PET-CT vs brain MRI for the detection of cerebral metastases of melanoma, a 5-year retrospective study

BACKGROUND

Melanoma patients present a high risk of developing extra cutaneous metastases. PET-CT is one of the preferred examinations for the staging of oncological patients. It is not the method of choice to detect brain metastases, but this technique has shown significant improvement and allows the detection of some of them, although it is unclear how it performs compared to the MRI, the current gold standard for diagnosing brain metastases.

OBJECTIVE

To compare the accuracy of PET-CT and cerebral MRI to detect brain metastases in melanoma patients.

METHODS

We retrospectively included all patients diagnosed with melanoma stage IIC-IV (AJCC 8th Edition-2017) presented at the skin tumor board of the University Hospital of Bern between 01/2018 and 12/2022. All radiological reports extracted from the patient management system were analyzed to assess a discrepancy between the visibility of brain metastases on PET-CT and brain MRI.

RESULTS

In this study including 393 patients, brain MRI demonstrated significantly higher performance than PET-CT in detecting brain metastases. Cerebral metastases were detected completely, partially or were not detected by PET-CT in respectively 2 patients (4%), 15 patients (32%) and 30 patients (64%) out of 47.

CONCLUSION

Despite the increasing performance of PET-CT, this study highlights the crucial role of brain MRI, which remains the gold standard to detect cerebral metastases. Brain MRI should be performed on patients with high-risk melanoma from stage IIC to exclude brain metastases.

Dupilumab-associated ocular surface disease is characterized by a shift from Th2/Th17 toward Th1/Th17 inflammation

BACKGROUND

Dupilumab is used for the treatment of atopic dermatitis (AD). Approximately one third of AD patients develop a dupilumab-associated ocular surface disease (DAOSD), of which the pathomechanism is poorly understood. This study aimed at investigating inflammatory markers in tear fluids of patients on dupilumab therapy.

METHODS

Tear fluids were collected from AD patients with DAOSD (ADwDAOSD), AD patients without DAOSD (ADw/oDAOSD), and non-AD patients before and during dupilumab therapy, and analyzed using a specialized proteomic approach quantifying inflammatory markers. The ocular surface microbiome was determined by next generation sequencing technology.

RESULTS

Upon dupilumab therapy, an upregulation of 31 inflammatory markers was observed in DAOSD tear fluids compared to baseline in AD patients. While IL-12B was upregulated in both ADwDAOSD and ADw/oDAOSD groups, the pattern of inflammatory markers significantly differed between groups and over time. In the ADwDAOSD group, a shift from a mixed Th2/Th17 pattern at baseline toward a Th1/Th17 profile under dupilumab was observed. Furthermore, an upregulation of remodeling and fibrosis markers was seen in DAOSD. Semantic map and hierarchical cluster analyses of baseline marker expression revealed four clusters distinguishing between AD and non-AD as well as ADwDAOSD and ADw/oDAOSD patient groups. In a pilot study, dupilumab therapy was associated with a decrease in richness of the ocular surface microbiome.

CONCLUSIONS

DAOSD is characterized by a Th1/Th17 cytokine profile and an upregulation of markers known to promote remodeling and fibrosis. The expression pattern of inflammatory markers in tear fluids at baseline might serve as a prognostic factor for DAOSD.

Comparison of Perceptions of Skin Condition, Product Use and Allergen Reactivity Between People with Psoriasis and Controls in the European Dermato-Epidemiology Network (EDEN) Fragrance Study

Psoriasis, a chronic inflammatory skin disease, goes beyond visible symptoms and affects the general well-being of patients. The aim of this study is to understand how patients with psoriasis perceive their skin characteristics and reactivity to allergens. The study population includes 11,283 participants within the European Dermato-Epidemiology Network (EDEN) Fragrance study, covering several European regions. The study compared perceptions of skin dryness, sensitivity, product avoidance and reactivity to allergens between patients with psoriasis and controls, evaluating the potential influence of psoriasis severity. The results showed that subjects with psoriasis reported dry skin (71.1%) and sensitive skin (49.4%) more often than did controls (51.6% and 38.5%, respectively). Psoriasis patients were more likely to avoid specific products. Interestingly, there were no significant differences in patch-test results between the 2 groups and the severity of psoriasis did not have a consistent impact on these perceptions. In conclusion, people with psoriasis tend to perceive their skin as drier and more sensitive. Notably, the severity of psoriasis did not consistently influence these perceptions and objective reactivity to allergens did not align with subjective perception. Understanding these aspects is crucial for tailoring treatments to improve the well-being of patients with psoriasis, which warrants further research to explore subjective perceptions of skin well-being in patients with psoriasis.

Oral Acitretin Plus Topical Triamcinolone vs Topical Triamcinolone Monotherapy in Patients With Symptomatic Oral Lichen Planus: A Randomized Clinical Trial

Importance

Symptomatic oral lichen planus (OLP) can be challenging to treat.

Objective

To compare the efficacy of oral acitretin plus topical triamcinolone acetonide (TAC), 0.1%, with TAC monotherapy in patients with symptomatic OLP.

Design, Setting, and Participants

This monocentric, investigator-initiated, placebo-controlled, investigator- and patient-blinded randomized clinical trial was conducted from December 2018 to June 2020 at the Postgraduate Institute of Medical Education and Research, a tertiary referral center in Chandigarh, India. Sixty-four patients 18 years or older with symptomatic OLP were recruited by consecutive sampling. Data were analyzed from July to December 2020.

