Comparison of visual diagnostic accuracy of dermatologists practicing in Germany in patients with light skin and skin of color

Visual clinical diagnosis of dermatoses in people of color (PoC) is a considerable challenge in daily clinical practice and a potential cause of misdiagnosis in this patient cohort. The study aimed to determine the difference in visual diagnostic skills of dermatologists practicing in Germany in patients with light skin (Ls) and patients with skin of color (SoC) to identify a potential need for further education. From April to June 2023, German dermatologists were invited to complete an online survey with 24 patient photographs depicting 12 skin diseases on both Ls and SoC. The study's primary outcomes were the number of correctly rated photographs and the participants' self-assessed certainty about the suspected visual diagnosis in Ls compared to SoC. The final analysis included surveys from a total of 129 dermatologists (47.8% female, mean age: 39.5 years). Participants were significantly more likely to correctly identify skin diseases by visual diagnostics in patients with Ls than in patients with SoC (72.1% vs. 52.8%, p ≤ 0.001, OR 2.28). Additionally, they expressed higher confidence in their diagnoses for Ls than for SoC (73.9 vs. 61.7, p ≤ 0.001). Therefore, further specialized training seems necessary to improve clinical care of dermatologic patients with SoC.

Discontinuation of Fumaric Acid Esters is Affected by Depressive Symptomatology: A Retrospective Analysis

Fumaric acid esters (FAEs) remain a widespread therapy option for moderate-to-severe psoriasis. However, drug survival of FAEs is limited by adverse events (AEs) or inadequate treatment response. Depressive disturbances are highly prevalent in psoriasis patients and are hypothesized to be associated with the reporting of AEs and therapy discontinuation. This study's aim was to analyze whether psoriasis patients with comorbid depressive symptomatology are more likely to discontinue treatment with FAEs due to AEs and/or inadequate treatment response. Data were retrospectively extracted from the records of patients starting therapy with FAEs in the Department of Dermatology, University Hospital Essen, Germany between 2017 and 2022, covering the first 52 weeks of treatment. Psoriasis severity and depressive symptomatology, as well as AEs and therapy discontinuation, were analyzed. Psoriasis patients (N = 95, 47.37% female) with depressive symptomatology (42.11%) were more likely to discontinue therapy due to patient-reported AEs, while the total number of reported AEs was not associated with depression. The results support the hypothesis that among psoriasis patients with depressive symptoms, the associated introspection and somatization may result in increased sensitivity for AEs and thus in quicker therapy discontinuation. In these patients, the occurrence of nocebo effects should be minimized, e.g. by special communication techniques.

How familiar are German dermatologists with placebo and nocebo effects and to what extent are these targeted in clinical practice: A survey within the dermatological community

BACKGROUND

Every medical treatment inevitably comprises not only physiological, but also psychological components, reflected by placebo and nocebo effects, which significantly affect treatment outcome. However, the extent of knowledge on the mechanisms steering placebo and nocebo effects in the dermatological community in Germany is currently unclear.

OBJECTIVES

To assess the state of knowledge about placebo and nocebo effects in the German dermatological community, to evaluate whether this knowledge is already being used in clinical practice, and to investigate whether German dermatologists are interested in learning more about the topic.

METHODS

German Dermatologists, the majority working in their own practice, were asked to fill in an online survey addressing the knowledge about placebo and nocebo effects and the feasibility of special techniques to enhance placebo and minimize nocebo effects within the clinical routine.

RESULTS

N = 154 complete (79%) or partial (21%) responses to the survey were recorded in the online database and included in the analysis. All participants reported to know what the placebo effect is and 59.7% (74/124) indicated that they already had experience with prescribing or recommending a treatment without active substances. In contrast, only 62.0% (80/129) stated to know what the nocebo effect is. Participants showed a rather superficial knowledge regarding placebo and nocebo mechanisms. The majority of participants (76.7%, 99/129) expressed their willingness to be further educated about the underlying mechanisms mediating placebo and nocebo effects and the possible application in clinical practice.

CONCLUSIONS

The current survey offers a so far unique insight into the state of knowledge of German dermatologists on placebo and nocebo effects. The results indicate a need for education about this topic. Encouragingly, however, German dermatologists considered communication strategies to maximize placebo and reduce nocebo effects and expressed motivation to be trained to implement these strategies in everyday clinical practice.

