1
|
Kouwenhoven TA, van Muijen ME, van de Kerkhof PCM, de Jong EMGJ, Kamsteeg M, Seyger MMB. Effectiveness of systemic treatments on pruritus associated with atopic dermatitis: A systematic review in pediatric patients. Pediatr Dermatol 2024; 41:34-40. [PMID: 38018272 DOI: 10.1111/pde.15468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/17/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND/OBJECTIVES Itch is one of the hallmarks of atopic dermatitis (AD), which has a significant impact on the quality of life of pediatric patients with AD and their caregivers. We aimed to conduct a systematic review and meta-analysis to evaluate the antipruritic effects of systemic AD treatments in pediatric patients with AD. METHODS PubMed, EMBASE, Cochrane, and Web of Science databases were searched, including studies providing original data on the effects of systemic treatment on pruritus in pediatric patients (<18 years) with AD. Placebo-controlled trials reporting a Peak Pruritus Numerical Rating Scale 4 (PP-NRS4) response were included in a meta-analysis. RESULTS A total of 30 studies were included, with most evidence available for dupilumab. Overall, marked improvements of pruritus (50% or greater reduction in pruritus outcome measurements) were found for treatment with cyclosporin A (2-16 years), dupilumab (6 months-17 years), abrocitinib, and upadacitinib (both 12 and 17 years). Nemolizumab (12-17 years) may be promising in reducing pruritus in pediatric patients; however, data are limited. Only five randomized controlled trials could be included in our meta-analysis, in which dupilumab, abrocitinib, and upadacitinib showed a significantly higher probability of achieving a PP-NRS4 response compared with placebo. Our study was limited by a lack of homogeneity of included studies. CONCLUSIONS Cyclosporin A, dupilumab, abrocitinib, and upadacitinib are all effective in decreasing pruritus and, therefore, in improving the quality of life in children with AD. As more systemic treatments for AD become available, it will be imperative to incorporate patient-oriented treatment goals such as reduction of pruritus into therapeutic decision-making.
Collapse
Affiliation(s)
- Tessa A Kouwenhoven
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marloes E van Muijen
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marijke Kamsteeg
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
2
|
Bronckers IMGJ, de Jong EMGJ, Michielsens CAJ, Groenewoud HMM, van de Kerkhof PCM, Seyger MMB. Identification of children at risk for the development of severe paediatric plaque psoriasis: Findings from the prospective observational long-term Child-CAPTURE registry. J Eur Acad Dermatol Venereol 2023. [PMID: 36800316 DOI: 10.1111/jdv.18984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/15/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Inge M G J Bronckers
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud University, Nijmegen, The Netherlands
| | - Celia A J Michielsens
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans M M Groenewoud
- Department for Health Evidence, Radboud University, Nijmegen, The Netherlands
| | | | - Marieke M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
3
|
van de Kerkhof PCM. Creating room for innovation in the treatment of psoriasis. J DERMATOL TREAT 2022; 33:2885. [PMID: 36258307 DOI: 10.1080/09546634.2022.2138396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
4
|
Ter Haar ELM, Tummers M, Bronkhorst EM, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Age-based treatment differences in and reluctance to treating older adults with systemic antipsoriatic therapy - a mixed-method pilot study. J DERMATOL TREAT 2022; 33:2983-2990. [PMID: 35762362 DOI: 10.1080/09546634.2022.2089330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Evidence-based guidance in older adults (≥65 years) with psoriasis is sparse and undertreatment might be present. OBJECTIVES To assess prescribing patterns, comfort levels, barriers and needs of dermatologists when treating older adults with systemic antipsoriatic therapy. METHODS A mixed-methods design was used including a survey among all Dutch dermatologists and residents, followed by semi-structured interviews. RESULTS Most of the survey respondents applied systemic treatment to the same extent in older versus younger patients (n = 49; 67.1%) and weren't reluctant prescribing systemic therapy (n = 50; 68.5%) in older adults. However, 26% (n = 19) of the respondents treated older adults less often with systemic therapy compared to younger patients and 68.1% (n = 49) performed additional actions in older adults, e.g. intensified monitoring or dose reduction. Based on the survey and interviews (n = 10), the main reasons for these age-based treatment differences were comorbidity, comedication, and fear of adverse events. More evidence-based guidance, education, and time to assess older adults were identified as most important needs, especially regarding frailty screening. CONCLUSIONS Age-based treatment differences in and reluctance to treating older adults with systemic antipsoriatic therapy were common. There is a need for more evidence-based guidance, education, and consultation time, to improve treatment in this growing population.
Collapse
Affiliation(s)
- Elke L M Ter Haar
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcia Tummers
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ewald M Bronkhorst
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Satish F K Lubeek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
5
|
van de Kerkhof PCM. From clinical trial to real world evidence: a learning healthcare environment. J DERMATOL TREAT 2022; 33:1803. [PMID: 35695298 DOI: 10.1080/09546634.2022.2089506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
6
|
van de Kerkhof PCM. Dermatology in a changing world. J DERMATOL TREAT 2022; 33:605. [PMID: 35261327 DOI: 10.1080/09546634.2022.2051835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
7
|
Atalay S, Berends SE, Groenewoud HMM, Mathot RAA, Njoo DM, Mommers JM, Ossenkoppele PM, Koetsier MIA, Berends MA, de Vries A, van de Kerkhof PCM, den Broeder AA, de Jong EMGJ, van den Reek JMPA. Serum drug levels and anti-drug antibodies in the context of dose tapering by interval prolongation of adalimumab, etanercept and ustekinumab in psoriasis patients: results of the CONDOR trial. J DERMATOL TREAT 2022; 33:2680-2684. [PMID: 35193441 DOI: 10.1080/09546634.2022.2043546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Biologics for psoriasis are registered in standard dosages. In patients with low disease activity, reduction of the dose by interval prolongation can prevent overtreatment, and lower risks and costs. However, fear for increased anti-drug antibody (ADA) formation due to interval prolongation of biologics is an important barrier. OBJECTIVE To investigate the course of serum drug concentrations, ADA levels, and predictors for successful dose reduction of adalimumab, ustekinumab, and etanercept for psoriasis. METHODS Patients were randomized to dose reduction (DR) or usual care (UC) and followed for one year. The course and extent of detectable ADA levels were expressed as proportions/relative risks for DR vs. UC. Association of baseline characteristics with successful tapering was investigated with log-binomial regression analysis. RESULTS In total, 118 patients were included. In adalimumab-treated patients, no significant difference in the proportion of patients with relevant ADA levels in DR vs. UC was seen. For ustekinumab, relevant ADA development was absent in both groups. Baseline trough levels were not predictive for successful DR. CONCLUSIONS Immunogenicity may not increase by interval prolongation in psoriasis patients with low disease activity. This pilot provides important and reassuring insight into the pharmacological changes after dose tapering of adalimumab, etanercept, and ustekinumab.
Collapse
Affiliation(s)
- Selma Atalay
- Department of Dermatology, Radboudumc, Nijmegen René Descartesdreef 1, Nijmegen, Netherlands
| | - Sophie E Berends
- Department of Hospital Pharmacy, Academic Medical Center, Amsterdam, Netherlands
| | - Hans M M Groenewoud
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, Netherlands
| | - Ron A A Mathot
- Department of Hospital Pharmacy, Academic Medical Center, Amsterdam, Netherlands
| | - David M Njoo
- Department of Dermatology, Ziekenhuis Groep Twente, Hengelo, Netherlands
| | | | | | | | - Maartje A Berends
- Department of Dermatology, Slingelandziekenhuis, Doetinchem, Netherlands
| | - Annick de Vries
- Biologics Lab, Bioanalysis, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | | | | | - Elke M G J de Jong
- Department of Dermatology, Radboudumc, Nijmegen René Descartesdreef 1, Nijmegen, Netherlands.,Radboud University, Nijmegen, Netherlands
| | - Juul M P A van den Reek
- Department of Dermatology, Radboudumc, Nijmegen René Descartesdreef 1, Nijmegen, Netherlands
| |
Collapse
|
8
|
Feldman SR, van de Kerkhof PCM. Another transition. J DERMATOL TREAT 2022; 33:1. [DOI: 10.1080/09546634.2022.2036409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Steven R. Feldman
- Professor of Dermatology, Pathology and Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Peter C. M. van de Kerkhof
- Radboud University Nijmegen Medical Centre, Nijmegen, The NetherlandsProfessor of Dermatology, Nijmegen, The Netherlands
| |
Collapse
|
9
|
van de Kerkhof PCM. Foreword. Am J Clin Dermatol 2022; 23:3-4. [PMID: 35061225 PMCID: PMC8801398 DOI: 10.1007/s40257-021-00656-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Peter C M van de Kerkhof
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| |
Collapse
|
10
|
van Winden MEC, Hetterschijt CRM, Bronkhorst EM, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Evaluation of Watchful Waiting and Tumor Behavior in Patients With Basal Cell Carcinoma: An Observational Cohort Study of 280 Basal Cell Carcinomas in 89 Patients. JAMA Dermatol 2021; 157:1174-1181. [PMID: 34495284 DOI: 10.1001/jamadermatol.2021.3020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Few studies have examined watchful waiting (WW) in patients with basal cell carcinoma (BCC), although this approach might be suitable in patients who might not live long enough to benefit from treatment. Objective To evaluate reasons for WW and to document the natural course of BCC in patients who chose WW and reasons to initiate later treatment. Design, Setting, and Participants An observational cohort study was performed at a single institution between January 2018 and November 2020 studying patients with 1 or more untreated BCC for 3 months or longer. Exposures Watchful waiting was chosen by patients and proxies regardless of this study. Main Outcome and Measures The reasons for WW and treatment were extracted from patient files and were categorized for analyses. Linear mixed models were used to estimate tumor growth and identify covariates associated with tumor growth. Results Watchful waiting was chosen for 280 BCCs in 89 patients (47 men [53%] and 42 women [47%]), with a median (interquartile range [IQR]) follow-up of 9 (4-15) months. The median (IQR) age of the included patients was 83 (73-88) years. Patient-related factors or preferences (ie, prioritizations of comorbidities, severe frailty, or limited life expectancy) were reasons to initiate WW in 74 (83%) patients, followed by tumor-related factors (n = 49; 55%). Treatment-related and circumstantial reasons were important for 35% and 46% of the patients, respectively. The minority of tumors increased in size (47%). Tumor growth was associated with BCC subtype (odds ratio, 3.35; 95% CI, 1.47-7.96; P = .005), but not with initial tumor size and location. The estimated tumor diameter increase was 4.46 mm (80% prediction interval, 1.42 to 7.46 mm) in 1 year for BCCs containing at least an infiltrative/micronodular component and 1.06 mm (80% prediction interval, -1.79 to 4.28 mm) for the remaining BCCs (only nodular/superficial component/clinical diagnosis). Most common reasons to initiate treatment were tumor burden or potential tumor burden, resolved reason(s) for WW, and reevaluation of patient-related factors. Conclusions and Relevance In this cohort study of patients with BCC, WW was an appropriate approach in several patients, especially those with asymptomatic nodular or superficial BCCs and a limited life expectancy. Patients should be followed up regularly to determine whether a WW approach is still suitable and whether patients still prefer WW and to reconsider consequences of treatment and refraining from treatment.