Intervention

The patients were randomized to receive either a combination of oral acitretin (25-35 mg/d) and TAC (treatment group) or TAC in combination with placebo (placebo group) for 28 weeks, with an additional 8 weeks of treatment-free follow-up after the end of treatment (36 weeks of total study duration).

Main Outcomes and Measures

The disease severity and treatment response were assessed using Oral Disease Severity Score (ODSS), Oral Health Impact Profile 14 (OHIP-14), and visual analog scale (VAS). The primary aim was to assess the number of patients achieving ODSS-75 (75% reduction in ODSS compared with baseline) in both groups at 28 weeks and at the end of 36 weeks.

Results

Among 64 patients, 31 in the treatment group and 30 in the placebo group completed the study (mean [SD] age, 50.6 [15.2] years vs 49.2 [14.4] years; male-female ratio, 13:19 vs 16:16). Baseline ODSS, visual analog scale, and Oral Health Impact Profile 14 scores were comparable in both groups. In the intention-to-treat analysis, there was a statistically significant higher number of patients achieving 75% or higher reduction in ODSS in the treatment group compared with the placebo group at the end of 28 weeks (28 [88%] vs 15 [47%], a 41 [95% CI, 20-61] percentage point difference between groups; P < .001; Cramér V = 0.47) and 36 weeks (27 [84%] vs 13 [41%], a 43 [95% CI, 23-67] percentage point difference between groups; P < .001; Cramér V = 0.47). Relapses during the posttreatment follow-up of 8 weeks were low among patients in both treatment and placebo groups (1 [3%] vs 2 [6%], a 3 [95% CI, -13 to 7] percentage point difference between groups; P > .99; Cramér V = 0.07).

Conclusion and Relevance

In this randomized clinical trial, the combination of oral acitretin and TAC was more effective than TAC monotherapy in patients with symptomatic OLP.

Trial Registration

Clinical Trial Registry of India Identifier: CTRI/2018/11/016448.

Skin hyperpigmentation index in melasma: A complementary method to classic scoring systems

BACKGROUND

Due to relapsing nature of melasma with significant impact on quality of life, an objective measurement score is warranted, especially to follow-up the patients with melasma and their therapy response in a quantitative and precise manner.

AIMS

To prove concordance of skin hyperpigmentation index (SHI) with well-established scores in melasma and demonstrate its superiority regarding inter-rater reliability. Development of SHI mapping for its integration in common scores.

METHODS

Calculation of SHI and common melasma scores by five dermatologists. Inter-rater reliability was assessed by intraclass correlation coefficient (ICC) and concordance by Kendall correlation coefficient.

RESULTS

Strong concordance of SHI with melasma area and severity index (MASI)-Darkness (0.48; 95% CI: 0.32, 0.63), melasma severity index (MSI)-Pigmentation (0.45; 95% CI: 0.26, 0.61), and melasma severity scale (MSS) (0.6; 95% CI: 0.42, 0.74). Using step function for mapping SHI into pigmentation scores showed an improvement of inter-rater reliability with a difference in (ICC of 0.22 for MASI-Darkness and 0.19 for MSI-Pigmentation), leading to an excellent agreement.

CONCLUSION

Skin hyperpigmentation index could be an important additional cost-and time-conserving assessment method, to follow-up the patients with melasma undergoing brightening therapies in clinical studies, as well as in routine clinical practice. It is in strong concordance with well-established scores but superior regarding inter-rater reliability.

Palmoplantar Pustulosis: A Systematic Review of Risk Factors and Therapies

Palmoplantar pustulosis (PPP) is a chronic, relapsing, inflammatory disease that can occur alone or in association with arthritis. There is still controversy about whether it should be separated from psoriasis or classified as pustular psoriasis. Furthermore, drug-induced paradoxical PPP is a special variant of PPP that differs from classic PPP in several ways. Treatment of PPP is still challenging, and there are a number of treatment-resistant cases. This review summarizes the risk factors for the development of PPP and the currently available treatment modalities. Female sex, smokers or ex-smokers, obesity, thyroid dysfunction, and treatment with a tumor necrosis factor (TNF)-α inhibitor have been identified as risk factors for the disease's development, severity, and course. Topical treatments and phototherapy are effective for some patients and are used as a first-line or adjuvant treatment modality. Conventional treatments including retinoids and fumaric acid show good effects and can increase the efficacy of treatment with psoralen + ultraviolet light therapy (PUVA). Ciclosporin is fast acting, but relapse mostly occurs immediately after cessation. TNF-α inhibitors are efficient, and an even better response can be achieved with IL-17 and IL-23 blockers as well as apremilast. The effect of Janus kinase inhibitors seems to be promising according to case reports, but further investigations with larger cohorts are needed.

Variables associated with joint involvement and development of a prediction rule for arthritis in patients with psoriasis. An analysis of the Italian PsoReal database

BACKGROUND

Limited data exist to predict the development of psoriatic arthritis (PsA) in patients with psoriasis (PsO).

OBJECTIVE

To analyze factors associated with incident PsA in patients with PsO, and to develop a predictive algorithm for progression to arthritis using a full set of variables and a restricted one applicable to administrative data.

