RESUMO
This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.
Assuntos
Urticária/diagnóstico , Urticária/terapia , Gerenciamento Clínico , Europa (Continente) , Necessidades e Demandas de Serviços de Saúde , Humanos , Pesquisa , Urticária/etiologiaAssuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Fármacos Dermatológicos/uso terapêutico , Guias de Prática Clínica como Assunto , Psoríase/tratamento farmacológico , Talidomida/análogos & derivados , Anti-Inflamatórios não Esteroides/efeitos adversos , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais Humanizados , Conferências de Consenso como Assunto , Fármacos Dermatológicos/efeitos adversos , Humanos , Literatura de Revisão como Assunto , Talidomida/efeitos adversos , Talidomida/uso terapêuticoAssuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Fármacos Dermatológicos/uso terapêutico , Psoríase/tratamento farmacológico , Talidomida/análogos & derivados , Anti-Inflamatórios não Esteroides/efeitos adversos , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais Humanizados , Fármacos Dermatológicos/efeitos adversos , Humanos , Talidomida/efeitos adversos , Talidomida/uso terapêuticoRESUMO
People with chronic plaque psoriasis often have lesions on the scalp that are difficult to treat. This report is a summary of a Cochrane review on the efficacy and safety of topical treatments for scalp psoriasis. For quality-of-evidence assessment, we used the Grading of Recommendations Assessment, Development and Evaluation Working Group approach. Only randomized controlled trials (RCTs) were eligible for inclusion. We searched the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS; ongoing trials; indexes of included studies and screened abstracts of six psoriasis-specific conferences up to August 2015. We included 59 RCTs, with 11 561 participants overall. Most findings were limited to short-term treatments (< 6 months). According to the clinician and patients' self-assessment, a corticosteroid-vitamin D combination (e.g. betamethasone dipropionate plus calcipotriol) and corticosteroids of high and very high potency were better than vitamin D. The two-compound combination was superior to the corticosteroid alone, but the additional benefit was small. Reporting of quality-of-life data was insufficient. The two-compound combination and corticosteroids caused fewer withdrawals due to adverse events than vitamin D. There was no difference between the two-compound combination and corticosteroid monotherapy concerning this outcome. Overall the evidence was of moderate quality. Evaluation of other topical treatments was limited. Given the comparable safety profile and only slim benefit of the two-compound combination over the corticosteroid alone, monotherapy with generic topical corticosteroids of high and very high potency may be fully acceptable for short-term therapy. More quality-of-life data and long-term assessments are needed.
Assuntos
Fármacos Dermatológicos/administração & dosagem , Psoríase/tratamento farmacológico , Dermatoses do Couro Cabeludo/tratamento farmacológico , Administração Cutânea , Corticosteroides/administração & dosagem , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Vitamina D/administração & dosagemRESUMO
Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction in the incidence of postherpetic neuralgia (PHN) and other complications. The guideline development followed a structured and pre-defined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence-Based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this second part of the guideline, therapeutic interventions have been evaluated. The expert panel formally consented recommendations for the treatment of patients with HZ (antiviral medication, pain management, local therapy), considering various clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.
Assuntos
Antivirais/uso terapêutico , Herpes Zoster/tratamento farmacológico , 2-Aminopurina/análogos & derivados , 2-Aminopurina/uso terapêutico , Aciclovir/uso terapêutico , Analgésicos/uso terapêutico , Criança , Europa (Continente) , Famciclovir , Feminino , Herpes Zoster/fisiopatologia , Herpes Zoster Oftálmico/tratamento farmacológico , Humanos , Manejo da Dor/métodos , Medição da Dor , Gravidez , Complicações na Gravidez/tratamento farmacológico , Qualidade de Vida , Sociedades MédicasRESUMO
Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction of the incidence of postherpetic neuralgia and other complications. The guideline development followed a structured and predefined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this first part of the guideline, diagnostic means have been evaluated. The expert panel formally consented recommendations for the management of patients with (suspected) HZ, referring to the assessment of HZ patients, considering various specific clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.
Assuntos
Herpes Zoster , Humanos , Anticorpos Antivirais/análise , Anticorpos Antivirais/genética , Antígenos Virais/análise , Antígenos Virais/genética , Linhagem Celular , Europa (Continente) , Herpes Zoster/diagnóstico , Herpes Zoster/fisiopatologia , Herpesvirus Humano 3/genética , Herpesvirus Humano 3/imunologia , Reação em Cadeia da Polimerase , Fatores de Risco , Sensibilidade e Especificidade , Sociedades MédicasRESUMO
Guidelines are systematically developed decision aids for specific medical conditions. The German Dermatological Society, together with the German Professional Association of Dermatologists, takes the lead in the development of the guidelines for dermatology in Germany. In addition to national guidelines, European and international guidelines also exist. In 2014 and 2015 German guidelines on the following topics were newly developed or updated: cutaneous larva migrans, anticoagulation during dermatosurgery, pemphigus vulgaris and bullous pemphigoids, Mohs surgery, anal dysplasia, and anal carcinoma in HIV-infected patients. European guidelines on psoriasis vulgaris and hand eczema were updated among others. An international guideline on actinic keratosis was also published. The guidelines are available at www.awmf.org and www.euroderm.org .