Collapse
Affiliation(s)
- Marieke E C van Winden
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Charlotte R M Hetterschijt
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ewald M Bronkhorst
- Department of Biostatistics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter C M van de Kerkhof
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elke M G J de Jong
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Satish F K Lubeek
- Radboud Institute for Health Sciences, Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
11
|
van de Kerkhof PCM. Future perspectives on care for patients with psoriasis. What did we learn during the COVID-19. J DERMATOL TREAT 2021; 32:477. [PMID: 34182877 DOI: 10.1080/09546634.2021.1945655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Peter C M van de Kerkhof
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
12
|
van Winden MEC, Bronkhorst EM, Visch MB, Krekels GAM, van der Geer S, Damen GWJA, Amir A, Aben KKH, Gerritsen MJJP, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Predictors of surgical treatment burden, outcomes, and overall survival in older adults with basal cell carcinoma: Results from the prospective, multicenter BATOA cohort. J Am Acad Dermatol 2021; 86:1010-1019. [PMID: 34082036 DOI: 10.1016/j.jaad.2021.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/24/2021] [Accepted: 05/06/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Incorporating patient-related factors associated with treatment outcomes could improve personalized care in older patients with basal cell carcinoma (BCC). OBJECTIVE To evaluate and identify predictors of treatment burden, treatment outcomes, and overall survival in patients aged ≥70 years, surgically treated for BCC in the head and neck area. METHODS The data from the prospective, multicenter Basal Cell Carcinoma Treatment in Older Adults (BATOA) cohort study were extracted to evaluate the experienced treatment burden (visual analog scale, 0-10 cm; lower scores indicating higher treatment burden), treatment outcomes, and mortality. RESULTS A total of 539 patients were included (median age, 78 years). The patients experienced a low overall treatment burden (median, 8.6) and good cosmetic results. The predictors of higher treatment burden were instrumental activities of daily living (iADL) dependency, female sex, complications, larger tumor diameter, and polypharmacy. Thirty-five patients (6.5%) died (none of the deaths were due to BCC) within the follow-up period; the predictors of mortality were increasing comorbidity index and iADL dependency. No difference in these outcomes was seen between Mohs micrographic surgery and conventional excision after correction for covariates. Age was not significantly associated with any outcome. LIMITATIONS A selection bias may exist owing to the observational design. CONCLUSION BCC management decisions based on chronological age alone should be avoided, whereas more attention is recommended for patient-related factors. Based on these data, early BCC intervention is beneficial for robust and fit patients or those experiencing symptoms.
Collapse
Affiliation(s)
- Marieke E C van Winden
- Department of Dermatology, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Ewald M Bronkhorst
- Department of Biostatistics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M Birgitte Visch
- Department of Dermatology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | | | | | - Avital Amir
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Katja K H Aben
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | | | | | - Elke M G J de Jong
- Department of Dermatology, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Satish F K Lubeek
- Department of Dermatology, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| |
Collapse
|
13
|
Atalay S, van den Reek JMPA, den Broeder AA, van Vugt LJ, Otero ME, Njoo MD, Mommers JM, Ossenkoppele PM, Koetsier MI, Berends MA, van de Kerkhof PCM, Groenewoud HMM, Kievit W, de Jong EMGJ. Comparison of Tightly Controlled Dose Reduction of Biologics With Usual Care for Patients With Psoriasis: A Randomized Clinical Trial. JAMA Dermatol 2020; 156:393-400. [PMID: 32049319 DOI: 10.1001/jamadermatol.2019.4897] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Biologics revolutionized the treatment of psoriasis. Biologics are given in a fixed dose, but lower doses might be possible. Objective To investigate whether dose reduction (DR) of biologics in patients with stable psoriasis is noninferior to usual care (UC). Design, Setting, and Participants This pragmatic, open-label, prospective, controlled, noninferiority randomized clinical trial was conducted from March 1, 2016, to July 22, 2018, at 6 dermatology departments in the Netherlands. A total of 120 patients with plaque psoriasis and stable low disease activity who were receiving treatment with adalimumab, etanercept, or ustekinumab were studied. Interventions Patients were randomized 1:1 to DR (n = 60) or UC (n = 60). In the DR group, injection intervals were prolonged stepwise, leading to 67% and 50% of the original dose. Main Outcomes and Measures The primary outcome was between-group difference in disease activity corrected for baseline at 12 months compared with the predefined noninferiority margin of 0.5. Secondary outcomes were Psoriasis Area and Severity Index (PASI) score and health-related quality of life (including Dermatology Life Quality Index [DLQI] and Medical Outcomes Study 36-Item Short Form Health Survey scores), proportion of patients with short and persistent flares (defined as PASI and/or DLQI scores >5 for ≥3 months), and proportion of patients with successful dose tapering. Results Of 120 patients (mean [SD] age, 54.0 [13.2] years; 82 [68%] male), 2 patients were lost to follow-up, 2 patients had a protocol violation, and 5 patients had a protocol deviation, leaving 111 patients for the per-protocol analysis (53 in the DR group and 58 in the UC group). The median PASI scores at month 12 were 3.4 (interquartile range [IQR], 2.2-4.5) in the DR group and 2.1 (IQR, 0.6-3.6) in the UC group (mean difference, 1.2; 95% CI, 0.7-1.8). This indicates that noninferiority was not demonstrated for DR compared to UC. The median DLQI score at month 12 was 1.0 (IQR, 0.0-2.0) in the DR group and 0.0 (IQR, 0.0-2.0) in the UC group (mean difference, 0.8; 95% CI, 0.3-1.3), indicating noninferiority for DR compared with UC. No significant difference was found regarding persistent flares between groups (n = 5 in both groups). Twenty-eight patients (53%; 95% CI, 39%-67%) in the DR group tapered their dose successfully at 12 months. No severe adverse events related to the intervention occurred. Conclusions and Relevance In this trial, noninferiority was not demonstrated for DR of adalimumab, etanercept, and ustekinumab based on the PASI in patients with psoriasis compared with UC with the chosen noninferiority margin. However, the strategy was noninferior based on the DLQI. Dose tapering did not lead to persistent flares or safety issues. Trial Registration ClinicalTrials.gov Identifier: NCT02602925.