METHODS

Cohort study within the PsoReal registry in Italy. Multivariable generalized linear models were used to assess factors associated with PsA and to derive a predictive model.

RESULTS

Among 8895 patients, 226 PsA cases were identified (incidence 1.9 per 100 patient-years). Independent predictors in the full model were as follows: female sex, age 40 to 59 years, body mass index ≥ 25, chronic-plaque PsO features, presence of palmoplantar pustulosis, hospitalization for PsO in the last 5 years, and previous use of systemic PsO therapy (area under the receiver operating characteristic curve = 0.74). Female sex, age 40 to 59 years, hospitalization for PsO, and previous use of systemic PsO therapy were independent predictors in the restricted model (area under the receiver operating characteristic curve = 0.72).

LIMITATIONS

Lack of other potential predictors for PsA.

CONCLUSION

Our models could be used by clinicians and health authorities when planning intervention and population surveillance. Future studies should confirm our models using larger datasets and additional variables.

Melanoma Prognosis and Associated Risk Factors: A Retrospective Cohort Study Using Semantic Map Analysis

The overall patterns of correlations among various melanoma risk factors have not yet been examined. The aim of this study was to assess the impact of different parameters on disease-free and melanoma-related overall survival. A retrospective cohort study was conducted encompassing all patients with a primary cutaneous melanoma diagnosed in a university referral centre. Associations were explored using semantic map analysis, which uses graph theory to find the strongest path of connections between variables. A total of 1,110 melanoma patients (median follow-up 10.6 years) were included. The analysis revealed a clustering of variables around 2 main hubs: Breslow thickness < 1 mm and ≥ 4 mm. Factors connected with high melanoma thickness were: older age, positive sentinel lymph node biopsy findings, presence of ulceration, nodular melanoma type, and light skin phototype. Both disease-free and melanoma-related overall survival were in this cluster and connected with positive sentinel lymph node biopsy and Breslow ≥ 4 mm. Patients with Breslow between 1 and 3.9 mm were also in this cluster and linked with negative sentinel lymph node biopsy, nodular melanoma and safety distance > 10 mm. This semantic analysis confirmed the close link between Breslow thickness, age, sentinel lymph node biopsy findings, skin type, melanoma subtype and prognosis, and provides prognostic information useful for the further stratification and management of patients with melanoma.

Lasers for the treatment of psoriasis: a systematic review

INTRODUCTION

Phototherapy has been one of the first and still frequently used treatment modality for psoriasis. In the last decades, different types of lasers have been used for the treatment of psoriasis and other inflammatory skin diseases with variable success.

AREAS COVERED

Efficacy and safety of laser devices and intense pulsed light for the treatment of psoriasis. The literature search was conducted using the bibliographic databases MEDLINE, EMBASE and Cochrane. Search terms included "laser" AND "psoriasis", "IPL" AND "psoriasis", "intense pulsed light" AND "psoriasis".

EXPERT OPINION

Due to its high efficacy and safety profile 308nm Excimer laser retains its specific place in the treatment of plaque psoriasis as a first- or second-line therapy in mild disease or as an adjuvant treatment in case of partial response to systemic treatments in moderate to severe disease. Vascular lasers remain a last line therapy that can be tried in patients with recalcitrant limited plaques or nail affection. They are easy to apply and have a very good safety profile and tolerability, but the efficacy is limited. Fractional ablative lasers for application of laser assisted drug delivery appear interesting and a topic for further research. When using lasers for psoriasis, a good pre-treatment is mandatory.

Skin hyperpigmentation after sclerotherapy with polidocanol: A systematic review

Skin hyperpigmentation after sclerotherapy with polidocanol-containing sclerosants is a common local side effect. Sclerotherapists should be familiar with factors that trigger hyperpigmentation after sclerotherapy with polidocanol-containing sclerosants. A systematic literature review of works reporting hyperpigmentation after sclerotherapy for telangiectasias, reticular veins, side branches and truncal varices with polidocanol-containing sclerosants was performed. Reported incidence rates, follow-up periods and potentially triggering factors were assessed and analysed. The search yielded 1687 results; of these, 27 reports met the inclusion criteria. The incidence of hyperpigmentation seemed to increase with higher concentrations of polidocanol and was more evident after sclerotherapy for epifascial veins than for intrafascial truncal veins when the polidocanol concentration was more than 0.25%. Regarding sclerotherapy for telangiectasias and reticular veins, the incidence of hyperpigmentation ranged between 2% and 25% for polidocanol 0.25% (liquid and foam), between 12.5% and 67.9% for polidocanol 0.5% (liquid and foam) and between 13% and 73% for polidocanol 1% (liquid and foam). Regarding truncal veins, the incidence ranged from 7% to 45.8% for polidocanol 1% (liquid and foam), from 16% to 17% for polidocanol 2% (foam) and from 7.4% to 32.5% for polidocanol 3% (liquid and foam). Regarding the treatment of side branches, the incidence of hyperpigmentation ranged from 5.6% to 53% for both foam and liquid sclerotherapy. Regarding the duration of hyperpigmentation, there are few data describing reticular veins and telangiectasias. Hyperpigmentation persisting for more than 6 months has been reported to have an incidence of up to 7.5%. Hyperpigmentation persisting for more than 1 year after foam polidocanol 1%-3% treatment for truncal veins has an incidence ranging from 8.1% to 17.5%. Other factors such as higher volumes and compression therapy after treatment seem to have a minor influence. Data regarding hyperpigmentation after polidocanol-related sclerotherapy are poor and should be improved by higher-quality research.

