Diagnostic accuracy of a short-form version of the diagnostic criteria for primary hyperhidrosis

INTRODUCTION

The gold standard method for diagnosing primary hyperhidrosis (PHH) is based on seven patient-reported criteria. By determining an individual criterion's diagnostic accuracy, one can identify short-version classification models.

METHODS

In this cross-sectional study, data were collected from Danish blood donors in 2021. Cohen's kappa and diagnostic accuracy were determined by comparing each criterion with the gold standard method.

RESULTS

The study included 1,039 participants. Of them, 59 (5.7%) had PHH and 980 (94.3%) were classified as control individuals. The PHH major criterion "focal visible excessive sweating for at least 6 months without an apparent cause" had the highest prevalence in the participants with PHH compared to the control individuals (100% vs. 0.6%; p < 0.0001). The agreement between this criterion and PHH was Cohen's kappa = 0.95 (95% confidence interval [CI] 0.91-0.99), and its sensitivity was 1.00 (95% CI 0.94-1.00) and specificity 0.99 (95% CI 0.99-1.00). The other criteria showed lower agreement and diagnostic accuracy.

CONCLUSIONS

The PHH major criterion showed near-perfect agreement and near-equal diagnostic accuracy compared with the gold standard method. This single criterion can be used as a short-form version to screen for PHH. Determination of reproducibility in independent populations is warranted.

The differentiating effect of COVID-19-associated stress on the morbidity of blood donors with symptoms of hidradenitis suppurativa, hyperhidrosis, or psoriasis

PURPOSE

The burden of different skin diseases may vary leading individuals to have different sensitivity to stress. Therefore, we compared the health-related quality of life (HRQoL) and stress before and during the universal stress from the severe acute respiratory syndrome coronavirus-2-pandemic in individuals with and without hyperhidrosis, hidradenitis suppurativa, or psoriasis.

METHODS

The study cohort was the Danish Blood Donor Study. Overall, 12,798 participants completed a baseline questionnaire before the pandemic, in 2018-2019, and a follow-up questionnaire during the pandemic, in 2020. Regression determined the association between the skin diseases and outcomes. Outcomes were the physical and mental component summary (MCS, PCS, respectively), which assess the mental and physical HRQoL, and the perceived stress scale, which assesses stress in the past four weeks.

RESULTS

Overall, 1168 (9.1%) participants had hyperhidrosis, 363 (2.8%) had hidradenitis suppurativa, and 402 (3.1%) had psoriasis. At follow-up, the participants with hyperhidrosis had worse MCS (coefficient -0.59 [95% confidence interval (CI) -1.05, -0.13]) and higher odds of moderate-to-severe stress (odds ratio 1.37 [95% CI 1.13, 1.65]) and the participants with hidradenitis suppurativa worse PCS (coefficient -0.74 [95% CI -1.21, -0.27]) than the control groups. The associations were independent of baseline HRQoL, stress, the Connor-Davidson Resilience scale, and other covariables. Psoriasis was not associated with the outcomes.

CONCLUSION

Individuals with hyperhidrosis or hidradenitis suppurativa experienced worse mental or physical well-being and individuals with hyperhidrosis also had higher stress during the pandemic compared to healthy individuals. This suggests that individuals with these skin diseases are particularly susceptible to external stress.

Quality of life in individuals with primary hyperhidrosis: a systematic review and meta-analysis

PURPOSE

Hyperhidrosis can be a debilitating disease that leads to the deterioration of well-being. In this study, the objective was to compare the health-related quality of life (HRQOL) in individuals with and without hyperhidrosis by conducting a systematic review and meta-analysis.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Meta-analysis Of Observational Studies in Epidemiology checklist were employed. We systematically searched Cochrane Library, Embase and PubMed. Two authors independently assessed the literature and extracted the data. The risk of bias was assessed using the Newcastle-Ottawa Scale. A random-effects model was employed. The heterogeneity was determined using I2.

RESULTS

Eleven studies met the eligibility criteria comprising 4297 and 147,604 participants with and without hyperhidrosis, respectively. The risk of bias ranged from high quality to very high risk of bias. The individuals with hyperhidrosis had a higher Dermatology Life Quality Index (mean difference 8.53; 95% confidence interval 3.47, 13.58; p = 0.0009) and a lower mental component summary of the short form-12 or -36 (mean difference -6.15; 95% confidence interval -9.00, -3.30; p < 0.0001) than the control individuals. No difference was found for the physical component summary score of the short form-12 or -36 (mean difference -0.88; 95% confidence interval -1.88, 0.12; p = 0.085). Studies using patient-reported outcomes, not included in the meta-analysis, showed similar results.

