Australian consensus: Treatment goals for moderate to severe psoriasis in the era of targeted therapies - Adult patients.

BACKGROUND: Over the last decade, the treatment landscape for moderate-severe psoriasis has rapidly evolved. The Australasian College of Dermatologists sought to review and update previously published treatment goals for moderate-severe psoriasis. METHODS: A modified Delphi approach was used. Comprehensive literature review and guideline evaluation resulted in the development of statements and other questions to establish current clinical practices. Two rounds of anonymous voting were undertaken, with a collaborative meeting held in between to discuss areas of discordance. Overall, consensus was defined as achievement of ≥75% agreement in the range 7-9 on a 9-point scale (1 strongly disagree; 9 strongly agree). RESULTS: Consensus was achieved on 26/29 statements in round 1 and a further 20 statements in round 2. There was strong agreement to expanding the classification/definition of psoriasis severity by including a choice of metrics, incorporating quality of life measures, and widening the scope of high-impact sites. Consensus was also reached on revised treatment response criteria, which were then incorporated into a new treatment algorithm. There was discordance with the current requirement to undertake a trial with established systemic agents before accessing targeted therapy. CONCLUSION: The ability of new targeted treatment options to change the narrative in psoriasis patient care can only be properly realised if challenges to timely and equitable access are addressed. The proposed framework for the assessment, classification and management of moderate-severe psoriasis aligns with international recommendations. Its adoption into Australian clinical practice is hoped to improve treatment outcomes and patients' satisfaction with their care.

Dermatological services; patient profiling in a rural tertiary hospital.

BACKGROUND/OBJECTIVES: There is a paucity of research available regarding the epidemiology of patients attending dermatology outpatient services in Australia. Our objective was to analyse who was attending public dermatology outpatient clinics in a Northern Territory tertiary hospital, with a particular focus on Indigenous and rural patients. METHODS: This is a retrospective cohort study of patients who attended dermatology outpatient clinics between 1 January 2016 and 31 December 2016. Outcome measures included patient demographics (age, gender, ethnicity and postcode) and referrer details. RESULTS: Over the 12 month study period, 923 appointments were scheduled for 500 patients. Of the appointments scheduled, 667 were attended. Twelve per cent of patients were Indigenous, and of the total appointment attendances, 10% were by Indigenous patients. Of the 923 appointments, 28% were not attended, with a higher non-attendance rate for Indigenous patients at 36%. The majority of patients seen were adults, for both groups, but a larger proportion of Indigenous children were seen. Nine per cent of patients with a recorded address were from a remote region. CONCLUSION: Dermatology outpatient services are likely under-utilised by Indigenous, and remote patients. If we are to improve skin health in Australia, barriers such as limited access to dermatological services in remote regions must be addressed.

Molecular diagnosis of scabies using a novel probe-based polymerase chain reaction assay targeting high-copy number repetitive sequences in the Sarcoptes scabiei genome.

BACKGROUND: The suboptimal sensitivity and specificity of available diagnostic methods for scabies hampers clinical management, trials of new therapies and epidemiologic studies. Additionally, parasitologic diagnosis by microscopic examination of skin scrapings requires sample collection with a sharp scalpel blade, causing discomfort to patients and difficulty in children. Polymerase chain reaction (PCR)-based diagnostic assays, combined with non-invasive sampling methods, represent an attractive approach. In this study, we aimed to develop a real-time probe-based PCR test for scabies, test a non-invasive sampling method and evaluate its diagnostic performance in two clinical settings. METHODOLOGY/PRINCIPAL FINDINGS: High copy-number repetitive DNA elements were identified in draft Sarcoptes scabiei genome sequences and used as assay targets for diagnostic PCR. Two suitable repetitive DNA sequences, a 375 base pair microsatellite (SSR5) and a 606 base pair long tandem repeat (SSR6), were identified. Diagnostic sensitivity and specificity were tested using relevant positive and negative control materials and compared to a published assay targeting the mitochondrial cox1 gene. Both assays were positive at a 1:100 dilution of DNA from a single mite; no amplification was observed in DNA from samples from 19 patients with other skin conditions nor from house dust, sheep or dog mites, head and body lice or from six common skin bacterial and fungal species. Moderate sensitivity of the assays was achieved in a pilot study, detecting 5/7 (71.4% [95% CI: 29.0% - 96.3%]) of clinically diagnosed untreated scabies patients). Greater sensitivity was observed in samples collected by FLOQ swabs compared to skin scrapings. CONCLUSIONS/SIGNIFICANCE: This newly developed qPCR assay, combined with the use of an alternative non-invasive swab sampling technique offers the possibility of enhanced diagnosis of scabies. Further studies will be required to better define the diagnostic performance of these tests.