Collapse
Affiliation(s)
- Selma Atalay
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Lieke J van Vugt
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marisol E Otero
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcellus D Njoo
- Department of Dermatology, Ziekenhuis Groep Twente, Hengelo, the Netherlands
| | - Johannes M Mommers
- Department of Dermatology, Sint Anna Ziekenhuis, Geldrop, the Netherlands
| | | | | | - Maartje A Berends
- Department of Dermatology, Slingelandziekenhuis, Doetinchem, the Netherlands
| | | | | | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
14
|
Puig L, Lomaga M, Hollister K, Dutronc Y, Berggren L, van de Kerkhof PCM. An Analysis of Patient-reported Outcomes in IXORA-S: Comparing Ixekizumab and Ustekinumab over 52 Weeks in Moderate-to-severe Psoriasis. Acta Derm Venereol 2020; 100:adv00344. [PMID: 33236124 PMCID: PMC9309708 DOI: 10.2340/00015555-3700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patient-reported outcomes are valuable for assessing new psoriasis therapies. This study investigated patient-reported outcomes in patients with moderate-to-severe plaque psoriasis treated with ixekizumab or ustekinumab, dosed according to their respective labels, for 52 weeks (IXORA-S-NCT02561806). Patient-reported outcomes investigated included patient global assessment, pruritus, skin pain, health-related quality of life, and work productivity. Ixekizumab-treated patients reported greater improvements in patient-reported outcomes sooner after treatment compared with ustekinumab-treated patients, and maintained greater improvements in patient global assessment scores (ixekizumab 0.72, ustekinumab 1.19; p < 0.001), rates of Dermatology Life Quality Index (0, 1) (ixekizumab 71.3%, ustekinumab 56.6%, p < 0.01), and 36-item Short-form Health survey physical component summary score change from baseline (ixekizumab 5.53, ustekinumab 3.28; p < 0.05) at week 52. While clinically meaningful improvements in patient-reported outcomes resulted with either treatment, ixekizumab provided more rapid improvements in patient-reported outcomes and superior outcomes for some assessments through one year of treatment, while maintaining statistically superior improvements in skin severity, as assessed by either physicians or patients.
Collapse
Affiliation(s)
- Lluís Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, ES-08041 Barcelona, Spain. E-mail:
| | | | | | | | | | | |
Collapse
|
15
|
Atalay S, van den Reek JMPA, Otero ME, Njoo MD, Mommers JM, Ossenkoppele PM, Koetsier MI, Berends MM, van de Kerkhof PCM, Groenewoud HMM, den Broeder AA, de Jong EMGJ, Kievit W. Health Economic Consequences of a Tightly Controlled Dose Reduction Strategy for Adalimumab, Etanercept and Ustekinumab Compared with Standard Psoriasis Care: A Cost-utility Analysis of the CONDOR Study. Acta Derm Venereol 2020; 100:adv00340. [PMID: 33196101 PMCID: PMC9309701 DOI: 10.2340/00015555-3692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A dose reduction strategy for adalimumab, etanercept and ustekinumab in patients with psoriasis who have stable and low disease activity has recently been compared with usual care in the CONDOR study (CONtrolled DOse Reduction) of biologics in patients with psoriasis with low disease activity. The aim of the current study was to perform a cost-utility analysis with a 12-month time horizon alongside this trial, using prospectively measured healthcare costs and quality-adjusted life years, based on Short-Form Six-Dimension utilities. Bootstrap analyses were used to calculate the decremental cost-utility ratio and the incremental net monetary benefit. The dose reduction strategy resulted in a mean cost saving of €3,820 (95th percentile –€3,099 to –€4,509) per patient over a period of 12 months. There was an 83% chance that dose reduction would result in a reduction in quality adjusted life years (mean –0.02 (95th percentile –0.06 to 0.02). In conclusion, dose reduction of biologics resulted in substantial cost savings with an acceptable reduction in quality of life.
Collapse
Affiliation(s)
- Selma Atalay
- Department of Dermatology, Radboud university medical center, 6525 Nijmegen, The Netherlands. E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Bruins FM, Bronckers IMGJ, Groenewoud HMM, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. Association Between Quality of Life and Improvement in Psoriasis Severity and Extent in Pediatric Patients. JAMA Dermatol 2020; 156:72-78. [PMID: 31774449 DOI: 10.1001/jamadermatol.2019.3717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Treatment of psoriasis is associated with improved quality of life (QOL) in those with the disease. However, in daily clinical practice, the association between the degree of psoriasis clearance and QOL has not been studied to date, especially in the pediatric population. Objectives To identify the association between the degree of psoriasis improvement (as measured by the Psoriasis Area Severity Index [PASI] and body surface area [BSA] response) and QOL (as measured by the Children's Dermatology Life Quality Index [CDLQI]) in pediatric psoriasis, and to assess the association of treatment type with QOL, independent of psoriasis improvement. Design, Setting, and Participants Data used in this single-center cohort study were extracted from the Child-CAPTURE (Continuous Assessment of Psoriasis Treatment Use Registry), a prospective, observational, daily clinical practice cohort of all children (aged <18 years) with a psoriasis diagnosis who attended the outpatient clinic of the Department of Dermatology at the Radboud University Medical Center in Nijmegen, the Netherlands, between September 3, 2008, and May 4, 2018. All records of treatment episodes with CDLQI, PASI, and BSA scores were included in the analysis. Exposures Patients were treated according to daily clinical care. Treatments were clustered into topical, dithranol, conventional systemic, and biological treatments. Because of low numbers of UV-B phototherapy, this treatment was not assessed. Main Outcomes and Measures Primary outcomes were mean change of CDLQI scores per PASI and BSA response categories (0 to <50, 50 to <75, 75 to <90, and ≥90) and mean CDLQI change per treatment categories. Results In total, 319 patients (median [interquartile range] age, 10.0 [7.0] years; 183 female [57.4%]) were analyzed for PASI score improvement (399 treatment episodes) and improvement in BSA involvement (366 treatment episodes). The greatest improvements in CDLQI scores were seen in the PASI ≥90 response category, with an estimated marginal mean change in CDLQI score of -6.6 (95% CI, -7.5 to -5.7). The greatest improvements in CDLQI scores were also observed in the BSA ≥90 response category, with an estimated marginal mean change in CDLQI score of -6.8 (95% CI, -7.5 to -6.1). Systemic treatment demonstrated a greater degree of improvement of CDLQI compared with topical treatment, independent of PASI response categories. Conclusions and Relevance This cohort study in a real-world setting found that the greatest improvements in QOL were associated with PASI 90 or greater, a decrease in BSA involvement of 90% or greater, and systemic treatments. These findings suggest that reaching PASI 90 or greater and decreasing BSA involvement by at least 90% may be clinically meaningful treatment goals that will help pediatric patients with psoriasis reach optimal QOL.
Collapse
Affiliation(s)
- Finola M Bruins
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Inge M G J Bronckers
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hans M M Groenewoud
- Department for Health Evidence, Radboud University, Nijmegen, the Netherlands
| | | | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marieke M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
17
|
van Winden MEC, van der Schoot LS, van de L’Isle Arias M, van Vugt LJ, van den Reek JMPA, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Effectiveness and Safety of Systemic Therapy for Psoriasis in Older Adults. JAMA Dermatol 2020; 156:1229-1239. [DOI: 10.1001/jamadermatol.2020.2311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | | | | | - Lieke J. van Vugt
- Department of Dermatology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Elke M. G. J. de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Satish F. K. Lubeek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
18
|
Goldman MP, Murrell DF, Al-Mutairi N, Arenbergerova M, Dréno B, Alhaddad M, Al-Suwaidan SN, Firooz A, van de Kerkhof PCM, Feldman SR. International collaboration. J DERMATOL TREAT 2020; 31:757. [PMID: 32646257 DOI: 10.1080/09546634.2020.1794290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Mitchel P Goldman
- University of California, San Diego, CA, USA West Dermatology, Cosmetic Laser Dermatology, San Diego, CA, USA
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Nawaf Al-Mutairi
- Department of Dermatology, Farwaniya Hospital, Kuwait University, Kuwait, Kuwait
| | - Monika Arenbergerova
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic
| | - Brigitte Dréno
- Dermatology Department, CHU Nantes, CRCINA, University Nantes, Nantes, France
| | | | - Sami N Al-Suwaidan
- Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alireza Firooz
- Center for Research and Training in Skin Diseases, Clinical Trial Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Steven R Feldman
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
19
|
van Winden MEC, ter Haar ELM, Groenewoud HMM, van de Kerkhof PCM, de Jong EMGJ, Lubeek SFK. Disease and Treatment Characteristics in Geriatric Psoriasis: A Patient Survey Comparing Age Groups. Acta Derm Venereol 2020; 100:adv00215. [PMID: 32556353 PMCID: PMC9199908 DOI: 10.2340/00015555-3569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Little is known about psoriasis in geriatric patients, whereas treating this growing population can be challenging due to comorbidities, comedication and physical impairments. To compare disease and treatment characteristics of psoriasis patients ≥65 years old with patients <65 years old, a self-assessment survey was sent to all members of the Dutch Psoriasis Association (n = 3,310). In total, 985 (29.7%) patients returned the survey, 414 (43.6%) respondents were ≥65 years old. Patients ≥65 years old had experienced erythrodermic psoriasis significantly more frequently than patients <65 years old, other disease characteristics were highly comparable. Despite a significantly higher prevalence of comorbidities and comedication use in patients ≥65 years old, no difference was seen between the age groups regarding systemic antipsoriatic treatment (38.3% in ≥65 years old vs 42.3% in <65 years old; p = 0.219). Remarkably, treatment-related side-effects were reported more frequently by patients <65 years old. In conclusion, age alone should not be a limiting factor in psoriasis management, and proper attention must be paid to additional patient-related factors.