The role of brain white matter in depression resilience and response to sleep interventions

Insomnia poses a high risk for depression. Brain mechanisms of sleep and mood improvement following cognitive behavioural therapy for insomnia remain elusive. This longitudinal study evaluated whether (i) individual differences in baseline brain white matter microstructure predict improvements and (ii) intervention affects brain white matter microstructure. People meeting the Diagnostic and Statistical Manual of Mental Disorders-5 criteria for Insomnia Disorder (n = 117) participated in a randomized controlled trial comparing 6 weeks of no treatment with therapist-guided digital cognitive behavioural therapy for insomnia, circadian rhythm support or their combination (cognitive behavioural therapy for insomnia + circadian rhythm support). Insomnia Severity Index and Inventory of Depressive Symptomatology-Self Report were assessed at baseline and followed up at Weeks 7, 26, 39 and 52. Diffusion-weighted magnetic resonance images were acquired at baseline and Week 7. Skeletonized white matter tracts, fractional anisotropy and mean diffusivity were quantified both tract-wise and voxel-wise using tract-based spatial statistics. Analyses used linear and mixed effect models while correcting for multiple testing using false discovery rate and Bonferroni for correlated endpoint measures. Our results show the following: (i) tract-wise lower fractional anisotropy in the left retrolenticular part of the internal capsule at baseline predicted both worse progression of depressive symptoms in untreated participants and more improvement in treated participants (fractional anisotropy × any intervention, PFDR = 0.053, Pcorr = 0.045). (ii) Only the cognitive behavioural therapy for insomnia + circadian rhythm support intervention induced a trend-level mean diffusivity decrease in the right superior corona radiata (PFDR = 0.128, Pcorr = 0.108), and individuals with a stronger mean diffusivity decrease showed a stronger alleviation of insomnia (R = 0.20, P = 0.035). In summary, individual differences in risk and treatment-supported resilience of depression involve white matter microstructure. Future studies could target the role of the left retrolenticular part of the internal capsule and right superior corona radiata and the brain areas they connect.

[Randomized clinical trial of compression therapy of the lower legs in patients with psoriasis]

BACKGROUND

Psoriatic plaques at the distal lower extremities are notoriously treatment resistant. Medical compression therapy could potentially be a useful supplementary therapeutic measure at this site. However, there is concern that the Koebner phenomenon may cause a worsening of the skin condition. Therefore, the purpose of this study was to investigate the effects of compression therapy on psoriatic plaques in the presence of coexisting edema of the lower legs.

PATIENTS AND METHODS

Compression therapy was performed in addition to standard of care on one lower leg for 4 weeks (half-side test) in patients with psoriatic plaques and edema on both lower legs. The primary endpoint of the study was clinical response of the psoriatic plaques on the lower legs measured with the lesion severity score (LSS) and the locally affected body surface area in a side-by-side comparison at week 4 compared with baseline. Secondary endpoints were related to patient-reported outcomes.

RESULTS

Data from 30 patients were included in the analysis. In the descriptive analysis, the mean LSS results and the subjective pain reported by the patients showed a slightly greater improvement on the compressed lower leg compared with the non-compressed lower leg. None of the patients showed evidence of the Koebner phenomenon induced by compression therapy.

CONCLUSION

This is the first clinical study that systematically investigated the impact of compression therapy on psoriatic plaques. During the study period of 4 weeks, there was no significant improvement in psoriatic plaques; however, there was also no evidence of worsening of the skin condition. Thus, anti-edematous compression therapy can be performed in psoriasis patients without causing complications if basic contraindications are considered.

COVID-19 vaccination in psoriasis patients receiving systemic treatment: A prospective single-center study

Background

The rate of seroconversion after COVID-19 vaccination in patients with moderate to severe psoriasis requiring systemic treatment is poorly understood.

Objectives

The aim of this prospective single-center cohort study performed between May 2020 and October 2021 was to determine the rate of seroconversion after COVID-19 vaccination in patients under active systemic treatment for moderate to severe psoriasis.