CONCLUSION

Individuals with hyperhidrosis experience a reduced HRQOL that is clinically meaningful and leads to perceivable deteriorations in their well-being. The evidence shows a high degree of heterogeneity, which warrants additional studies.

Position statement: Recommendations on the diagnosis and treatment of Malassezia folliculitis

Malassezia is a lipophilic yeast that is a part of the human mycobiome. Malassezia folliculitis appears when the benign colonization of the hair follicles, by the Malassezia yeasts, becomes symptomatic with pruritic papules and pustules. Although Malassezia folliculitis is common in hospital departments, diagnosing and treating it varies among dermatologists and countries. The European Academy of Dermatology and Venereology Mycology Task Force Malassezia folliculitis working group has, therefore, sought to develop these recommendations for the diagnosis and management of Malassezia folliculitis. Recommendations comprise methods for diagnosing Malassezia folliculitis, required positive findings before starting therapies and specific treatment algorithms for individuals who are immunocompetent, immunocompromised or who have compromised liver function. In conclusion, this study provides a clinical strategy for diagnosing and managing Malassezia folliculitis.

Comparative Efficacy and Safety of Monoclonal Antibodies and Janus Kinase Inhibitors in Moderate-to-severe Atopic Dermatitis: A Systematic Review and Meta-analysis

The aim of this study was to compare the efficacies of systemic treatments with dupilumab, tralokinumab and Janus kinase inhibitors for moderate-to-severe atopic dermatitis. A systematic review following Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines was performed using Medline, EMBASE and Cochrane library. All randomized controlled trials investigating the efficacy of systemic treatments for moderate-to-severe atopic dermatitis in adults were included. Primary outcomes were the proportion of patients with atopic dermatitis achieving 50%, 75%, and 90% improvement in Eczema Area and Severity Index (EASI) score after dupilumab, tralokinumab or Janus kinase inhibitors. Nineteen studies totalling 6,444 patients were included. In monotherapy studies, upadacitinib 30 mg once daily had the numerically highest efficacy regarding EASI-50, EASI-75 and EASI-90. In combination therapy studies with topical corticosteroids, dupilumab 300 mg once every other week had highest efficacy regarding EASI-50, and abrocitinib 200 mg once daily had the highest score regarding EASI-75 and EASI-90. Analysis provided evidence that dupilumab, tralokinumab and Janus kinase inhibitors all had an acceptable efficacy profile and resulted in clinically relevant improvements in EASI score. Furthermore, upadacitinib and abrocitinib seem to have great potential to treat patients with atopic dermatitis. However, further studies are needed to determine the long-term efficacy of Janus kinase inhibitors in adults with moderate-to-severe atopic dermatitis.

Treatment of Hyperhidrosis: An Update

Hyperhidrosis is a dermatosis presenting as pathologically excessive focal or generalized sweating. The stigmatizing nature of hyperhidrosis may cause patients to feel embarrassment and apprehension about their symptoms and experience a significant decrease in well-being. Severe cases of hyperhidrosis can also increase the risk of developing psychiatric and somatic comorbidities. Conventional non-surgical treatments of hyperhidrosis include aluminum salts, iontophoresis, botulinum toxin injections, and oral glycopyrronium. In recent years, new topical anticholinergic medications and devices have emerged that may improve the patients' symptoms and even prevent the development of comorbidities. The treatment of hyperhidrosis can be a complex matter and may require the combination of several therapies. The purpose of this paper was to firstly review the literature on existing non-surgical treatment options for hyperhidrosis, and secondly provide a stepwise approach to investigating and treating patients with hyperhidrosis.

Hyperhidrosis and the risk of being treated for skin infections

BACKGROUND

A few studies have described an increased prevalence of skin infections in individuals with hyperhidrosis compared to others. However, it remains uncertain whether hyperhidrosis is an independent risk factor for skin infections.

OBJECTIVE

To compare the risk of skin infections in individuals with and without hyperhidrosis.

METHODS

In this retrospective cohort study, data on hyperhidrosis were collected from the Danish Blood Donor Study. Blood donors included in 2010-2019 were followed from inclusion until December 2019. Data on redeemed prescriptions against skin infections were collected from the National Prescription Register. The intensity of prescription-use by hyperhidrosis status was assessed in Andersen-Gill models.