Collapse
|
20
|
de Gruijl FR, van de Kerkhof PCM. [Phototherapy for psoriasis; clearing lesions and maintaining lesion-free status]. Ned Tijdschr Geneeskd 2020; 164:D4566. [PMID: 32757511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Since time immemorial, sunlight has been used to treat a wide variety of skin afflictions. Consequently, probably on the basis of patients' experience and consequent experimentation with lamps, phototherapy has become an important dermatological treatment, particularly for psoriasis. The active component in sunlight proved to be ultraviolet (UV) radiation. Optimized UV lamps (type TL01) are now routinely used for clearing psoriatic lesions, after which therapy is stopped due to potential carcinogenic effects. The lesions reappear after a few months. Daily home treatment with low-dose UV radiation is a possible one to keep patients lesion-free; this leads to a marked reduction in the need for topical medications. This maintenance therapy can provide adequate suppression of this chronic skin disease.
Collapse
Affiliation(s)
- Frank R de Gruijl
- Leids Universitair Medisch Centrum, afd. Huidziekten, Leiden
- Contact: Frank R. de Gruijl
| | | |
Collapse
|
21
|
van de Kerkhof PCM. Dermatology before, during and after COVID 19. J DERMATOL TREAT 2020; 31:435. [DOI: 10.1080/09546634.2020.1780024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
22
|
van de Kerkhof PCM. Translational Research and Drug Development in Psoriasis by Collaborative Efforts of Academia and Industry. J Invest Dermatol 2020; 140:524-526. [PMID: 31945346 DOI: 10.1016/j.jid.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/01/2020] [Accepted: 01/07/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Peter C M van de Kerkhof
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| |
Collapse
|
23
|
Kleyn CE, Talbot PS, Mehta NN, Sampogna F, Bundy C, Ashcroft DM, Kimball AB, van de Kerkhof PCM, Griffiths CEM, Valenzuela F, van der Walt JM, Aberra T, Puig L. Psoriasis and Mental Health Workshop Report: Exploring the Links between Psychosocial Factors, Psoriasis, Neuroinflammation and Cardiovascular Disease Risk. Acta Derm Venereol 2020; 100:adv00020. [PMID: 31742649 PMCID: PMC9128964 DOI: 10.2340/00015555-3375] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Psoriasis is a systemic, relapsing, inflammatory disease associated with serious comorbidities including mood problems and/or unhealthy lifestyle behaviours. Cutaneous and systemic abnormalities in innate and acquired immunity play a role in its pathogenesis. The exact pathogenetic mechanism remains elusive. Evidence is accumulating that TNF-alpha, IL-17 and IL-23 signalling are highly relevant as targeting these pathways reduces disease activity. Evidence suggests a strong link between psoriasis and depression in adults. The International Psoriasis Council (IPC) held a roundtable event, “Psoriasis and Mental Health”, in Barcelona, Spain which focused on the presence of depression and suicidality, plus the role of neuroinflammation in psoriasis, sleep disruption and the impact of depression on cardiovascular disease outcomes. We summarize here the expert presentations to provide additional insight into the understanding of psychiatric comorbidities of psoriasis and of the impact of chronic, systemic inflammation on neuro- and cardiovascular outcomes. the associations between psoriasis and other psychiatric comorbidities are still controversial and warrant further attention.
Collapse
Affiliation(s)
- C Elise Kleyn
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
van de Kerkhof PCM, Feldman SR. Our ambition in a changing landscape of psoriasis treatments. J DERMATOL TREAT 2020; 31:105-107. [PMID: 31903808 DOI: 10.1080/09546634.2020.1712095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Dermatology, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
25
|
Strober B, van de Kerkhof PCM, Callis Duffin K, Poulin Y, Warren RB, de la Cruz C, van der Walt JM, Stolshek BS, Martin ML, de Carvalho AVE. Feasibility and Utility of the Psoriasis Symptom Inventory (PSI) in Clinical Care Settings: A Study from the International Psoriasis Council. Am J Clin Dermatol 2019; 20:699-709. [PMID: 31228013 PMCID: PMC6764927 DOI: 10.1007/s40257-019-00458-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background The Psoriasis Symptom Inventory (PSI) is a patient-reported outcome measure designed to assess psoriasis signs and symptoms. Objectives The aim was to assess the usefulness of the PSI in enhancing patient care in the clinical setting. Methods Eight dermatology clinics in six countries enrolled adults representing the full spectrum of psoriasis severity who regularly received care at the clinic. Patients were administered the eight-item PSI (score range 0–32; higher scores indicate greater severity) while waiting for the physician; the physician conducted a static physician global assessment (sPGA) and estimated psoriasis-affected body surface area (BSA) at the same visit. Physicians completed a brief questionnaire after each patient visit, and were interviewed about the PSI after all patients were seen. Results The clinics enrolled 278 patients; mean [standard deviation (SD)] psoriasis-affected BSA was 7.6% (11.4). Based on BSA, 47.8% had mild psoriasis, 29.1% had moderate psoriasis, and 23.0% had severe psoriasis. Based on sPGA, 18.7% were clear/almost clear, 67.3% were mild/moderate, and 14.0% were severe/very severe. The mean (SD) PSI total score was 12.2 (8.3). Physicians spent a mean (SD) 4.9 (4.8) min discussing PSI findings with their patients (range 0–20 min). Key benefits of PSI discussions included the following: new information regarding symptom location and severity for physicians; prompting of quality-of-life discussions; better understanding of patient treatment priorities; change in treatment regimens to target specific symptoms or areas; and improvement of patient–physician relationship. Conclusions The PSI was useful for treated and untreated patients to enhance patient–physician communication, and influenced treatment decisions. Electronic supplementary material The online version of this article (10.1007/s40257-019-00458-2) contains supplementary material, which is available to authorized users.
Collapse
|
26
|
Otero ME, van den Reek JMPA, van de Kerkhof PCM, Mertens JS, Seyger MMB, Kievit W, de Jong EMGJ. Beliefs About Medicines in Patients with Psoriasis Treated with Methotrexate or Biologics: A Cross-sectional Survey Study. Acta Derm Venereol 2019; 99:386-392. [PMID: 30543381 DOI: 10.2340/00015555-3108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Methotrexate (MTX) and biologics are frequently used treatments for psoriasis. Exploring patients' beliefs about their treatment may help to elucidate patients' attitudes towards these therapies. A cross-sectional survey was conducted using the Beliefs about Medicines Questionnaire-Specific (BMQ-Specific) in patients treated with methotrexate or biologics. BMQ-Specific scores (Necessity and Concerns scales) were calculated and patients were classified as "accepting", "indifferent", "ambivalent" or "sceptical" towards their treat-ment. Biologics users scored higher on the Necessity scale than did methotrexate users. Both groups had lower Concerns scores than Necessity scores. A high Necessity scale was associated with a low Psoriasis Area and Severity Index score in both groups and long treatment duration in the methotrexate group. Although this study cannot make a direct comparison, it was observed that most patients on biologics could be classified as "accepting" (59%), and most patients on MTX could be classified as "indifferent" (47%). In conclusion, the BMQ-Specific is useful to identify patients with a sceptical, ambivalent or indifferent profile. These profiles may negatively influence patient's attitude towards their medication.
Collapse
Affiliation(s)
- Marisol E Otero
- Department of Dermatology, Radboud university medical center, 6500 HB Nijmegen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
27
|
van de Kerkhof PCM. Augmentation of Understanding in Clinical Practise and Big Data Analytics. Dermatology 2019; 235:253-254. [PMID: 30879000 PMCID: PMC7050668 DOI: 10.1159/000495691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 11/22/2018] [Indexed: 08/30/2023] Open
|
28
|
Kouwenhoven TA, van de Kerkhof PCM, Kamsteeg M. Use of Systemic Treatment in Patients with Chronic Pruritus: A Survey of Dermatologists in the Netherlands. Acta Derm Venereol 2019; 99:304-308. [PMID: 30521056 DOI: 10.2340/00015555-3101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Treatment of chronic pruritus can be a challenge for clinicians. Several systemic treatments have been suggested to reduce itch, such as gabapentinoids and antidepressants. The aim of this study was to assess the current practice of dermatologists regarding systemic treatment in patients with chronic pruritus, and to identify possible barriers in the prescription of these treatments. An online survey was sent to all dermatologists and dermatology residents in the Netherlands between July 2017 and April 2018. A total of 193 physicians completed the questionnaire (response rate 27.0%). Overall, 61.7% prescribed gabapentinoids or antidepressants in patients with chronic pruritus. Amitriptyline was prescribed most frequently, followed by gabapentin, doxepin and mirtazapine. Reasons not to prescribe systemic treatment included lack of knowledge or experience, risk of side-effects, and lack of available evidence. As only a minority of respondents felt comfortable prescribing these drugs, more education on effective and safe dosing is needed.
