TRASS: a global approach to assess the severity of truncal acne.

INTRODUCTION: Only a small amount of published data regarding truncal acne is available, and no proper tool to assess its severity exists. AIM: The aim of the study was to provide dermatologists with an easy-to-use tool to assess truncal acne (TRASS, truncal acne severity scale) using a global approach. METHODS: A scoring tool that assesses the severity of acne (based on GEA and ECLA scales) on the trunk using a global approach was built, including three sub-scores: family history, clinical signs and quality of life (QoL). In order to test TRASS, the experts used photographs of 47 patients attending their clinics with truncal acne. The regression optimized (ROP) model was applied to assess the diagnosis performance of TRASS and to identify items contributing to the classification of the patients. Internal testing was made to demonstrate the robustness of the model. Correlation analyses between the different items were performed to evaluate the interaction between the different items and their impact on the severity grading of truncal acne. RESULTS: Patients with the most severe acne were identified by TRASS. The error level was 6.6% after internal validation and 10.4% when using the median value or the centile 75th (6.6% and 10.4%). Correlation was significant between systemic treatment and scars (P = 0.0025) and nodules (P = 0.01988) and between location and QoL (P = 0.0095). CONCLUSION: Truncal acne severity scale is the first global, patient-centred approach to evaluate truncal acne by scoring the importance of each factor independently from its clinical severity. TRASS may allow the practitioner to choose and validate the most suitable therapy together with the patient in order to treat his or her truncal acne successfully and to limit treatment failure.

Acne from the young patient's perspective.

Acne may significantly impact quality of life, self-esteem and self-worth. The aim of this paper was to provide an overview of the knowledge and perception of acne and its risk factors in adolescents and young adults. The most critical issues reported for an optimal management of this specific population were identified. A PubMed literature review of results from patient-oriented surveys published between 2007 and 2018 was conducted. Two different types of survey were used: those using either validated questionnaires or specifically developed questionnaires. No consistency or directly comparable data with regards to age, onset, duration, severity and treatment of acne and by whom and where data were collected were observed. Acne affected female patients psychologically more than male patients. The majority referred to their treating physician in order to obtain information, and all surveys pointed out that specific treatment programs would allow to increase awareness about acne. Beliefs, traditions and economic factors continue to impact the perception of and treatment choices for acne in almost all countries and cultures, maintaining the improvement of awareness about acne a major global health challenge. In conclusion, identifying, considering and managing the patient's concerns about acne may improve the young patient's well-being and thus decrease additional healthcare expenses for emerging psychological comorbidities. This can be achieved by creating substantial and structured awareness through local and global information campaigns via the treating physicians, Internet, social networks and education.

Truncal acne, what do we know?

Truncal acne is frequently overlooked in dermatological practice, even though it may result in scars and impact on self-esteem and body image. Therefore, it is important to identify the disease early in order to initiate treatment in time and, thus, to prevent it from worsening and resulting in physical and psychological sequelae. The aim of this review is to provide an overview of what is currently known about truncal acne, its prevalence, aetiology and physiopathology, how its severity is currently evaluated, how to differentiate it from other skin afflictions and current treatment options. A review of literature considering the issue of truncal acne published up to 2019 and available from PubMed was conducted, and in total, 76 articles were selected from PubMed. Currently, only little information about truncal acne is available. Considered as having the same pathophysiology as facial acne, the clinical picture and treatment response seem to differ. Specific acne severity grading systems and quality of life questionnaires as well as a specific treatment algorithm are still lacking. Filling this gap should allow clinicians to assess truncal acne in the best possible way, choosing suitable treatment options, helping patients to improve treatment adherence and quality of life and finally allowing a better management of truncal acne. In conclusion, more knowledge is required to treat more efficiently truncal acne.

Acne and nutrition: hypotheses, myths and facts.