Randomized Open-Label Trial Comparing Teledermatology vs. Face-to-Face Consultation in the Follow-Up of Patients with Mild-to-Moderate Acne

Background: Acne vulgaris is one of the most common dermatological diseases, especially in adolescents and young adults. Objective: The current study aimed to compare teledermatology versus face-to-face consultation in the follow-up of patients with mild-to-moderate acne. Methods: In this investigator-initiated, parallel arms, open-label, randomized clinical trial, after screening, participants were randomly assigned in a 1:1 ratio to be followed up through teledermatology or standard face-to-face consultations for a period of 6 months. The primary endpoint was the cumulative time spent by physician for consultations or online assessments. Results: 24 patients (21 females and 3 males; mean age 23.0 ± 3.3 years) underwent randomization in the two study groups. In intention-to-treat analysis, the cumulative time spent by physician was higher in the teledermatology group compared to face-to-face consultations with an average difference of 8:24 mm:ss (95% CI: 1:17-15:31). However, the cumulative time spent by the patient was significantly lower in the teledermatology group (mean difference 1:21:39 hh:mm:ss; 95% CI: 41:51-2:01:27). An optimal reduction of acne-severity was observed in both groups, without significant differences between them. The patient’s satisfaction did not change significantly over time and between groups, and was generally quite high. AEs were reported by one patient in the teledermatology group and four patients in the consultation group. Conclusion: Acne might be an optimal disease to be followed up using a teledermatology platform, to relieve the burden on patients and medical staff. However, it is necessary to implement more user-friendly platforms in order to achieve the best possible results in the treatment and follow-up of acne patients.

Outcome and long-term treatment protocol for topical tacrolimus in oral lichen planus

BACKGROUND AND OBJECTIVE

Topical tacrolimus has been shown to be beneficial in the treatment of oral lichen planus (OLP). However, long-term effects and its optimal application protocol with gradual reduction have not been studied. Accordingly, we analysed the clinical response of OLP to tacrolimus in our daily clinical practice with a focus on the optimal long-term therapeutic scheme.

METHODS

Retrospective analysis of all consecutive patients diagnosed with OLP and treated with topical tacrolimus (0.03% oral rinse) in a clinical setting between 2015 and 2020. The objective clinical response was measured by a 4-point scale (complete remission, major remission, partial remission and no response), and subjective impairment by a 3-point scale (severe, moderate and none).

RESULTS

Fifty-seven patients (74% women; median age: 66 years) were included. Fifty-six (98%) patients had prior treatment with topical steroids. After introduction of tacrolimus, objective remission (major or complete) was reached by 28%, 62%, 87% and 97% of patients after 3, 6, 12 and 24 months respectively. Subjective remission was reported by 16%, 48%, 69% and 83% after 3, 6, 12 and 24 months of treatment respectively. The treatment frequency could be gradually reduced from initially twice daily to once daily or less in 28%, 61%, 78% and 87% after 3, 6, 12 and 24 months respectively; 41% of patients completely suspended the treatment at one point, but 67% of them experienced a relapse after a median time of 3.3 months. Four patients (7%) developed a squamous cell carcinoma (SCC) during the observation period. Otherwise, there were only few and minor side-effects.

CONCLUSION

Topical tacrolimus can be an effective second-line therapy for OLP refractory to potent topical corticosteroids. The therapy frequency can often be reduced during the maintenance period. Both signs of clinical activity and subjective impairment should guide therapy. Regular follow-up is necessary to recognize possible SCC.

Comorbidities in lichen planus by phenome-wide association study in two biobank population cohorts

BACKGROUND

Lichen planus (LP) is a relatively frequent mucocutaneous inflammatory disease affecting the skin, skin appendages and mucosae, including oral mucosae, and less frequently the anogenital area, conjunctivae, oesophagus or larynx.

OBJECTIVES

To estimate the association of LP, with emphasis on dermatological and gastrointestinal conditions, in two large independent population cohorts.

MATERIALS AND METHODS

We performed a phenome-wide association study (PheWAS) and examined conditions associated with LP in two unrelated cohorts, i.e. the multicentre, community-based UK Biobank (UKB: 501 381 controls; 1130 LP subjects) and the healthcare-associated Penn Medicine BioBank (PMBB; 42 702 controls; 764 LP subjects). The data were analysed in 2021. The 'PheWAS' R package was used to perform the PheWAS analyses and Bonferroni correction was used to adjust for multiple testing. Odds ratios (ORs) were adjusted for age, sex and body mass index.

RESULTS

In the UKB, PheWAS revealed 133 phenome codes (PheCodes) significantly associated with LP and most of them were confirmed in PMBB. Dermatological and digestive PheCodes were the most abundant: 29 and 34 of these disorders, respectively, were significantly overrepresented in LP individuals from both cohorts. The 29 dermatological and 12 oral disorders were often highly enriched, whereas hepatic, gastric, oesophageal and intestinal PheCodes displayed ORs in the range of 1·6-4·5. Several autoimmune disorders also exhibited OR > 5 in both cohorts.