Collapse
Affiliation(s)
- Tessa A Kouwenhoven
- Department of Dermatology, Radboud university medical center, 6500HB Nijmegen, The Netherlands.
| | | | | |
Collapse
|
29
|
Bronckers IMGJ, Bruins FM, van Geel MJ, Groenewoud HMM, Kievit W, van de Kerkhof PCM, Pasch MC, de Jong EMGJ, Seyger MMB. Nail Involvement as a Predictor of Disease Severity in Paediatric Psoriasis: Follow-up Data from the Dutch ChildCAPTURE Registry. Acta Derm Venereol 2019; 99:152-157. [PMID: 30206638 DOI: 10.2340/00015555-3036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Little is known about the relationship between nail psoriasis and psoriasis severity in children, and there has been no longitudinal assessment of psoriasis severity related to nail psoriasis. The aim of this study was to assess whether nail psoriasis could serve as a predictor for a more severe disease course. De-identified data were obtained from the ChildCAPTURE registry, a daily clinical practice cohort of children with psoriasis, from September 2008 to November 2015. Cross-sectional analyses were performed at baseline. Longitudinal data until 2-year follow-up were analysed by linear mixed models. Nail psoriasis was present in 19.0% of all 343 patients at baseline and cross-sectionally associated with higher Psoriasis Area and Severity Index (PASI) (p = 0.033). Longitudinal analysis demonstrated higher PASI (p <0.001) during 2-year follow-up in patients with nail involvement at baseline. These findings suggest that nail psoriasis is a potential clinical predictor for more severe disease course over time in paediatric psoriasis.
Collapse
Affiliation(s)
- Inge M G J Bronckers
- Department of Dermatology, Radboud university medical center, 6500 HB Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Richters RJH, Uzunbajakava NE, Timofeeva N, van de Kerkhof PCM, van Erp PEJ. Development of a Novel Approach to Studying Corneodesmosomes and Stratum Corneum Adhesion: Extending Knowledge on the Pathophysiology of Sensitive Skin. Skin Pharmacol Physiol 2019; 32:81-93. [PMID: 30673682 DOI: 10.1159/000495070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Aberrant skin barrier and intercorneocyte adhesion are potential contributors to the pathomechanism of sensitive skin (SS). Here we aimed to develop a novel and easy-to-apply method to analyze corneodesmosomes and to interrogate potential differences between corneocytes of subjects with SS and non-SS (NSS). METHODS Corneocytes of the volar forearm and upper outer quadrant of the left buttock of SS (n = 10) and NSS (n = 8) subjects were extracted as a function of depth using adhesive tape and stained with anti-desmoglein 1 (DSG1) antibody. The total area of corneocytes and the number and average size of cells per tape was estimated using image processing. RESULTS The total area of extracted corneocytes and the quantity of DSG1 decreased with depth. The level of decrease, total area of corneocytes, and average area of individual cells differed between anatomical locations. In SS, a larger total area of extracted corneocytes and a larger average cell size per tape was found at all inspected depths. CONCLUSION The developed novel and easy-to-apply approach allows investigation of corneodesmosome components. We confirm a role of altered corneocytes in the pathomechanism of SS. The disclosed protocol can further be optimized in studies of skin conditions with strongly affected corneodesmosomes.
Collapse
Affiliation(s)
- Renée J H Richters
- Department of Dermatology, Radboud university medical center, Nijmegen, The Netherlands
| | | | | | | | - Piet E J van Erp
- Department of Dermatology, Radboud university medical center, Nijmegen, The Netherlands
| |
Collapse
|
31
|
Falcone D, Uzunbajakava NE, van Abeelen F, van Erp PEJ, van de Kerkhof PCM. Effects of red light on inflammation and skin barrier recovery following acute perturbation. Pilot study results in healthy human subjects. Photodermatol Photoimmunol Photomed 2018; 35:275-276. [PMID: 30520139 DOI: 10.1111/phpp.12444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/24/2018] [Accepted: 11/29/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Denise Falcone
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Piet E J van Erp
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | |
Collapse
|
32
|
Abstract
Nocebo effects, i.e. reduced treatment effects due to patients' negative expectations, play a role in itch. Recent studies have shown that nocebo effects can be induced experimentally on itch and also be minimized and even turned into the opposite direction, i.e. placebo effects. It is not known whether these effects generalize to itch-associated scratching behaviour. The aim of this study was to determine whether induction and reversal of nocebo effects on itch evoked by electrical and histamine stimuli generalized to scratching. Ninety-seven healthy participants were included in the study. The manipulation was successful, as during the nocebo learning phase, increased scratching responses were found for higher intensity compared with lower intensity itch stimuli. During the testing phase of induction or reversal of the nocebo effects, however, no significant nocebo effects or reversed nocebo effects, were found in scratching. Thus, no straightforward generalization of nocebo effects from itch to scratching was found in this laboratory setting. Further investigation into possible generalization is needed in different settings and in patients with chronic itch.
Collapse
Affiliation(s)
- Danielle J P Bartels
- Health Medical and Neuropsychology, Leiden University, NL-2300 RB Leiden, The Netherlands.
| | | | | | | |
Collapse
|
33
|
Bronckers IMGJ, van Geel MJ, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. A cross-sectional study in young adults with psoriasis: potential determining factors in quality of life, life course and work productivity. J DERMATOL TREAT 2018; 30:208-215. [PMID: 30102075 DOI: 10.1080/09546634.2018.1506077] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Psoriasis can have a substantial impact on health-related quality of life (HRQoL), life course, and work productivity. Young adulthood is a critical, sensitive period of development that includes major life changing decisions. The impact of psoriasis on this vulnerable population is yet unknown. OBJECTIVES To assess QoL, life course, and work productivity in young adults with psoriasis and identify characteristics influencing these patient-reported outcomes (PRO). METHODS An explorative, cross-sectional study was performed in psoriasis patients aged 18-30 years. Individuals completed a set of questionnaires regarding their health status (DLQI, SF-36, EQ-5D), achievement of developmental milestones (COLQ), and work productivity (WPAI-PSO, PRODISQ). RESULTS Seventy-five patients (22 males, 53 females; median age [IQR], 21.0 [8.0]). Median PASI and BSA, respectively, were 4.4 [4.9] and 4.5 [8.4]. Young adults experienced feelings of embarrassment, impairments in physical health and work productivity, and difficulties in social development. Patients with more severe psoriasis, longer disease duration, higher body mass index (BMI), female patients and patients closer to their thirties tended to be more affected. CONCLUSION In the young adult psoriasis population, substantial QoL impairments were found. Female patients, patients with high BMI, or long disease duration in particular tended to experience more difficulties. These exploratory findings indicate the need for further studies in young adults to detect potential clinical predictors for severe HRQoL impairments.
Collapse
Affiliation(s)
- Inge M G J Bronckers
- a Department of Dermatology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Maartje J van Geel
- a Department of Dermatology , Radboud University Medical Center , Nijmegen , The Netherlands
| | | | - Elke M G J de Jong
- a Department of Dermatology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Marieke M B Seyger
- a Department of Dermatology , Radboud University Medical Center , Nijmegen , The Netherlands
| |
Collapse
|
34
|
van den Reek JMPA, van Vugt LJ, van Doorn MBA, van der Kraaij GE, de Kort WJA, Lucker GPH, Horvath B, Njoo MD, Bovenschen HJ, Ossenkoppele PM, De Bruin-Weller MS, de Groot M, Mommers R, Prevoo RLMA, van de Kerkhof PCM, Spuls PI, Kievit W, de Jong EMGJ. Initial Results of Secukinumab Drug Survival in Patients with Psoriasis: A Multicentre Daily Practice Cohort Study. Acta Derm Venereol 2018; 98:648-654. [PMID: 29405245 DOI: 10.2340/00015555-2900] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Interleukin 17-antagonist secukinumab demonstrated high efficacy for treatment of psoriasis in randomized controlled trials. However, performance in daily practice may differ from trials. Drug survival is a comprehensive outcome covering effectiveness and safety, suitable for analyses of daily practice. The aim of this study was to evaluate drug survival of secukinumab in a daily practice psoriasis cohort. Data were collected from 13 hospitals. Drug survival was analysed using Kaplan-Meier survival curves, split for reason of discontinuation. In total, 196 patients were included (83% biologic experienced). Overall, 12 and 18 months drug survival of secukinumab was 76% and 67%, respectively, and was mostly determined by ineffectiveness. There was a trend towards shorter drug survival in women and in biologic experienced patients. Thirteen percent of patients experienced at least one episode of fungal infection. This is one of the first studies of drug survival of secukinumab in patients with psoriasis treated in daily practice.
Collapse
Affiliation(s)
- Juul M P A van den Reek
- Department of Dermatology, Radboud University Medical Centre, PO Box 9101, NL-6500 HB Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Meeuwis KAP, Potts Bleakman A, van de Kerkhof PCM, Dutronc Y, Henneges C, Kornberg LJ, Menter A. Prevalence of genital psoriasis in patients with psoriasis. J DERMATOL TREAT 2018; 29:754-760. [PMID: 29565190 DOI: 10.1080/09546634.2018.1453125] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Psoriatic lesions in the genital area (GenPs) can cause considerable physical and emotional distress. To increase physician awareness, we estimated the GenPs prevalence among patients with psoriasis. METHODS An English language literature search was performed. Articles reporting GenPs prevalence met the search criteria and were included. Because GenPs is rarely reported in demographics of prospective clinical trials, GenPs prevalence and baseline demographics of patients with and without GenPs in two prospective randomized phase 3b trials (NCT02561806 and NCT02634801) involving patients with moderate-to-severe psoriasis are reported. RESULTS Overall, 600 references were screened. Eighteen articles met the search criteria. Patient populations were highly heterogeneous across articles. Broadly, the presence of GenPs was either physician-reported (physical examinations) or patient-reported (questionnaires). In the literature, GenPs prevalence at the time of reporting ranged from 7% to 42% and the prevalence of GenPs at any time during the course of psoriasis ranged from 33% to 63%. In the two prospective clinical trials, the prevalence of GenPs at the time of enrollment was 35-42%. CONCLUSION A substantial proportion of patients experience genital lesions at some time during the course of psoriasis. Increased awareness of GenPs prevalence may drive improved assessment and treatment.