Acne is an inflammatory and multifactorial skin disease. Different external and internal factors, including air pollution, aggressive skincare products, medication, mechanical, hormonal and familial factors and, more recently, lifestyle and stress, have been suggested as having an impact on acne. Moreover, for many years nutrition was believed to cause or worsen acne. Over the last decades, however, it has become a dermatological doctrine that there is no direct association between diet and acne. Even if recent research has allowed to identify certain nutritional elements and behaviour that may impact on acne, including the excessive intake of dairy products and hyperglycaemic food, modern lifestyle nutrition, obesity and eating disorders, knowledge about the role of nutrition in the physiopathology of acne still remains sparse and hypotheses and myths continue to dominate the debate. Thus, further clinical and translational research is necessary to investigate and confirm the association between nutrition and acne.

Management of actinic keratosis at specific body sites in patients at high risk of carcinoma lesions: expert consensus from the AKTeam™ of expert clinicians.

Actinic keratoses (AK) arise on sun-exposed regions of the skin. If left untreated, AK may progress to invasive squamous cell carcinoma (SCC), although the rate of progression is low. A practical treatment algorithm for the treatment of AK in standard situations has been published by the AKTeam™ expert panel. However, management of particular situations of AK with increasing/higher carcinoma risk or AK progressing into carcinomas with increased aggressiveness due to their anatomical location (risky areas), or in patients with an increased risk of SCC requires further discussion. These include AK on the dorsal hands, forearms, legs, periorbital region, eyelids, ears, or lips, and organ transplant recipients, patients undergoing treatment with carcinogenic agents and patients with chronic lymphocytic leukaemia. The main objective was to propose therapeutic strategies for the treatment of AK located in risky areas and in patients with more invasive/aggressive lesions and a higher risk of progression to SCC. A systematic review of the literature was initially performed, and results were discussed by the experts to propose best management practices in specific situations. Finally, adapted management strategies for AK occurring in risky areas and in high-risk patients are presented, taking into account the experts' own clinical experience and current guidelines. In most of these 'at-risk' situations, patients can be treated according to the AKTeam™ treatment algorithm. Difficult-to-treat lesions should be treated more aggressively due to their higher risk of transformation. For patients with skin that is highly susceptible to actinic damage, monitoring and sun protection strategies are mandatory, and patients should undergo more regular follow-up. Further assessment of newer therapies in clinical trials is necessary to determine optimal treatment conditions. This expert consensus provides guidance for the management of AK in risky body sites and in patients with an increasing/higher risk for SCCs.

[Cosmetics and topical medications in acne: Where is the boundary?] / Cosmétiques et médicaments topiques dans l'acné : où est la frontière ?

Acne is a chronic disease that may cause sequels such as atrophic or hypertrophic scars or post-inflammatory hyperpigmentation. Topical and systemic medications with proven pharmacologic activity and which have received marketing authorization are the key actors in the treatment of acne. However, these topical or systemic treatments frequently cause adverse effects related to impairment of the skin barrier, and cosmetics must therefore be used in combination to help protect the skin barrier. Nowadays, new cosmetic products containing active ingredients tested in vitro or in a small number of subjects have changed the world of cosmetics. In being described as "dermo-cosmetic" and in integrating active ingredients in their formulations, these cosmetics are now being presented as being specifically adapted for a given disease, and no longer limited to skin care and hygiene but suitable as an adjunctive or even an alternative to current medications. The aim of this article is to provide a better understanding of the respective roles of medications and cosmetics in the management of acne.

AFAST - Adult Female Acne Scoring Tool: an easy-to-use tool for scoring acne in adult females.