Methods

Inclusion criteria were systemic treatment for moderate to severe psoriasis, known COVID-19 vaccination status, and repetitive anti-SARS-CoV-2-S IgG serum quantification. The primary outcome was the rate of anti-SARS-CoV-2-S IgG seroconversion after complete COVID-19 vaccination.

Results

77 patients with a median age of 55.9 years undergoing systemic treatment for moderate to severe psoriasis were included. The majority of patients received interleukin- (n=50, 64.9%) or tumor necrosis factor (TNF)-α inhibitors (n=16, 20.8%) as systemic treatment for psoriasis; nine patients (11.7%) were treated with methotrexate (MTX) monotherapy, and one patient each received dimethyl fumarate (1.3%), respectively apremilast (1.3%). All included patients completed COVID-19 vaccination with two doses over the course of the study. Serum testing revealed that 74 patients (96.1%) showed an anti-SARS-CoV-2-S IgG seroconversion. While all patients on IL-17A, -12 or -12/23 inhibitors (n=50) achieved seroconversion, three of 16 patients (18.8%) receiving MTX and/or a TNF-α inhibitor as main anti-psoriatic treatment did not. At follow-up, none of the patients had developed symptomatic COVID-19 or died from COVID-19.

Conclusions

Anti-SARS-CoV-2-S IgG seroconversion rates following COVID-19 vaccination in psoriasis patients under systemic treatment were high. An impaired serological response, however, was observed in patients receiving MTX and/or TNF-α inhibitors, in particular infliximab.

Common Fundamentals of Psoriasis and Depression

Psoriasis is an inflammatory, immune-mediated disease that is frequently associated with psychological comorbidities such as depression. The stigma patients feel because of the appearance of their skin may contribute to the high psycho-social burden of psoriasis. However, there is emerging evidence that overlapping biological mechanisms are, to a substantial degree, responsible for the close interaction between psoriasis and depression. Increased proinflammatory mediators, such as C-reactive protein or interleukin-6, are present in both psoriasis and depression, indicating that inflammation may represent a pathophysiological link between the diseases. Anti-inflammatory biologic therapies treat the clinical manifestations of psoriasis, but might also play a significant role in reducing associated depressive symptoms in patients with psoriasis. Comparison between single studies focusing on the change in depressive symptoms in psoriasis is limited by inconsistency in the depression screening tools applied.

A brief screening tool for depression in psoriasis patients: The Two Questions Test in clinical practice

Patients suffering from chronic inflammatory diseases such as psoriasis are prone to develop depressive symptoms. However, within the time constraints of dermatological clinics, depressive symptoms in psoriasis patients are often overlooked and thus underdiagnosed. The Two Questions Test may serve as a quick screening tool for an initial assessment of depressive burden in these patients. We evaluated its usefulness in the clinical context analyzing the records of patients starting systemic treatment for psoriasis with a selective interleukin (IL)23- or IL17A-inhibitor. In a total sample of N = 139 patients, baseline Two Questions Test scores were analyzed together with measures of psoriatic and psychiatric symptoms. In addition, the development of the Two Questions Test scores over the course of the first 28 weeks of treatment was assessed. No association was found between the Two Questions Test scores and skin symptoms measured by the Psoriasis Area and Severity Index and the visibility of skin lesions. However, skin related quality of life analyzed with the Dermatology Life Quality Index was associated with the Two Questions Test scores. In addition, the longitudinal analysis revealed improvement in Two Questions Test outcomes over the course of patients' treatment. These results indicate the Two Questions Test's usefulness both as an initial screening tool of depressive symptoms, as well as in its use as a sensitive tool for the repeated assessment of depressive symptoms in psoriasis patients.

[The effect of treatment expectations on pruritus and skin pain]

Hintergrund

Patientenerwartungen in Bezug auf den Nutzen einer medizinischen Behandlung stellen eine wichtige Determinante für die Placeboantwort dar. Sie können Entwicklung und Verlauf von Erkrankungen sowie Wirksamkeit und Verträglichkeit von Therapien maßgeblich beeinflussen. Die Mechanismen, die diese Placebo- und Noceboeffekte vermitteln, wurden bislang am besten auf dem Gebiet der Placeboanalgesie beschrieben. Aber auch in der Dermatologie findet sich eine zunehmende Evidenz dafür, dass verschiedene Symptome wie Schmerzen an der Haut und Pruritus (Jucken) sowie verschiedene dermatologische Erkrankungen durch die Behandlungserwartungen von Patienten moduliert werden können.