Collapse
Affiliation(s)
- Kim A P Meeuwis
- a Department of Dermatology , Radboud University Nijmegen Medical Center , Nijmegen , Netherlands
| | | | - Peter C M van de Kerkhof
- a Department of Dermatology , Radboud University Nijmegen Medical Center , Nijmegen , Netherlands
| | | | | | | | - Alan Menter
- f Baylor University Medical Center , Dallas , TX , USA
| |
Collapse
|
36
|
Roest YBM, van Middendorp HT, Evers AWM, van de Kerkhof PCM, Pasch MC. Nail Involvement in Alopecia Areata: A Questionnaire-based Survey on Clinical Signs, Impact on Quality of Life and Review of the Literature. Acta Derm Venereol 2018; 98:212-217. [PMID: 28967977 DOI: 10.2340/00015555-2810] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Alopecia areata (AA) is an immune-mediated disease causing temporary or permanent hair loss. Up to 46% of patients with AA also have nail involvement. The aim of this study was to determine the presence, types, and clinical implications of nail changes in patients with AA. This questionnaire-based survey evaluated 256 patients with AA. General demographic variables, specific nail changes, nail-related quality of life (QoL), and treatment history and need were evaluated. Prevalence of nail involvement in AA was 64.1%. The specific nail signs reported most frequently were pitting (29.7%, p = 0.008) and trachyonychia (18.0%). Red spots on the lunula were less frequent (5.1%), but very specific for severe AA. Nail-related QoL was only minimally affected by nail changes. In conclusion, nail involvement is common in patients with AA and presents mostly with pitting and trachyonychia. The presence of these nail changes reflects the severity of the disease, with red spots on the lunula as a predictor for severe alopecia.
Collapse
Affiliation(s)
- Yvonne B M Roest
- Department of Dermatology, Radboud University Nijmegen Medical Center, PO Box 9101, NL-6500 HB Nijmegen, The Netherlands.
| | | | | | | | | |
Collapse
|
37
|
Koulil SSV, Ferwerda M, van Beugen S, van Middendorp H, van de Kerkhof PCM, van Riel PLCM, Evers AWM. Tailored Therapist-guided Internet-based Cognitive-behavioural Treatment for Psoriasis and Rheumatoid Arthritis: Two Case Reports. Acta Derm Venereol 2018; 98:225-233. [PMID: 28952654 DOI: 10.2340/00015555-2803] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic somatic conditions, such as psoriasis, arthritis psoriatica and rheumatoid arthritis, have a large impact on patients' lives. Tailored therapist-guided internet-based cognitive-behavioural therapy (ICBT) has been shown to be effective in improving physical and psychological well-being in these patients. Two cases are presented here, in order to provide an in-depth illustration of the course and content of this novel treatment and to investigate the therapeutic alliance in an online treatment. After face-to-face intakes, both patients received therapist-guided ICBT tailored to their specific problems and treatment goals. The treatment resulted in improved physical and psychological well-being and these clinically significant improvements were maintained at 6-month follow-up. In addition, the therapeutic relationship was evaluated positively by both patients and increased further during treatment, indicating an adequate therapeutic working alliance in this online treatment. These case reports show that tailored ICBT may contribute to improved care for patients with chronic somatic conditions.
Collapse
|
38
|
Falcone D, Uzunbajakava NE, van Abeelen F, Oversluizen G, Peppelman M, van Erp PEJ, van de Kerkhof PCM. Effects of blue light on inflammation and skin barrier recovery following acute perturbation. Pilot study results in healthy human subjects. Photodermatol Photoimmunol Photomed 2017; 34:184-193. [PMID: 29150968 DOI: 10.1111/phpp.12367] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND/PURPOSE While growing evidence supports the therapeutic effect of 453 nm blue light in chronic inflammatory skin diseases, data on its effects on acutely perturbed human skin are scarce. In this study, we investigated the impact of 453 nm narrow-band LED light on healthy skin following acute perturbation. METHODS Tape stripping and histamine iontophoresis were performed on the forearm of 22 healthy volunteers on 2 consecutive weeks. In 1 week, challenges were followed by irradiation for 30 minutes. In the other week (control), no light was administered. Reactions were evaluated up to 72 hours thereafter by transepidermal water loss (TEWL), diffuse reflectance spectroscopy, and skin surface biomarkers. RESULTS Skin barrier disruption resulted in upregulation of IL-1α at 24 hours after tape stripping (P = .029). In contrast, irradiation abrogated this effect (P > .05). Irradiation also resulted in higher TEWL at 24 hours and in higher b* value at 72 hours after tape stripping compared to the control (P = .034 and P = .018, respectively). At 30 minutes following histamine iontophoresis and irradiation, a trend toward a higher a* value compared to the control was observed (P = .051). CONCLUSION We provide the first in vivo evidence that blue light at 453 nm exerts biological effects on acutely perturbed healthy human skin.
Collapse
Affiliation(s)
- Denise Falcone
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - Malou Peppelman
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Piet E J van Erp
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | |
Collapse
|
39
|
Klaassen KMG, Ploegmakers MJM, van de Kerkhof PCM, Klein WM, Pasch MC. Subclinical enthesitis in nail psoriasis patients: a case-control study. J Dtsch Dermatol Ges 2017; 15:405-412. [PMID: 28378489 DOI: 10.1111/ddg.13222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/15/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with nail psoriasis have a higher prevalence of psoriatic arthritis; however, the pathogenetic relationship between these two disorders is as yet unclear. Entheses have been suggested as disease epicenter, which might explain the pathogenesis on an anatomical level. OBJECTIVE To contribute to the elucidation of the hypothesis as regards the anatomical link between nail psoriasis and psoriatic arthritis, with the extensor enthesis of the distal interphalangeal joint as the epicenter. METHODS We conducted a cross-sectional cohort study, visualizing the distal interphalangeal (DIP) joints entheses of patients with fingernail psoriasis (n = 54), psoriasis patients without nail involvement (n = 32), and healthy controls (n = 32) using three-dimensional ultrasound. Patients with nail psoriasis underwent repeat imaging studies after one year. RESULTS Individuals with nail psoriasis had significantly thicker radial entheses than psoriasis patients without nail involvement. However, there were no significant differences in entheseal thickness between adjacent nails that were affected and those that were not (1.297 mm vs. 1.253 mm, p = 0.13). Follow-up after one year showed no significant differences in entheseal thickness in correlation with nail psoriasis activity. CONCLUSIONS The present study provides evidence for subclinical enthesitis at the level of the DIP joint in patients with nail psoriasis. However, an anatomical correlation between nail psoriasis and psoriatic arthritis could not be confirmed.
Collapse
Affiliation(s)
- Karlijn M G Klaassen
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Willemijn M Klein
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel C Pasch
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
40
|
Hanssen SCA, Hendriks AGM, Keijsers RMC, van Erp PEJ, van der Vleuten CJM, Seyger MMB, van de Kerkhof PCM. Response of the Endothelium to the Epicutaneous Application of Leukotriene B4. Skin Pharmacol Physiol 2017; 30:306-314. [PMID: 29050008 DOI: 10.1159/000481204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/01/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Vascular changes, both endothelial and functional, are crucial events in inflammatory responses. OBJECTIVES To investigate the dynamics of endothelial cell (EC) and functional changes during acute inflammation in an in vivo model of the skin using leukotriene B4. METHODS EC proliferation, vascular network size, vessel diameter (VD), and hypoxia-inducible factor (HIF)-1α were studied by immunohistochemical CD31/Ki67 double staining and single staining of HIF-1α. Cutaneous perfusion (CP) was assessed using the Twente Optical Perfusion Camera. RESULTS The initial phase illustrated an increase in VD, Ki67+ EC, and HIF-1α expression and late-phase vascular expansion. The HIF-1α and Ki67+ EC expression was limited. CP and VD were augmented after 24 h. CONCLUSION The early phase of inflammation is characterized by EC proliferation and HIF-1α expression. Vascular expansion continues over time. CP and VD are seen in both phases of inflammation. Angiogenesis, vascular network formation, and perfusion are time-dependent processes which are mutually related during inflammation.
Collapse
Affiliation(s)
- Sabina C A Hanssen
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
41
|
Falcone D, Spee P, van de Kerkhof PCM, van Erp PEJ. Minimally-invasive Sampling of Interleukin-1α and Interleukin-1 Receptor Antagonist from the Skin: A Systematic Review of In vivo Studies in Humans. Acta Derm Venereol 2017; 97:1066-1073. [PMID: 28536733 DOI: 10.2340/00015555-2709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Interleukin-1α (IL-1α) and its receptor antagonist IL-1RA play a pivotal role in skin homeostasis and disease. Although the use of biopsies to sample these cytokines from human skin is widely employed in dermatological practice, knowledge about less invasive, in vivo sampling methods is scarce. The aim of this study was to provide an overview of such methods by systematically reviewing studies in Medline, EMBASE, Web of Science and Cochrane Library using combinations of the terms "IL-1α", IL-1RA", "skin", "human", including all possible synonyms. Quality was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. The search, performed on 14 October 2016, revealed 10 different sampling methods, with varying degrees of invasiveness and wide application spectrum, including assessment of both normal and diseased skin, from several body sites. The possibility to sample quantifiable amounts of cytokines from human skin with no or minimal discomfort holds promise for linking clinical outcomes to molecular profiles of skin inflammation.