CONCLUSIONS

PheWAS in two large unrelated cohorts identified previously unknown comorbidities and may support clinical counselling of patients with LP. What is already known about this topic? Lichen planus (LP) is known to affect the skin, skin appendages and mucosae, including oral mucosae, and less frequently the anogenital area, conjunctivae, oesophagus or larynx. What does this study add? Our data provide the most comprehensive collection of associated dermatological, digestive and autoimmune disorders to date. Our findings are expected to be useful for the evaluation and management of patients with LP.

Agreement on classification of clinical photographs of pigmentary lesions: Exercise after a training course with young dermatologists

Smartphone apps may help promoting the early diagnosis of melanoma. The reliability of specialist judgment on lesions should be assessed. Hereby, we evaluated the agreement of six young dermatologists, after a specific training. Clinical judgment was evaluated during two online sessions, one month apart, on a series of 45 pigmentary lesions. Lesions were classified as highly suspicious, suspicious, non suspicious or not assessable. Cohen’s and Fleiss’ kappa were used to calculate intra- and inter-rater agreement. The overall intra-rater agreement was 0.42 (95% confidence interval - CI: 0.33-0.50), varying between 0.12-0.59 on single raters. The inter-rater agreement during the first phase was 0.29 (95% CI: 0.24-0.34). When considering the agreement for each category of judgment, kappa varied from 0.19 for not assessable to 0.48 for highly suspected lesions. Similar results were obtained in the second exercise. The study showed a less than satisfactory agreement among young dermatologists. Our data point to the need for improving the reliability of the clinical diagnoses of melanoma especially when assessing small lesions and when dealing with thin melanomas at a population level.

Characteristics of Dermatological Patients With Blood Eosinophilia: A Retrospective Analysis of 453 Patients

BACKGROUND

Skin diseases associated with blood or tissue eosinophilia are common. Because these have various clinical manifestations, making the correct diagnosis can be challenging. So far, dermatological patients with concomitant blood eosinophilia have not been characterized.

OBJECTIVE

To investigate patterns of dermatological patients with concomitant blood eosinophilia to obtain information helpful for optimizing disease management.

METHODS

In this retrospective study, demographic and clinical data and diagnostic test results of all patients presenting with dermatoses associated with blood eosinophilia referred to a university center from 2014 to 2018 were extracted from the electronic patient charts and evaluated using descriptive and semantic map analyses.

RESULTS

A total of 453 patients (51.4% females; mean age, 58.4 ± 21.7 years) were included and grouped according to blood absolute eosinophil counts: severe, greater than or equal to 1.5 G/L (n = 87; 19.2%); moderate, 1.0 to 1.49 G/L (n = 73; 16.1%); and mild eosinophilia, 0.5 to 0.99 G/L (n = 293; 64.7%). Most patients presented with chronic (64.6%), generalized skin lesions (75.9%), and pruritus (88.1%). Statistical analyses revealed 3 distinct patterns: (1) mild eosinophilia associated with localized skin disease, age less than 50 years, history of atopy, and diagnosis of eczema or infectious disease; (2) moderate eosinophilia linked to generalized skin lesions, pruritus, age more than 70 years, and autoimmune bullous disease; and (3) severe eosinophilia associated with diagnosis of hypereosinophilic syndromes, drug hypersensitivity, or malignant disease.

CONCLUSIONS

Based on the pattern analysis of patients with dermatoses associated with blood eosinophilia, a diagnostic workup has been developed aiming at setting the correct differential diagnosis in a feasible and effective manner.

Face mask use in the community and cutaneous reactions to them during the COVID-19 pandemic: results of a national survey in Italy

To mitigate the outbreak of coronavirus disease 2019 pandemic, many countries have imposed the public use of face masks. We investigated attitudes and skin reactions in the Italian individuals wearing face masks during the pandemic. A cross-sectional survey on a random sample (N=1001) of the Italian adult population was conducted in May 2020 by the Italian Group for Epidemiological Research in Dermatology, and the Gallup International Association. Univariable and multivariable regression analysis were used to estimate the odds ratios and their 95% confidence intervals. Most individuals (72.5%) wore a mask, 56.5% used a surgical mask and 53.0% a disposable mask. One-third changed the mask at least once a day, two-thirds kept a distance of at least one meter from each other, 50% washed their hands before wearing a mask, and 17.6% adopted multiple hygienic behaviors. Twenty percent of individuals reported redness, swelling, itching or erosions in the skin area of mask contact; the risk of this reaction was associated with young age, the use of respirators and a history of pre-existing contact eczema, psoriasis or atopic dermatitis. Health educational programs may improve compliance with combined preventive measures and reduce skin reactions.

Reliability Assessment and Validation of the Skin Hyperpigmentation Index Compared to the Physician Global Assessment Score

BACKGROUND

The skin hyperpigmentation index (SHI), a new objective method for measuring skin hyperpigmentation, needs validation.

OBJECTIVE

To gain evidence of the reliability and validity of the SHI.

METHODS

Fifteen raters were divided into 3 groups (5 dermatologists, 5 nondermatologist physicians, and 5 nonphysician clinicians). Each rated 5 pigmented mole lesions with mild-to-severe hyperpigmentation to determine intra- and interrater reliability. All raters photographed the lesions and rated them using the subjective Physician Global Assessment (PGA) score. The same photographs were then assessed based on automatic computer measurement software using the online SHI tool (https://shi.skinimageanalysis.com).