BACKGROUND: Acne is a concern in adults, especially in women. The specifications in current acne grading systems are not applicable to this particular population. OBJECTIVE: To develop and validate a measurement tool (AFAST: adult female acne scoring tool) for acne in women by taking into account the specific locations of adult female acne, and to evaluate the impact of the photographic modalities on rating reproducibility. METHODS: Six experts in dermatology rated pictures of 54 women with a phototype from I to IV during two sessions, with an interval of 24 h. They rated the acne severity on the face using the GEA scale (Score 1) together with a new scale to assess acne on the mandibular zone (Score 2). Pictures of 30 women were taken using a standardized photographic device; pictures of the other 24 women were taken by their own dermatologists during daily practice. RESULTS: At session 1, the inter-rater's reproducibility was good for Score 1 with an ICC of 0.77 [0.72-0.83], and excellent for Score 2 with an ICC of 0.87 [0.82-0.91]. Between sessions 1 and 2, the mean intra-rater's reproducibility was excellent for both scores with an ICC of 0.88 [0.84-0.92] for Score 1, and an ICC of 0.87 [0.78-0.92] for Score 2. Photographic modalities had no significant effect on the inter- and intra-rater's reproducibility. CONCLUSION: For the first time, it has been demonstrated that AFAST can accurately rate acne severity in women. It is a promising, easy-to-use tool for both daily practice and clinical investigation.

Topical acne treatments in Europe and the issue of antimicrobial resistance.

Acne vulgaris (acne) is a chronic inflammatory disease of the sebaceous gland, characterized by follicular hyperkeratinization, excessive colonization by Propionibacterium acnes (P. acnes) as well as immune reactions and inflammation. Despite an armamentarium of topical treatments available including benzoyl peroxide, retinoids and azelaic acid, topical antibiotics in monotherapies, especially erythromycin and clindamycin, are still used in Europe to treat acne. This intensive use led to antimicrobial-resistant P. acnes and staphylococci strains becoming one of the main health issues worldwide. This is an update on the current topical acne treatments available in Europe, their mechanism of action, their potential to induce antimicrobial resistance and their clinical efficacy and safety.

Management of actinic keratosis: a practical report and treatment algorithm from AKTeam™ expert clinicians.

BACKGROUND: Actinic keratoses (AK) are common photo-induced cutaneous lesions that may progress to invasive squamous-cell carcinoma and serve as a risk marker for skin cancer. Although numerous studies present the various therapeutic options for AK, publications that can be used to pragmatically guide dermatologists in their daily practice are limited. National and international guidelines have been published, however, they are based on clinical trials with highly selected patient populations and do not always capture the range of patients seen in everyday practice. OBJECTIVE: The objective of this expert panel of French dermatologists was to present an analysis of AK geared towards everyday practice, to express an informed opinion about most recent treatments, and to propose a treatment algorithm for AK for daily practice in France. METHODS: Over a 12 month period, six expert dermatologists in the field of AK (AKTeam(TM) expert panel) met regularly to formulate an opinion about treatment in everyday practice compared with the analysis of the literature and guidelines published since 1990. RESULTS: Definitions, terminology, diagnosis and risk factors were summarized. Data from the literature and current practices related to the initial evaluation, indications for biopsy, therapeutic indications, therapeutic options and effectiveness, monitoring and prevention were discussed. A pragmatic treatment algorithm was formalized according to current data available. This practical algorithm distinguishes between different clinical situations depending on the number of AK, their hyperkeratotic or suspicious nature, and includes cryotherapy, curettage-electrocoagulation, 5% 5-fluorouracil, 3% diclofenac sodium, 5% imiquimod, 150 and 500 µg/g ingenol mebutate, lasers, photodynamic therapy and surgery. CONCLUSION: This up-to-date expert opinions about AK and its treatment provide a management strategy and practical treatment algorithm for AK for French dermatologists to use.

Propionibacterium acnes: an update on its role in the pathogenesis of acne.