Collapse
Affiliation(s)
- Denise Falcone
- Department of Dermatology, Radboud university medical center, 6500HB Nijmegen, The Netherlands
| | | | | | | |
Collapse
|
42
|
Bartels DJP, van Laarhoven AIM, Stroo M, Hijne K, Peerdeman KJ, Donders ART, van de Kerkhof PCM, Evers AWM. Minimizing nocebo effects by conditioning with verbal suggestion: A randomized clinical trial in healthy humans. PLoS One 2017; 12:e0182959. [PMID: 28910291 PMCID: PMC5598922 DOI: 10.1371/journal.pone.0182959] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 07/25/2017] [Indexed: 11/19/2022] Open
Abstract
Nocebo effects, i.e., adverse treatment effects which are induced by patients' expectations, are known to contribute to the experience of physical symptoms such as pain and itch. A better understanding of how to minimize nocebo responses might eventually contribute to enhanced treatment effects. However, little is known about how to reduce nocebo effects. In the current randomized controlled study, we tested whether nocebo effects can be minimized by positive expectation induction with respect to electrical and histaminic itch stimuli. First, negative expectations about electrical itch stimuli were induced by verbal suggestion and conditioning (part 1: induction of nocebo effect). Second, participants were randomized to either the experimental group or one of the control groups (part 2: reversing nocebo effect). In the experimental group, positive expectations were induced by conditioning with verbal suggestion. In the control groups either the negative expectation induction was continued or an extinction procedure was applied. Afterwards, a histamine application test was conducted. Positive expectation induction resulted in a significantly smaller nocebo effect in comparison with both control groups. Mean change itch NRS scores showed that the nocebo effect was even reversed, indicating a placebo effect. Comparable effects were also found for histamine application. This study is the first to demonstrate that nocebo effects can be minimized and even reversed by conditioning with verbal suggestion. The results of the current study indicate that learning via counterconditioning and verbal suggestion represents a promising strategy for diminishing nocebo responses.
Collapse
Affiliation(s)
- Danielle J. P. Bartels
- Unit Health, Medical and Neuropsychology, Institute of Psychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, the Netherlands
- * E-mail:
| | - Antoinette I. M. van Laarhoven
- Unit Health, Medical and Neuropsychology, Institute of Psychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, the Netherlands
| | - Michiel Stroo
- Unit Health, Medical and Neuropsychology, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Kim Hijne
- Unit Health, Medical and Neuropsychology, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Kaya J. Peerdeman
- Unit Health, Medical and Neuropsychology, Institute of Psychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, the Netherlands
| | - A. Rogier T. Donders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Andrea W. M. Evers
- Unit Health, Medical and Neuropsychology, Institute of Psychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, the Netherlands
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Psychiatry, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
43
|
van Beugen S, Ferwerda M, Spillekom-van Koulil S, Smit JV, Zeeuwen-Franssen MEJ, Kroft EBM, de Jong EMGJ, Otero ME, Donders ART, van de Kerkhof PCM, van Middendorp H, Evers AWM. Tailored Therapist-Guided Internet-Based Cognitive Behavioral Treatment for Psoriasis: A Randomized Controlled Trial. Psychother Psychosom 2017; 85:297-307. [PMID: 27508937 DOI: 10.1159/000447267] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 05/28/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Patients with somatic conditions, such as psoriasis, frequently suffer from high burden of their disease in daily life and might benefit from internet-based cognitive behavioral therapy (ICBT) tailored to their adjustment problems. The aim of this multicenter randomized controlled trial was to examine the effects of therapist-guided, individually tailored ICBT in a clinical sample of patients with psoriasis. METHODS A total of 131 patients with psoriasis, who were screened for a psychological risk profile, were randomized to either care as usual (CAU, n = 66) or ICBT in addition to CAU (n = 65). Participants filled out standardized self-report questionnaires assessing physical and psychological functioning and impact on daily activities at baseline, posttreatment assessment, and 6-month follow-up. RESULTS In covariate-controlled linear mixed-model analyses, significantly larger improvements in ICBT compared to CAU were found in the primary outcomes physical functioning (p = 0.03, d = 0.36) and impact on daily activities (p = 0.04, d = 0.35), but not in psychological functioning (p = 0.32), up to 6 months after treatment compared to baseline. In explorative analyses, the working alliance measured at the beginning of ICBT treatment predicted improved physical (p = 0.02) and psychological (p < 0.001) outcomes. CONCLUSIONS Results underline the promise of therapist-guided, individually tailored ICBT to improve physical functioning and reduce the impact of psoriasis on daily activities in patients with a psychological risk profile. Establishing a good therapeutic relationship early on may be an important factor that influences treatment outcomes in personalized ICBT interventions. Further research is needed to evaluate ICBT effectiveness in additional samples and to explore its underlying mechanisms.
Collapse
Affiliation(s)
- Sylvia van Beugen
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Lubeek SFK, Michielsens CAJ, Borgonjen RJ, Bronkhorst EM, van de Kerkhof PCM, Gerritsen MJP. Impact of High Age and Comorbidity on Management Decisions and Adherence to Guidelines in Patients with Keratinocyte Skin Cancer. Acta Derm Venereol 2017; 97:825-829. [PMID: 28417143 DOI: 10.2340/00015555-2670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Appropriate medical decision-making in patients with keratinocyte skin cancer (KSC) can be challenging, especially in those with a limited life expectancy (LEx). Treatment should be beneficial for the individual patient, the risk of both over- and under-treatment should be carefully considered, and deviation from guideline recommendations may be necessary. In this study retrospective analysis was performed to determine the influence of age and comorbidity, both factors strongly related to limited LEx, on KSC management in daily practice. After analysis of 401 patients it was found that management in patients with KSC is not influenced, or is only minimally influenced, by high age and comorbidity. Better integration of aspects related to a limited LEx in KSC management might optimize care and prevent overtreatment. Future research on the general prognostication, prediction of the patient burden caused by tumour and treatment, and time-to-benefit in KSC management is strongly recommended.
Collapse
Affiliation(s)
- Satish F K Lubeek
- Department of Dermatology, Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | | | | | | | | | | |
Collapse
|
45
|
Lubeek SFK, van Vugt LJ, Aben KKH, van de Kerkhof PCM, Gerritsen MJP. The Epidemiology and Clinicopathological Features of Basal Cell Carcinoma in Patients 80 Years and Older: A Systematic Review. JAMA Dermatol 2017; 153:71-78. [PMID: 27732698 DOI: 10.1001/jamadermatol.2016.3628] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The number of very elderly (≥80 years) is rapidly growing worldwide. Basal cell carcinoma (BCC) are common in this age group and treatment is often challenging in this population. Objective Obtaining an overview of the epidemiology and clinicopathological features of BCC in the very elderly to guide clinicians and policy makers. Evidence Review A systematic review of literature was performed using PubMed, Excerpta Medica Database (EMBASE), and the Cochrane Library. Study selection, quality assessment, and data extraction was performed by 2 independent reviewers. For quality assessment (including the risk of bias) the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist was used, combined with the Quality Rating Scheme for Studies and Other Evidence. Data were described though a narrative synthesis and tabulation. Findings Of 13 628 studies identified, 83 studies were included and quality assesment was performed for 76 studies; 27 studies (representing >350 000 patients) were found that included age-specific incidence rates of BCC in the very elderly. High and increasing incidence rates of BCC in the very elderly were found ranging from 13 to 12 112 per 100 000 person-years, strongly depending on factors like study population and clinical setting. Basal cell carcinoma in the very elderly were more common in men, mostly of the nodular subtype, and located in the head and neck region. Interpretation and generalization of the data was limited by the heterogeneity of study populations, methods, and outcomes. Data concerning impact on health-related quality of life (HRQoL) and prognostication were scarce. Conclusions and Relevance The incidence of BCC among the very elderly is high and increasing. Epidemiologic and clinicopathological data from current literature provide only limited guidance in clinical decision making owing to heterogeneity and scarcity. Future research should focus more specifically on BCC in the very elderly, together with prognostication and their relation with HRQoL in both the short and longer term.