RESULTS

The SHI reliability was excellent for all intra- and interrater assessments, while most PGA assessments showed good intra- and interrater agreement. Between-group reliability was excellent for SHI, while moderate-to-good for PGA evaluations. Concordance between the SHI and PGA assessments was strong across all groups of assessors.

CONCLUSION

There is evidence that the SHI is a reliable instrument for measuring skin hyperpigmentation, and can be used by nonexperienced clinicians.

Efficacy Assessment of the High-Frequency High-Intensity Focused Ultrasound as a New Treatment for Actinic Keratosis

BACKGROUND

Actinic keratosis (AK) is the most common precancerous cutaneous lesion, with risk of progression to cutaneous squamous cell carcinoma. In the current study, we evaluated the efficacy of 20-MHz high-intensity focused ultrasound (HIFU), as a new treatment modality for AK.

MATERIALS AND METHODS

Patients with AK lesions (grades I-III) treated with HIFU were included in the study. The clinical assessment was performed 3 months after therapy.

RESULTS

Twenty-one patients (14 men, 7 women) with 108 AK lesions (grades I-III) were included in the current study. Ages ranged from 62 to 85 years (mean 72.6 years). Clinically complete resolution of the actinic damage in the treated area was detected in 72.2% of lesions. Furthermore, 28 lesions (26%) showed a reduction of the AK grade, or partial response, after the therapy. Most of the patients experienced annoying but short pain during the procedure. However, late adverse effects of the therapy, such as hypopigmentation, hyperpigmentation and erythema were reported only in a small portion of the lesions.

CONCLUSIONS

20-MHz HIFU could be an effective and safe alternative treatment for AK.

Assessing the Risk and Outcome of COVID-19 in Patients with Psoriasis or Psoriatic Arthritis on Biologic Treatment: A Critical Appraisal of the Quality of the Published Evidence

The need to rapidly spread information about the risk of COVID-19 in patients with psoriasis and psoriatic arthritis on biologics may have hampered the methodological rigor in published literature. We analyzed the quality of papers dealing with the risk and outcomes of COVID-19 in patients with psoriasis and psoriatic arthritis receiving biologic therapies. The Newcastle-Ottawa Scale was used to estimate the quality of the published studies. Moreover, to better contextualize results, specific internal and external validity items were further considered, that is, case definition, modality of COVID-19 assessment, evidence for self-selection of participants, percentage of dropout/nonparticipants, and sample size calculation. A total of 25 of 141 papers were selected. The median Newcastle-Ottawa Scale score was 47% for psoriasis and 44% for psoriatic arthritis, indicating an overall high risk of bias. A total of 37% of psoriasis and 44% of psoriatic arthritis studies included patients with suspected COVID-19 without a positive swab. No studies provided a formal sample size calculation. A significant risk of bias in all the published papers was found. Major issues to be considered in future studies are reduction of ascertainment bias, better consideration of nonresponse or participation bias, and provision of formal statistical power calculation.

Preference for Telemedicine Versus In-Person Visit Among Patients with Psoriasis Receiving Biological Drugs

Introduction

The use of telemedicine has significantly increased since the outbreak of the SARS-CoV-2 pandemic. In the dermatological setting, patients with stable plaque psoriasis on maintenance therapy with biological drugs may be suitable candidates for telemedicine, although their preference for telemedicine has not yet been investigated. The aim of this study was to investigate the preference for telemedicine versus in-person visit among patients with psoriasis receiving biological drugs and the reported reasons behind their preferences.

Methods

Consecutive adult patients with chronic plaque psoriasis in stable clinical remission (Psoriasis Area Severity Index [PASI] ≤ 3 for at least 12 months) receiving maintenance biological therapy answered a survey investigating whether they would choose telemedicine or in-person visit for the next scheduled visit and the reasons behind their preference. The survey was undertaken through a questionnaire that was developed according to a structured process.

Results

Of the 246 participants in the survey, 118 (48%) preferred telemedicine over an in-person visit for their next scheduled visit with a dermatologist. Multivariate logistic regression analysis revealed that previous experience with digital video-communication tools was a significant predictor for the preference for telemedicine (odds ratio [OR] 10.75; 95% confidence interval [CI] 3.61–32.03), while older age (< 60 years) was negatively associated with the preference for telemedicine (OR 0.30; 95% CI 0.10–0.90). The most common reasons (75%) for preferring telemedicine were saving time and safety in relation to the risk presented by the Sars-CoV-2 pandemic (38%). In contrast, 56% of the patients who preferred the in-person visit option declared that they were unable to use video-communication tools.

Conclusion

About half of the patients with stable psoriasis receiving biological drugs may be good candidates for telemedicine.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00555-3.

Long-Term Effectiveness and Drug Survival of Apremilast in Treating Psoriasis: A Real-World Experience

BACKGROUND

Apremilast is an oral phosphodiesterase 4 (PDE4) inhibitor used for the treatment of moderate to severe psoriasis. Long-term data on the effectiveness and drug survival of patients treated with apremilast are limited.

OBJECTIVE

The aim of this study was to analyze the characteristics, effectiveness, and drug survival of patients treated with apremilast in a real-world setting.

METHODS

We conducted a retrospective cohort study of patients with psoriasis who received at least 1 dose of apremilast between 2015 and 2018. We documented sex; age; type, duration, and severity (using Psoriasis Area Severity Index [PASI] and Dermatology Life Quality Index [DLQI]) of psoriasis; comorbidities; previous treatment modalities; adverse events; and reasons for therapy discontinuation. For drug survival, estimates and efficacy analysis with Kaplan-Meier statistics were used.