RESULTS

Overall, 4,176 (9.6%) of 43,477 blood donors had self-reported hyperhidrosis and 437 (0.34%) of 127,823 blood donors had hospital diagnosed hyperhidrosis. Self-reported hyperhidrosis was associated with the use of antibiotic prescriptions (adjusted hazard ratio = 1.21; 95% confidence interval 1.00-1.45, p = 0.047). Hospital diagnosed hyperhidrosis was associated with the use of antibiotic (adjusted hazard ratio = 1.33; 95% confidence interval 1.03-1.68, p = 0.028) and topical antifungal prescriptions (adjusted hazard ratio = 1.43; 95% confidence interval 1.04-1.97, p = 0.027).

CONCLUSIONS

Hyperhidrosis is associated with the use of prescriptions for antibiotics and topical antifungals. This suggests a clinically relevant association between hyperhidrosis and skin infections.

The association between water hardness and xerosis-Results from the Danish Blood Donor Study

BACKGROUND

The pathophysiology of xerosis depends on extrinsic and intrinsic exposures. Residential hard water may constitute such an exposure.

OBJECTIVES

To estimate the prevalence of xerosis and to compare water hardness exposure in blood donors with and without xerosis.

METHODS

In this retrospective cohort study in 2018-2019, blood donors with self-reported moderately or severely dry skin were compared to blood donors without dry skin. Blood donors with ichthyosis, lichen planus and psoriasis were excluded. Water hardness data was collected from the Geology Survey of Denmark and Greenland.

RESULTS

Overall, 4,748 of 30,721 (15.5%; 95% confidence interval 15.1-15.9%) blood donors had xerosis. After excluding blood donors with ichthyosis, lichen planus and psoriasis, 4,416 blood donors (2,559 females; median age 38.4 years [interquartile range 28.0-49.8]; 700 smokers) remained in this study. Water softer than 12-24 degrees Deutsche härte was associated with decreased probability of xerosis (odds ratio 0.83; 95% confidence interval 0.74-0.94) and water harder than 12-24 degrees Deutsche härte was associated with increased probability of xerosis (odds ratio 1.22; 95% confidence interval 1.03-1.45). The association between water hardness and xerosis remained significant after excluding blood donors with dermatitis.

CONCLUSIONS

Water hardness is associated with xerosis independent of other dermatoses.

Epidemiology of Hyperhidrosis in Danish Blood Donors

The risk factors and disease implications of hyper-hidrosis are unknown. The objectives of this retrospective cohort study were to estimate the prevalence of hyperhidrosis and to compare demographic, life-style, and socioeconomic parameters in blood donors with and without self-reported or hospital-diagnosed hyperhidrosis. The study included blood donors from the Danish Blood Donor Study for the period 2010-2019. Registry data were collected from Statistics Denmark. Overall, 2,794 of 30,808 blood donors (9.07%; 95% confidence interval (95% CI) 8.75-9.40) had self- reported hyperhidrosis and 284 of 122,225 (0.23%; 95% CI 0.21-0.26) had hospital-diagnosed hyperhidrosis. Self-reported hyperhidrosis was associated with smoking (odds ratio (OR) 1.17; 95% CI 1.05-1.31), overweight (OR 1.72; 95% CI 1.58-1.87), "unemployed" (OR 1.60; 95% CI 1.24-2.08), "short education" (OR 0.76; 95% CI 0.64-0.90), and lower income (beta-coefficient -26,121; 95% CI -37,931, -14,311). Hospital-diagnosed hyperhidrosis did not differ from controls. Thus, self-reported hyperhidrosis was associated with potential hyperhidrosis risk factors (smoking, overweight) and disease implications (unemployment, low education level and income).

Occupational Skin Disease in Physicians: A Review of the Literature

OBJECTIVES

Occupational skin disease (OSD) arises from work-related activity. However, there is a paucity of literature on OSD in physicians. The aim of the this review was therefore to examine and summarize what types of symptomatic OSD physicians experience.

METHODS

We conducted a systematic literature search on Cochrane Library, Embase, and Pubmed.

RESULTS

Contact dermatitis from formaldehyde and glutaraldehyde were found in 11.5 and 13.5% of cases, respectively. In total 2.4-14.9% had latex allergy. The reported standardized incidence ratio of squamous cell carcinoma and melanoma was up to 2.15 [95% confidence interval (CI) 1.57-1.95] and 3.2 (95% CI 1.38-6.31). Transmission of human papilloma virus (HPV) particles during carbon dioxide laser wart ablation were found in 70% of samples collected from protective gloves and in 52% of samples from vapors.