Assuntos
Fármacos Dermatológicos/uso terapêutico , Procedimentos Cirúrgicos Dermatológicos/normas , Dermatologia/normas , Guias de Prática Clínica como Assunto , Dermatopatias/diagnóstico , Dermatopatias/terapia , Fármacos Dermatológicos/normas , Europa (Continente) , Medicina Baseada em Evidências , Alemanha , HumanosRESUMO
Clinical practice guidelines are systematically developed tools to assist clinicians and health policy makers in decision making for clearly defined clinical situations. In the light of the demand for evidence-based medicine and quality in health care and the increasing methodological requirements concerning guidelines development, it is important to evaluate existing practice guidelines to systematically identify strengths and weaknesses. Currently, the most accepted tool for the methodological evaluation of guidelines is the Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. Intention of this assessment is to identify and critically appraise clinical practice guidelines commissioned by the European Dermatology Forum (EDF). A quality assessment of a predefined set of guidelines, including all available clinical practice guidelines published on the EDF guidelines internet site, was performed using the AGREE II instrument. To assure an objective assessment, four independent assessments were performed by evaluators situated in different European countries. Twenty-five EDF guidelines covering different dermatological topics were identified and evaluated. The assessment included seven guidelines developed on the highest methodological standard (systematic literature search and structured consensus conference, S3). Eighteen guidelines were identified that were based on either a structured consensus process (S2k), a systematic literature assessment (S2e) or on informal consensus only (S1). The methodological and reporting quality among the evaluated guidelines was heterogeneous. S3 guidelines generally received the highest scores. The domains 'clarity of presentation' and 'scope and purpose' achieved the highest mean ratings within the different domains of assessment, whereas the domains of 'applicability', 'stakeholder involvement' and 'editorial independence' scored poorly. Considering the large variations in the achieved scores, there is need for methodological harmonization within the EDF guidelines to achieve comparable methodological standards.
Assuntos
Consenso , Dermatologia/normas , Guias de Prática Clínica como Assunto , Dermatopatias/terapia , Europa (Continente) , HumanosRESUMO
BACKGROUND: Actinic keratosis (AK) is a frequent health condition attributable to chronic exposure to ultraviolet radiation. Several treatment options are available and evidence based guidelines are missing. OBJECTIVES: The goal of these evidence- and consensus-based guidelines was the development of treatment recommendations appropriate for different subgroups of patients presenting with AK. A secondary aim of these guidelines was the implementation of knowledge relating to the clinical background of AK, including consensus-based recommendations for the histopathological definition, diagnosis and the assessment of patients. METHODS: The guidelines development followed a pre-defined and structured process. For the underlying systematic literature review of interventions for AK, the methodology suggested by the Cochrane Handbook for Systematic Reviews of Interventions, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was adapted. All recommendations were consented during a consensus conference using a formal consensus methodology. Strength of recommendations was expressed based on the GRADE approach. If expert opinion without external evidence was incorporated into the reasoning for making a certain recommendation, the rationale was provided. The Guidelines underwent open public review and approval by the commissioning societies.RESULTS: Various interventions for the treatment of AK have been assessed for their efficacy. The consenting procedure led to a treatment algorithm as shown in the guidelines document. Based on expert consensus, the present guidelines present recommendations on the classification of patients, diagnosis and histopathological definition of AK. Details on the methods and results of the systematic literature review and guideline development process have been published separately. CONCLUSIONS: International guidelines are intended to be adapted to national or regional circumstances (regulatory approval, availability and reimbursement of treatments).(AU)
Assuntos
Humanos , Ceratose Actínica/terapia , Raios Ultravioleta/efeitos adversos , Terapia CombinadaAssuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Imunossupressores/uso terapêutico , Psoríase/tratamento farmacológico , Acitretina/uso terapêutico , Adalimumab/uso terapêutico , Ciclosporina/uso terapêutico , Quimioterapia Combinada , Etanercepte/uso terapêutico , Fumaratos/uso terapêutico , Humanos , Ceratolíticos/uso terapêutico , Metotrexato/uso terapêutico , Ustekinumab/uso terapêuticoRESUMO
BACKGROUND: Actinic keratosis (AK) is a frequent health condition attributable to chronic exposure to ultraviolet radiation. Several treatment options are available and evidence based guidelines are missing. OBJECTIVES: The goal of these evidence- and consensus-based guidelines was the development of treatment recommendations appropriate for different subgroups of patients presenting with AK. A secondary aim of these guidelines was the implementation of knowledge relating to the clinical background of AK, including consensus-based recommendations for the histopathological definition, diagnosis and the assessment of patients. METHODS: The guidelines development followed a pre-defined and structured process. For the underlying systematic literature review of interventions for AK, the methodology suggested by the Cochrane Handbook for Systematic Reviews of Interventions, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was adapted. All recommendations were consented during a consensus conference using a formal consensus methodology. Strength of recommendations was expressed based on the GRADE approach. If expert opinion without external evidence was incorporated into the reasoning for making a certain recommendation, the rationale was provided. The Guidelines underwent open public review and approval by the commissioning societies. RESULTS: Various interventions for the treatment of AK have been assessed for their efficacy. The consenting procedure led to a treatment algorithm as shown in the guidelines document. Based on expert consensus, the present guidelines present recommendations on the classification of patients, diagnosis and histopathological definition of AK. Details on the methods and results of the systematic literature review and guideline development process have been published separately. CONCLUSIONS: International guidelines are intended to be adapted to national or regional circumstances (regulatory approval, availability and reimbursement of treatments).
