.8) to 21.3×10-5 (95% CI 20.4-22.1) during the study period. Thin melanomas comprised 55.2% of the total and contributed to 13.5% of all melanoma deaths. Non-ulcerated melanomas 0.76-1 mm and ulcerated melanomas 0.26-1.0 mm showed a poorer survival compared with other thin melanomas.

Variation in Staphylococcus aureus Colonization in Relation to Disease Severity in Adults with Atopic Dermatitis during a Five-month Follow-up

The aim of this study was to monitor Staphylococcus aureus colonization and disease severity in adults with atopic dermatitis (AD) during 5 months. Twenty-one patients attended 3 visits each for severity SCORing of Atopic Dermatitis (SCORAD) assessment, quantitative cultures from the skin and conventional cultures from the anterior nares, tonsils and perineum. S. aureus isolates were typed for strain identity with pulsed-field gel electrophoresis (PFGE). Seventy-one percent of patients were colonized with S. aureus on lesional skin at least once. Density (colony-forming units (CFU)/cm2) was higher on lesional skin than on non-lesional skin (p < 0.05). Density on lesional skin and number of colonized body sites were positively correlated with SCORAD (p = 0.0003 and p = 0.007, respectively). Persistent carriers of the same strain on lesional skin had higher mean SCORAD index than intermittent/non-carriers (36.3 and 17.1, respectively, p = 0.002). The results show a temporal correlation between several aspects of S. aureus colonization and disease severity in AD raising the question of the importance of this in pathogenesis and treatment.

Multiple Primary Melanomas: A Common Occurrence in Western Sweden

Patients diagnosed with a single primary cutaneous melanoma are at increased risk of developing multiple primary melanomas. The aim of this study is to describe the epidemiology of multiple primary melanomas (invasive and in situ) in Western Sweden. Data from the Swedish Melanoma Registry from 1990 to 2013 revealed that 898 patients (7.4%) developed 2,037 multiple primary lesions and 11,254 patients developed single lesions. The proportion of subsequent lesions that were melanoma in situ was 47%, compared with 26% of first melanomas (p < 0.0001).The median and mean time to diagnosis of a subsequent melanoma was 38 and 58 months (95% confidence interval (CI), 53-62 months). In total, 49% of subsequent melanomas were detected within 3 years. Patients and physicians should be aware of the high proportion of multiple primary melanomas in Western Sweden, especially during the first years of follow-up.

Methotrexate treatment and risk for cutaneous malignant melanoma: a retrospective comparative registry-based cohort study

BACKGROUND

Methotrexate (MTX) is frequently used as an immunosuppressive drug in inflammatory diseases. It is controversial and it has not been thoroughly investigated whether MTX increases the risk of cutaneous malignant melanoma (CMM).

OBJECTIVES

The aim of the present study was to investigate whether MTX exposure increases the risk for CMM.

METHODS

A retrospective cohort study was conducted using statistics from the National Board of Health and Welfare. All patients over 18 years in the time period August 2005 to December 2014 that were dispensed MTX from Swedish pharmacies were registered (n = 101 966). For every MTX-exposed patient, five age- and sex-matched patients who had been dispensed a random drug other than MTX during the same time period were randomly selected (n = 509 279). The lists were matched with the Swedish Cancer Registry.

RESULTS

Overall, a small but statistically significant (P < 0·001) risk increase for CMM was observed in MTX-exposed patients compared with patients without MTX exposure. The Kaplan-Meier estimates for the 5-year risk of CMM was 0·48% [95% confidence interval (CI) 0·43-0·53] in the MTX-exposed group and 0·41% (95% CI 0·39-0·43) in the MTX-unexposed group. However, in a subgroup analysis, the difference between the groups was preserved only in women older than 70 years at treatment start. Moreover, there was no significant difference in incidences between the MTX-exposed and MTX-unexposed patients in the time period.

CONCLUSIONS

Our results suggest a small but significant increase in risk for CMM in patients treated with MTX. However, the risk increase observed was considerably lower than in earlier observations.

Effectiveness of photodynamic therapy in Bowen's disease: a retrospective observational study in 423 lesions

BACKGROUND

Photodynamic therapy (PDT) is a well-known technique that is often used for treating superficial precancerous and cancerous skin lesions. However, only a handful of studies, with a relatively small number of treated lesions, have been carried out on the effectiveness of PDT for Bowen's disease (BD).

OBJECTIVES

This study aimed to assess the effectiveness and recurrence risk of PDT in the treatment of BD. The secondary objectives were to determine what factors affected the response rates and the cosmetic result of the treatment.

METHOD

In this retrospective observational study, the electronic patient charts at Sahlgrenska University Hospital (SUH) in Gothenburg, Sweden, were searched to find all patients diagnosed with BD who were treated with PDT between 1 January 2002 and 31 December 2014. Data were collected regarding clinical response at the first follow-up visit, recurrences during later follow-up visits and other relevant patient and tumour characteristics.

RESULTS

In total, 423 BD lesions in 335 patients were included in the study. The mean FU duration was 11.2 months (range 0.2-151 months). The complete response rate at the first FU visit was 77.5% for all BD lesions. During later FU visits, another 60 recurrences were observed, which resulted in a recurrence rate of 18.3%. Thus, the overall clearance rate after FU was 63.4% for all BD lesions. Significant risk factors for unsuccessful treatment in this study were large lesion size (>2 cm) and a single PDT session.

CONCLUSION

This study shows that PDT is a relatively effective treatment modality for BD.

Clinical Features, Complications and Autoimmunity in Male Lichen Sclerosus

Lichen sclerosus is a chronic inflammatory disease associated with substantial morbidity. Knowledge of the aetiology and progression of lichen sclerosus is therefore needed. In this cross-sectional study, 100 male patients diagnosed with lichen sclerosus were interviewed and examined. Since there is a possible link between lichen sclerosus and autoimmunity, blood tests were analysed for thyroid disease, antinuclear antibodies and antibodies to extracellular matrix protein 1, but autoimmunity was found to be infrequent. In 72 participants active genital lichen sclerosis was observed and complications were common; 27 patients had preputial constriction and 12 meatal engagement. In total, 13 patients needed a referral to the Department of Urology, including 1 patient with suspected penile cancer. In conclusion, despite available treatment with ultra-potent steroids and circumcision, lichen sclerosus in males is frequently complicated by phimosis and meatal stenosis. However, the disease can also go into remission, as seen in 27% of our patients.