CONCLUSIONS

The most frequently reported OSD in physicians is contact dermatitis from allergens in disinfectants and rubber gloves. There is also a risk of cutaneous reactions to latex. The incidence of skin cancer was higher in physicians than in the general population, and the reason for this remains unexplained and potentially biased. There are no reports of transmission of patient HPV to surgeons during wart ablation, possibly because of proper use of protective equipment.

Incomplete Schnitzler Syndrome

Schnitzler syndrome (SS) is a rare autoinflammatory disease that presents with chronic urticaria and monoclonal immunoglobulin (Ig) M or G, accompanied by fever, abnormal bone remodeling, skin biopsy with a neutrophilic dermal infiltrate, leukocytosis, or elevated C-reactive protein. It is usually refractory to antihistamines and immunosuppression. We present a case report of clinical SS without monoclonal Ig with robust response to interleukin-1 inhibitor anakinra. This suggests the possible existence of an incomplete form of SS and underlines the risk of false negative diagnosis in individuals with such "incomplete SS".

Critical synthesis of available data in Malassezia folliculitis and a systematic review of treatments

Folliculitis is an inflammatory process involving the hair follicle, frequently attributed to infectious causes. Malassezia, an established symbiotic yeast that can evolve to a skin pathogen with opportunistic attributes, is a common source of folliculitis, especially when intrinsic (e.g. immunosuppression) or extrinsic (high ambient temperature and humidity, clothing) impact on the hair follicle and the overlying skin microenvironment. Our aim was to critically review the pathophysiology and clinical characteristics of Malassezia folliculitis, to describe laboratory methods that facilitate diagnosis and to systematically review treatment options. Malassezia folliculitis manifests as a pruritic, follicular papulopustular eruption distributed on the upper trunk. It commonly affects young to middle-aged adults and immunosuppressed individuals. Inclusion into the differential diagnosis of folliculitis is regularly oversighted, and the prerequisite-targeted diagnostic procedures are not always performed. Sampling by tape stripping or comedo extractor and microscopic examination of the sample usually identifies the monopolar budding yeast cells of Malassezia without the presence of hyphae. However, confirmation of the diagnosis with anatomical association with the hair follicle is performed by biopsy. For systematic review of therapies, PubMed was searched using the search string "(malassezia" [MeSH Terms] OR "malassezia" [All Fields] OR pityrosporum [All Fields]) AND "folliculitis" [MeSH Terms] and EMBASE was searched using the search string: 'malassezia folliculitis.mp OR pityrosporum folliculitis.mp'. In total, 28 full-length studies were assessed for eligibility and 21 were selected for inclusion in therapy evaluation. Conclusively Malassezia folliculitis should be considered in the assessment of truncal, follicular skin lesions. Patient's history, comorbidities and clinical presentation are usually indicative, but microscopically and histological examination is needed to confirm the diagnosis. Adequate samples obtained with comedo extractor and serial sections in the histological material are critical for proper diagnosis. Therapy should include systemic or topical measures for the control of the inflammation, as well as the prevention of recurrences.

Preadmission quality of life can predict mortality in intensive care unit--a prospective cohort study

PURPOSE

We sought to investigate whether preadmission quality of life could act as a predictor of mortality among patients admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

This is a prospective observational study of all patients above the age of 18 years admitted to the ICU with a length of stay longer than 24 hours. Short form 36 (SF-36) and Acute Physiology and Chronic Health Evaluation II (APACHE II) were used. Mortality was assessed during ICU admission, 30, and 90 days hereafter.

RESULTS

We included 318 patients. No patients were lost to follow-up. Using the physical component summary of short form 12 (SF-12) as a predictor of ICU mortality, the area under the curve (0.70; confidence interval, 0.62-0.77) was comparable with that of APACHE II (0.74; confidence interval, 0.67-0.82). The difference between SF-12 and SF-36 was nonsignificant.

CONCLUSIONS

Preadmission quality of life, assessed by SF-36 and SF-12, is as good at predicting ICU, 30-, and 90-day mortality as APACHE II in patients admitted to the ICU for longer than 24 hours. This indicates that estimated preadmission quality of life, potentially available in the pre-ICU setting, could aid decision making regarding ICU admission and deserves more attention by those caring for critically ill patients.