Assuntos
Ceratose Actínica/terapia , Terapia Combinada , Medicina Baseada em Evidências , Humanos , Ceratose Actínica/diagnóstico , Ceratose Actínica/etiologiaAssuntos
Antineoplásicos/uso terapêutico , Crioterapia , Inibidores de Ciclo-Oxigenase/uso terapêutico , Ceratose Actínica/terapia , Terapia a Laser , Fotoquimioterapia , Aminoquinolinas/uso terapêutico , Terapia Combinada , Curetagem , Diclofenaco/uso terapêutico , Diterpenos/uso terapêutico , Medicina Baseada em Evidências , Fluoruracila/uso terapêutico , Humanos , Imiquimode , Ceratose Actínica/diagnóstico , Ceratose Actínica/etiologia , Lasers de Gás/uso terapêuticoRESUMO
As a chronic disease psoriasis often requires long-term treatment. Successful continuation of therapy during a maintenance phase is therefore important. A systematic review was performed on the efficacy of psoriasis drugs during maintenance treatment in patients who had achieved sufficient treatment success during the induction period. Maintenance therapy is defined as treatment during the period after successful induction therapy. Inclusion criteria were prospective studies with systemic therapies recommended by the 2009 European psoriasis guidelines (plus ustekinumab), and a study population that had achieved a defined treatment response criterion after induction therapy within a period of ≥ 6 months. Maintenance studies on conventional treatments were identified for ciclosporin (CSA) only (no studies investigating acitretin, methotrexate or ustekinumab were found). Compared with placebo, CSA was shown to be effective in maintenance therapy, yet CSA 1·5 mg kg(-1) seems to be insufficient to maintain disease control. Based on the evidence, it is uncertain whether there is any difference between daily or intermittent treatment. For biologics, maintenance data were available for adalimumab, etanercept and infliximab. No differences in 75% improvement in Psoriasis Area and Severity Index (PASI 75) response were identified between adalimumab 40 mg once and twice a month. Continuous infliximab treatment was shown to be superior to as-needed treatment. For etanercept, only observational postrandomized controlled trial data were available, indicating a maintained PASI 75 response in approximately three-quarters of patients during long-term treatment. Only limited evidence is available for a conclusion on how patients with an adequate response should be optimally treated during the maintenance period. A clear ranking of the available treatments is not yet possible.
Assuntos
Anti-Inflamatórios/administração & dosagem , Fármacos Dermatológicos/administração & dosagem , Imunossupressores/administração & dosagem , Psoríase/tratamento farmacológico , Adulto , Relação Dose-Resposta a Droga , Esquema de Medicação , Quimioterapia Combinada , Humanos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Background Management of anticoagulation and anti-platelet drugs during cutaneous surgery is still a challenge for many dermatologists and standards of care with respect to stopping, continuing or bridging vary widely. Methods We performed a systematic review (Medline, Cochrane Library, until August 27th, 2013) of studies assessing the risk of complications due to anticoagulation during cutaneous surgery. Primary outcomes were mild-moderate and severe postsurgical bleeding. The secondary outcomes were excessive and uncontrollable intraoperative bleeding and other postsurgical complications as wound dehiscence, erythema, wound infection. Results 1.287 publications were identified and 10 studies were included into the review. The frequencies of bleeding in the control groups in general were low (about 1%). In patients on aspirin, increased risks were seen neither with respect to mild-moderate postoperative bleeding (RR 1.1, CI 0.5-2.3), nor with respect to severe bleeding (RR 0.9, CI 0.2-4.6). The studies with patients on warfarin showed a risk for mild-moderate bleeding that was three times as high as in controls (RR 3.2, CI 1.4-7.1) and for severe bleeding that was 15 times higher (RR 14.8, CI 2.7-80.4). In general the study sizes were small and the methodological quality low. Conclusion The risk of bleeding due to a medication with aspirin seems to be negligible. With warfarin, the risk is increased; an exact estimate of the risk increase is difficult to give, because of the lack of sufficient high quality studies. A two-fold increase appears likely, the 15-fold increase is most likely due to statistical reasons arising from the rareness of the event in the small number of included patients. Stopping, bridging or continuing a medication should always be an individual decision. In accordance with guidelines from internal medicine for most patients it will be recommendable to continue with the medication.