RESULTS

The drug survival rate of the 93 reviewed patients was 69.5% at 6 months, 34.7% at 12 months, and 25.8% at 24 months after initiating therapy. The median survival duration was 8.0 months. Therapy was discontinued in 66.6 and 27.8% due to loss of efficacy and adverse events, respectively. At 24 months, 35.9% had achieved PASI75 response and 23.7% had achieved PASI90 response. Most observed adverse events were gastrointestinal issues, weight loss, and headache.

CONCLUSIONS

Apremilast is an effective and well-tolerated therapy for patients with moderate to severe psoriasis, especially for patients with difficult-to-treat locations and/or contraindications to other biologics. Furthermore, apremilast was used for patients with a history of nonresponse to biologics and was favored for patients with relatively low PASI (<10) and a high DLQI.

Time of Onset of Selected Skin Lesions Associated with COVID-19: A Systematic Review

INTRODUCTION

Distinct skin lesions associated with coronavirus disease 2019 (COVID-19) have been described, but data regarding their time of onset during the COVID-19 course are scant. Our objective was to systematically review the studies reporting the time of onset of selected skin lesions with respect to the reported onset of the COVID-19 core symptoms.

METHODS

A comprehensive search of studies published before 21 January 2021 was performed on MEDLINE via PubMed database using a predefined strategy to identify relevant articles.

RESULTS

Out of 354 references, 87 were selected, reporting a total of 895 patients with skin lesions associated with COVID-19. The most frequent pattern was exanthema (n = 430, 48%), followed by vascular (n = 299, 33%), urticarial (n = 105, 12%) and others (n = 66, 7%). Skin lesions occurred more frequently in the first 4 weeks from the COVID-19 onset (n = 831, 92%), whereas prodromal or late lesions were rarer (n = 69, 8%). The urticarial and exanthema patterns were more frequent in the first 2 weeks. About the vascular pattern some differences were noted among its subtypes. Livedoid lesions occurred mainly in the first 2 weeks, while chilblain-like lesions between weeks 2 and 4. Purpuric/petechial lesions were equally distributed during the first 4 weeks. Several skin manifestations did not fall into the pattern classification, including erythema multiforme, generalized pruritus, Kawasaki disease and others.

CONCLUSION

The diversity in the time of onset of skin lesions as well as their polymorphic nature likely reflects the diversity of the pathogenetic underlying mechanisms.

PROSPERO DATABASE REGISTRATION NUMBER

CRD42021236331.

Inter-Observer and Intra-Observer Variations in the Assessment of Epithelial Dysplasia in Oral Lichenoid Diseases

Oral lichen planus (OLP) and oral lichenoid lesions (OLL) can both present with histological dysplasia. Despite the presence of WHO-defined criteria for the evaluation of epithelial dysplasia, its assessment is frequently subjective (inter-observer variability). The lack of reproducibility in the evaluation of dysplasia is even more complex in the presence of a lichenoid inflammation. We evaluated dysplasia in 112 oral biopsies with lichenoid inflammation in order to study the inter-observer and the intra-observer variability.

Melanoma of the Nail Apparatus: An Analysis of Patients' Survival and Associated Factors

BACKGROUND

There are no proper management guidelines for nail apparatus melanoma (NAM).

OBJECTIVE

This study aimed to describe the clinical features, the presence of locoregional and distant metastases and disease-free and overall survival of NAM treated at our institution.

METHODS

A retrospective cohort review of patients with single, primary localized histopathologically confirmed NAM was performed. Collected data consisted of patients' characteristics and tumor features. In addition, local recurrence, locoregional metastases, distant metastases, disease-free survival (DFS) and overall survival (OS) were used as the main outcomes in our analysis.

RESULTS

Thirty patients with NAM were included. The overall survival (OS) in our patients at 5 and 10 years was 85.6 and 73.4%, respectively. DFS was significantly higher in patients with primary tumor location in the hand and without tumor-infiltrating lymphocytes (p value = 0.01 and 0.04, respectively). The patients with in situ melanoma or Breslow thickness <1 mm had a significantly higher chance of DFS and OS (90.0 and 94.1% at 5 years, respectively) than those with thicker NAM (58.3 and 55.6% at 5 years, respectively). A total of 53.3% of 30 patients underwent primary excision and covering with a full-thickness skin graft, while 13.3% of our 30 patients underwent digit amputation. The patients who underwent excision and covering with a full-thickness skin graft showed a complete overall survival (100% at 5 years).

CONCLUSION

Primary tumor location in the hand and lower tumor thickness might be correlated with better patients' survival. The study results suggest that total amputation might not be necessary in all NAM cases.

Skin exposure to scented products used in daily life and fragrance contact allergy in the European general population - The EDEN Fragrance Study

BACKGROUND

Fragrances are widely used in scented products used in daily life with the potential to induce skin sensitization.

OBJECTIVE

To evaluate exposure to scented products and to explore associations between exposure and fragrance contact allergy.

METHODS

A cross-sectional study on individuals from 18 to 74 years of age, who were randomly selected from the general population in five European countries. A random sample (N = 3119) was patch tested and interviewed on exposure to scented products.