Collapse
Affiliation(s)
- Satish F K Lubeek
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lieke J van Vugt
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Katja K H Aben
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands3Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | | | | |
Collapse
|
46
|
Atalay S, van den Reek JMPA, van Vugt LJ, Otero ME, van de Kerkhof PCM, den Broeder AA, Kievit W, de Jong EMGJ. Tight controlled dose reduction of biologics in psoriasis patients with low disease activity: a randomized pragmatic non-inferiority trial. BMC Dermatol 2017; 17:6. [PMID: 28482858 PMCID: PMC5422943 DOI: 10.1186/s12895-017-0057-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/25/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated chronic inflammatory skin disorder for which several targeted biologic therapies became available in the last 10 years. Data from patients with rheumatoid arthritis revealed that dose tapering combined with tight control of disease activity is successful. For psoriasis patients the lowest effective dose of biologics needs to be determined. The objective was to assess whether dose tapering of biologics guided by Psoriasis Area and Severity Index (PASI) and Dermatology Quality of Life Index (DLQI) scores in psoriasis patients with controlled disease activity is non-inferior (NI) to usual care. METHODS/DESIGN This is a multicenter, pragmatic, randomized, non-inferiority trial with cost- effectiveness analysis. One hundred and twenty patients with stable low disease activity (PASI ≤ 5 and DLQI ≤ 5) for at least 6 months with a stable use of adalimumab, etanercept or ustekinumab will be randomized 1:1 to the dose reduction group or usual care. In the dose reduction group, the treatment intervals will be prolonged stepwise, resulting in a 33% and 50% dose reduction, respectively. Disease activity is monitored every three months with PASI and DLQI. In case of flare the treatment is adjusted to the previous effective dose. The primary outcome (PASI) at 12 months will be analyzed with ANCOVA in which the baseline PASI will be included as covariate to gain efficiency. The secondary outcomes include number of and time to disease flares, health-related quality of life, serious adverse events, and costs. DISCUSSION With this study we want to assess whether disease activity guided dose reduction of biologics can be achieved for psoriasis patients with low stable disease activity, without losing disease control. By using the lowest effective dose of biologics, we expect to minimize side effects and save costs. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov ( NCT 02602925 ). Trial registration date October 9 2015.
Collapse
Affiliation(s)
- Selma Atalay
- Department of Dermatology, Radboud University Medical Center, Rene Descartesdreef 1, 6525 GL Nijmegen, The Netherlands
| | - Juul M. P. A. van den Reek
- Department of Dermatology, Radboud University Medical Center, Rene Descartesdreef 1, 6525 GL Nijmegen, The Netherlands
| | - Lieke J. van Vugt
- Department of Dermatology, Radboud University Medical Center, Rene Descartesdreef 1, 6525 GL Nijmegen, The Netherlands
| | - Marisol E. Otero
- Department of Dermatology, Radboud University Medical Center, Rene Descartesdreef 1, 6525 GL Nijmegen, The Netherlands
| | - Peter C. M. van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Rene Descartesdreef 1, 6525 GL Nijmegen, The Netherlands
| | - Alfons A. den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA Ubbergen, Nijmegen, The Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands
| | - Elke M. G. J. de Jong
- Department of Dermatology, Radboud University Medical Center, Rene Descartesdreef 1, 6525 GL Nijmegen, The Netherlands
- Radboud University, Comeniuslaan 4, 6525 HP Nijmegen, The Netherlands
| |
Collapse
|
47
|
Bartels DJP, van Laarhoven AIM, Heijmans N, Hermans D, Debeer E, van de Kerkhof PCM, Evers AWM. Cognitive Schemas in Placebo and Nocebo Responding: Role of Autobiographical Memories and Expectations. Clin Ther 2017; 39:502-512.e1. [PMID: 28341522 DOI: 10.1016/j.clinthera.2017.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Placebo effects are presumed to be based on one's expectations and previous experience with regard to a specific treatment. The purpose of this study was to investigate the role of the specificity and valence of memories and expectations with regard to itch in experimentally induced placebo and nocebo itch responses. It was expected that cognitive schemas with more general and more negative memories and expectations with regard to itch contribute to less placebo itch responding. METHODS Validated memory tasks (ie, the Autobiographical Memory Test and the Self-referential Endorsement and Recall Task) and expectation tasks (ie, Future Event Task and the Self-referential Endorsement and Recall Task) were modified for physical symptoms, including itch. Specificity and valence of memories and expectations were assessed prior to a placebo experiment in which expectations regarding electrical itch stimuli were induced in healthy participants. FINDINGS Participants who were more specific in their memories regarding itch and who had lesser negative itch-related expectations for the future were more likely to be placebo itch responders. There were no significant differences in effects between the nocebo responders and nonresponders. IMPLICATIONS The adapted tasks for assessing cognitive (memory and expectations) schemas on itch seem promising in explaining interindividual differences in placebo itch responding. Future research should investigate whether similar mechanisms apply to patients with chronic itch. This knowledge can be used for identifying patients who will benefit most from the placebo component of a treatment.
Collapse
Affiliation(s)
- Danielle J P Bartels
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands.
| | - Antoinette I M van Laarhoven
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands; Department of Psychiatry, Leiden University Medical Center, Leiden, the Netherlands
| | - Naomi Heijmans
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dirk Hermans
- Centre for the Psychology of Learning and Experimental Psychopathology, University of Leuven, Leuven, Belgium
| | - Elise Debeer
- Centre for the Psychology of Learning and Experimental Psychopathology, University of Leuven, Leuven, Belgium; Department of Applied Psychology, Thomas More University College, Antwerp, Belgium
| | | | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands; Department of Psychiatry, Leiden University Medical Center, Leiden, the Netherlands; Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
48
|
Richters RJH, Falcone D, Uzunbajakava NE, Varghese B, Caspers PJ, Puppels GJ, van Erp PEJ, van de Kerkhof PCM. Sensitive Skin: Assessment of the Skin Barrier Using Confocal Raman Microspectroscopy. Skin Pharmacol Physiol 2017; 30:1-12. [PMID: 28122376 DOI: 10.1159/000452152] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/27/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND/AIMS Sensitive skin (SS), a frequently reported condition in the Western world, has been suggested to be underlined by an impaired skin barrier. The aim of this study was to investigate the skin barrier molecular composition in SS subjects using confocal Raman microspectroscopy (CRS), and to compare it with that of non-SS (NSS) individuals as well as atopic dermatitis (AD) and allergic rhinoconjunctivitis (AR) subjects, who frequently report SS. METHODS Subjects with SS (n = 29), NSS (n = 30), AD (n = 11), and AR (n = 27) were included. Stratum corneum (SC) thickness, water, ceramides/fatty acids, and natural moisturizing factor (NMF) were measured by CRS along with transepidermal water loss and capacitance on the ventral forearm, thenar, and cheek. Sebum levels were additionally measured on the forearm and cheek. RESULTS No differences between SS and NSS subjects were found regarding SC thickness, water, and NMF content, yet a trend towards lower ceramides/fatty acids was observed in the cheek. Compared to AD subjects, the SS group showed higher ceramides/fatty acid content in the forearm, whereas no differences emerged with AR. The correlation of macroscopic biophysical techniques and CRS was weak, yet CRS confirmed the well-known lower content of NMF and water, and thinner SC in subjects with filaggrin mutations. CONCLUSION The skin barrier in SS is not impaired in terms of SC thickness, water, NMF, and ceramides/fatty acid content. The failure of biophysical techniques to follow alterations in the molecular composition of the skin barrier revealed by CRS emphasizes a strong need in sensitive and specific tools for in vivo skin barrier analysis.
Collapse
Affiliation(s)
- Renée J H Richters
- Radboud Institute for Molecular Life Sciences (RIMLS), Nijmegen, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Zweegers J, Bronckers IM, van den Reek JMPA, van Geel MJ, van de Kerkhof PCM, Seyger MMB, de Jong EMGJ. Comment on "Review of patient registries in dermatology". J Am Acad Dermatol 2016; 75:e241. [PMID: 27846976 DOI: 10.1016/j.jaad.2016.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Jeffrey Zweegers
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Inge M Bronckers
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Maartje J van Geel
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Marieke M B Seyger
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
50
|
Mertens JS, van den Reek JM, Kievit W, van de Kerkhof PCM, Thurlings RM, Radstake TRD, Seyger MMB, de Jong EMGJ. Drug Survival and Predictors of Drug Survival for Methotrexate Treatment in a Retrospective Cohort of Adult Patients with Localized Scleroderma. Acta Derm Venereol 2016; 96:943-947. [PMID: 26983450 DOI: 10.2340/00015555-2411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Data regarding the efficacy and safety of methotrexate (MTX) in adults with localized scleroderma (LoS) is scarce. This study gathered data from a retrospective cohort of adult patients with LoS (n?=?107), treated with MTX (1993-2015). MTX drug survival and predictors thereof were analysed. After 1 and 2 years, 26% and 63% of patients stopped MTX due to disease remission, respectively. Patients with younger age at MTX initiation (hazard ratio (HR) 1.159 (95% confidence interval (CI) 1.052-1.277)) and those with no other autoimmune diseases (HR 3.268 (95% CI 1.334-8.009)) more often stopped MTX due to disease remission. In addition, 24% of patients stopped MTX due to treatment failure within one year. Patients with circumscribed superficial LoS (HR 0.221 (95% CI 0.081-0.601)) experienced treatment failure less often than those with other LoS subtypes. Finally, adding folic acid (HR 0.184 (95% CI 0.079-0.425)) and reducing treatment delay (HR 1.056 (95% CI 1.004-1.112)) could be the most important factors in minimizing MTX treatment failure in LoS in clinical practice.
Collapse
Affiliation(s)
- Jorre S Mertens
- Department of Dermatology, Radboud University Medical Center, 6525 GL Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|