Overdiagnosis of scabies and overprescribing of scabies treatment in a scabies-endemic region.

OBJECTIVE: To assess the objective evidence upon which diagnosis of scabies and subsequent prescription of permethrin cream or oral ivermectin is based at a tertiary referral hospital in the Northern Territory. DESIGN, SETTING AND PARTICIPANTS: A retrospective cohort study of inpatients who were prescribed permethrin or ivermectin between July and September 2017 at a single tertiary referral hospital. Eighty-eight inpatient admissions, belonging to 77 unique patients, were included. This list was generated with the hospital's electronic prescribing software. MAIN OUTCOME MEASURES: Age, ethnicity, skin diagnosis on admission, which anti-scabies medications were prescribed, which concurrent medications were prescribed to treat a rash or pruritus, which differential or concurrent skin diagnoses were made, whether the dermatology department had seen the patient during their admission, and what evidence was documented as reason for diagnosis of scabies. RESULTS: In the cases in which scabies treatment was prescribed, less than one quarter had positive skin scrapings for scabies, and few had documentation of burrows, and documentation of a contact history combined with clinical lesions. Most cases met none of these diagnostic criteria. Very few were reviewed by the dermatology department as an inpatient. CONCLUSIONS: There were likely high rates of diagnostic uncertainty among the cases in which scabies treatment was prescribed. It is possible that anti-scabies medications are being prescribed empirically in this hospital.

A casemix study of patients seen by a dermatology trainee in rural and urban outpatient settings.

BACKGROUND/OBJECTIVES: For 8 years South Australian dermatologists have provided an outreach service to the Northern Territory (NT), including rural and remote areas. In 2012 and 2013, a trainee accompanied a dermatologist on these outreach visits. This is the first prospective study that documents the spectrum of dermatological diseases requiring outpatient specialist input in various settings in the NT, and also the first study to compare the clinical experience of one Australian dermatology trainee in urban and rural settings. MATERIALS AND METHODS: Characteristics of patients managed primarily by the outreach dermatology registrar were recorded prospectively from February 2013 to July 2013. The data from the trainee's urban encounters were compared to that of the rural centres. The spectrum of conditions seen in these two settings was placed in the disease categories specified in the Australasian College of Dermatologists (ACD) curriculum. RESULTS: The Royal Adelaide Hospital outpatient experience provided greater exposure to skin neoplasms, lymphoproliferative and myeloproliferative disorders and non-infectious neutrophilic/eosinophilic disorders. The outreach sites provided greater exposure to infections, adnexal diseases and genodermatoses. Both urban and rural experiences provided a broad exposure to the disease categories outlined in the ACD curriculum. CONCLUSIONS: The spectrum of disease requiring specialist dermatology input varies between urban South Australia and rural NT. The inclusion of dermatology trainees in outreach visits broadens their clinical exposure. It is recommended that other dermatology service providers in Australia consider documenting clinical casemix comparisons to assess dermatology demand, outcomes and trainee exposure.

Concurrent pyoderma gangrenosum and infection with Scedosporium apiospermum.

We present a patient with pyoderma gangrenosum (PG) following hip surgery, who developed an exacerbation of her ulceration in conjunction with new areas on her lower limbs. Clinically, features of PG and deep fungal infection were apparent. Scedosporium apiospermum was isolated from the ulcers.

Heavy metal (monoclonal) bands: a link between cutaneous T-cell lymphoma and contact allergy to potassium dichromate, nickel and cobalt?

It has been proposed that chronic antigenic stimulation plays a role in the pathogenesis of cutaneous T-cell lymphoma (CTCL). By definition, antigenic stimulation triggers allergic contact dermatitis (ACD). It is therefore plausible that chronic ACD could serve as a precursor to CTCL. We report two cases of contact allergy to potassium dichromate, nickel and cobalt, where CTCL was diagnosed in one patient, and a diagnosis of CTCL is imminent in the other. We also review the literature on the diagnostic criteria for CTCL in the setting of ACD and explore potential mechanisms for the progression from ACD tos CTCL.