RESULTS

Female participants were strongly associated with exposure to scented products relative to male participants. Participants age 40 years and older showed an inverse association with exposure to scented products. Compared to Sweden, The Netherlands followed by Germany showed the highest overall exposure to scented products. Sensitive skin was associated with exposure to scented products and with fragrance allergy. In univariable regression analysis, exposure to leave-on products and to specific scented product subgroups was significantly associated with fragrance allergy.

CONCLUSION

Exposure to scented products depends primarily on sex and age. Female sex and sensitive skin are relevant indicators for developing fragrance allergy. Because aggregate exposure, especially to scented leave-on products, may enhance the prevalence of contact allergy to fragrances, further investigations into exposure amounts and frequencies is warranted.

Research Techniques Made Simple: Latent Class Analysis

Latent class analysis (LCA) is a statistical technique that allows for identification, in a population characterized by a set of predefined features, of hidden clusters or classes, that is, subgroups that have a given probability of occurrence and are characterized by a specific and predictable combination of the analyzed features. Compared with other methods of so called data segmentation, such as hierarchical clustering, LCA derives clusters using a formal probabilistic approach and can be used in conjunction with multivariate methods to estimate parameters. The optimal number of classes is the one that minimizes the degree of relationship among cases belonging to different classes, and it is decided by relying on methods such as the Bayesian Information Criterion that capitalize on the value of the negative log-likelihood function, a well-established measure of the goodness of fit of a statistical model. LCA has not been extensively used in dermatology. The areas of application are manifold, from the phenotype classification to the analysis of behavior in relation with risk factors to the performance of diagnostic tests.

The skin hyperpigmentation index: An objective method of measuring the intensity of hyperpigmentation after sclerotherapy

Skin hyperpigmentation in chronic venous insufficiency and as a side effect in vein treatments are of great importance for the affected individuals. There are only a few qualitatively limited methods that allow its quantification. Previous techniques to develop a reliable scientific approach to quantification have failed due to the lack of standardized conditions including differences in lighting, distances and equipment. A newly developed measuring method, the "skin hyperpigmentation index", enables a fully automated and standardized quantification of skin hyperpigmentation with dermatoscopic images. The skin hyperpigmentation index defines the ratio of two scores, namely hyperpigmented skin of the affected area and normal sun protected skin from the same patient. This results in a range from 1 (no pigmentation) to 4 (maximum pigmentation). For a practical evaluation of the score, a free skin hyperpigmentation index calculator can be used online, which is accessible to all practitioners (https://shi.skinimageanalysis.com/). The skin hyperpigmentation index is a fully automated method for the quantitative assessment of skin pigmentation which can easily be applied to any skin type with any type of hyperpigmentation. This allows a simple, fast, and standardized quantification of skin hyperpigmentation and is useful for monitoring the progress and planning of whitening therapy.

Psoriasis severity matters when dealing with all-cause mortality in psoriasis patients: a record linkage analysis in Northern Italy

Psoriasis has been linked with several comorbidities and increased all-cause mortality compared with the general population. Data are still limited concerning mortality especially from Southern European countries. Between January 2012 and December 2018, we conducted a retrospective cohort study on psoriasis patients and population controls in Northern Italy. Through record linkage of health-care databases, psoriasis cases were identified, and their morbidity and mortality were compared with the general population. The Charlson index was used as an index of comorbidities. Standardized mortality ratios (SMR) were estimated for overall psoriasis cases and for patients with mild vs moderate-to-severe disease, separately. We identified 12,693 psoriasis patients (mean age: 60.8 ± 16.3 years). They had a significantly higher Charlson index compared with the general population (p < 0.001). In spite of the higher rate of comorbidities, age-specific SMR was not increased in the psoriasis population as a whole (1.04 (95% CI 0.89-1.20)) or in people with mild psoriasis. However, a 40% higher than the expected risk of all-cause mortality was documented in individuals with moderate-to-severe psoriasis (SMR: 1.41; 95% CI 1.12-1.75). Notably, an excess mortality in these patients occurred as early as age 40-49 years. The proportion of deaths from malignancies and cardiovascular diseases was remarkably high. Our results support the notion that psoriasis severity influences mortality and indicate that patients with psoriasis, especially those with severe disease, should receive appropriate screening and health education.

Successful Treatment of Iatrogenic Cutaneous Siderosis with Pigment Lasers: A Retrospective Study in 15 Consecutive Patients

Intravenous ferric carboxymaltose is increasingly used to treat iron deficiency. However, a common side-effect is paravenous extravasation of iron preparations, resulting in cutaneous siderosis. Quality-switched (QS) lasers and, recently, picosecond (PS) lasers have been used to treat these hyperpigmentations with variable success. The optimal treatment protocol remains unclear. The aims of this study were to assess the response of cutaneous siderosis to treatment with pigment lasers and to determine the optimal wavelength, number of treatment sessions and pulse duration. Fifteen patients with cutaneous siderosis on the arms were included. The effectiveness of laser treatment was evaluated using a 5-point standard Physician Global Assessment (PGA) grading system. Differences in continuous variables between distinct groups of patients were assessed with a Mann–Whitney Utest. In all 15 patients clearance of at least 50% was obtained. In 12 patients, at least 75% of pigment was removed. In conclusion, pigment lasers are an effective and safe method to treat cutaneous siderosis.