Ziel der Arbeit

Das Ziel dieser Arbeit ist die Darstellung der aktuellen Datenlage in Bezug auf den Einfluss von Erwartungseffekten auf dermatologische Symptome wie Pruritus und Hautschmerzen sowie auf verschiedene dermatologische Erkrankungen. Schließlich soll die Bedeutung dieses Themas für Ärzte, die Patienten mit Hautsymptomen behandeln, vermittelt werden.

Material und Methoden

Es handelt sich um eine narrative Übersichtsarbeit.

Ergebnisse und Diskussion

Eine zunehmende Anzahl von Studien an gesunden Probanden und dermatologischen Patienten zeigt, dass Hautsymptome wie Pruritus und Schmerzen durch die Induktion positiver Erwartungen verringert und durch die Induktion negativer Erwartungen verstärkt werden können. Vorherige Behandlungserfahrungen der Patienten sowie die Qualität und Quantität der Arzt-Patienten-Kommunikation spielen für die Induktion der Behandlungserwartung eine zentrale Rolle.

Schlussfolgerung

Techniken, die darauf abzielen, positive Erwartungseffekte von Patienten mit Hautsymptomen zu maximieren und negative zu minimieren, sollten in die klinische Routine implementiert werden.

Expectation-induced enhancement of pain, itch and quality of life in psoriasis patients: study protocol of a randomised controlled trial

INTRODUCTION

Experimental and clinical data demonstrate that skin diseases like psoriasis are affected by psychological factors and can be modulated by interventions other than conventional drug therapy. The expectation of patients towards the benefit of a forthcoming treatment as well as treatment pre-experiences have been demonstrated as crucial factors mediating placebo responses in inflammatory skin diseases. However, it is unknown whether and to what extent treatment outcomes of psoriasis patients under therapy with monoclonal antibodies like secukinumab can be experimentally modulated at subjective and physiological levels by modifying the expectation of patients via verbal instruction or prior experience.

METHODS AND ANALYSIS

Treatment expectations will be modulated in patients with moderate-to-severe psoriasis undergoing treatment with the anti-interleukin-17A monoclonal antibody secukinumab. Patients with a Psoriasis Area and Severity Index (PASI) >12 will be randomly allocated to one of three groups (N=40 each). As a standard schedule, patients in the pharmacological control group (group 1) will be treated weekly with 300 mg secukinumab, while patients in groups 2 and 3 will receive only 75 mg secukinumab (75% dose reduction) during all treatment weeks. In addition to the injections, patients in group 3 will ingest a novel tasting drink, with a cover story explaining that previous studies showed additional beneficial effects of this combination (drug and drink). Patients will be assessed and treated at nine visits over a 16-week period, during which the severity of pain and itch symptoms, skin lesions and quality of life will be analysed with standardised questionnaires and the PASI.

ETHICS AND DISSEMINATION

This study was approved by the Ethics committee of the Medical Faculty of the University Duisburg-Essen. Study outcomes will be published in peer-reviewed scientific journals.

Individual differences in crowding predict visual search performance

Visual search is an integral part of human behavior and has proven important to understanding mechanisms of perception, attention, memory, and oculomotor control. Thus far, the dominant theoretical framework posits that search is mainly limited by covert attentional mechanisms, comprising a central bottleneck in visual processing. A different class of theories seeks the cause in the inherent limitations of peripheral vision, with search being constrained by what is known as the functional viewing field (FVF). One of the major factors limiting peripheral vision, and thus the FVF, is crowding. We adopted an individual differences approach to test the prediction from FVF theories that visual search performance is determined by the efficacy of peripheral vision, in particular crowding. Forty-four participants were assessed with regard to their sensitivity to crowding (as measured by critical spacing) and their search efficiency (as indicated by manual responses and eye movements). This revealed substantial correlations between the two tasks, as stronger susceptibility to crowding was predictive of slower search, more eye movements, and longer fixation durations. Our results support FVF theories in showing that peripheral vision is an important determinant of visual search efficiency.