In recent years, significant progress has been made in the understanding of the pathophysiological mechanisms of acne and the role of Propionibacterium acnes. With this review, the authors aim to provide an update on the current understanding of the role of P. acnes in the development of acne lesions and analysing the potential implications for future treatments. A total of 188 articles published between January 1980 and March 2013 were searched using key words such as acne, P. acnes, microbiology, Corynebacterium acnes, acne vulgaris, pathogenesis, antibiotic, vaccination and a combination of those key words. From those articles, 77 were analysed in depth. Recent data confirm that P. acnes has a strong proinflammatory activity and targets molecules involved in the innate cutaneous immunity, keratinocytes and sebaceous glands of the pilosebaceous follicle and leads to the development of comedones. Furthermore, the profile of its different strains may differ between healthy subjects and acne patients. The better understanding of the role of P. acnes may allow for new perspectives in the treatment of acne. Novel therapies should target molecules implicated in the activation of innate immunity, including toll-like receptors, protease-activated receptors and topical antimicrobial peptides; the latter may be an alternative to topical antibiotics and thus a solution for limiting bacterial resistance induced by topical macrolides. Vaccines may also be promising. However, the most appropriate candidate remains to be selected.

Subdiaphragmatic implantation of implantable cardioverter defibrillator generator.

Despite several improvements in the surgical technique and in the technologic design of cardioverter defibrillators made over the past years, abdominal placement of the generator device, done as Mirowski did it in his first implantation performed in 1980, remains the widely used method. Although smaller defibrillators are available, they remain bulky and are a source of local complications. To prevent such complications and to enhance patient comfort, we performed a subdiaphragmatic implantation in 31 patients.

Hepatic cytolytic and cholestatic changes related to a change of lipid emulsions in four long-term parenteral nutrition patients with short bowel.

Long-term parenteral nutrition hepatic-related impairment is commonly reported and diversely explained. However, with a low cyclic caloric intake (100% to 130% of basal metabolism calculated with the Harris-Benedict formula) consisting of two-thirds glucose, one-third lipid, and 0.20 to 0.25 g of nitrogen per kilogram per day, these complications were infrequent in a clinical practice of home long-term parenteral nutrition. Retrospectively, it was noticed that the switch from Intralipid 20% to Ivelip 20% at the same amount was followed within 2 months by four cases of jaundice in a population of four home long-term parenteral nutrition patients with short bowel disease. Hepatic disturbances were characterized by cytolysis and cholestasis and were reversible after switching from Ivelip 20% back to Intralipid 20%. Neither viral, nor biliary, nor septic etiologies were detected. The exact pathological mechanism remains unknown. The basal composition of both lipid emulsions seems to be identical: soy oil emulsion emulsified by egg phospholipids. However, some differences exist such as the size of particles, the presence of sodium oleate in Ivelip 20%, and the purification process of lecithin. These may explain the difference in hepatic tolerance during long-term parenteral nutrition.

[Ablation of accessory pathways by radiofrequency current. Towards a simplified approach of Wolff-Parkinson-White syndrome?]. / Ablation des voies accessoires par courant de radiofrquence. Vers une approche simplifiée du syndrome de Wolff-Parkinson-White?

From December 1990 to April 1992, 41 consecutive patients (22 men and 19 women with an average age of 35 +/- 16 years -6-72) underwent ablation of accessory atrioventricular conduction pathways (Bundles of Kent) for poorly tolerated and/or medically resistant supraventricular tachycardias. In 33 cases, the arrhythmia was a paroxysmal SVT, in 7 cases atrial fibrillation, and in 1 patient incessant junctional tachycardia causing left ventricular dysfunction. The Wolff-Parkinson-White syndrome was apparent in 30 patients and concealed in 11 cases. The location of the Kent bundle was left lateral in 22 cases (53.7%), posterior paraseptal in 9 cases (21.9%), right lateral in 5 cases (12.2%) and anterior paraseptal in 5 cases (12.2%). The Kent bundles were ablated by radiofrequency currents in 38 cases (92.7%); in 2 patients (4.9%) in whom radiofrequency could not be used (increased impedance) high energy electrical shock was successful. In one patient (2.4%), it was not possible to suppress the Kent bundle. A single session of radiofrequency ablation was sufficient in 33 cases: 7 cases (17.5%) required 2 (4) or 3 (3) sessions. The average number of sites of application per patient was 8.8 +/- 8.8. The duration and intensity were respectively 32.2 +/- 9.3 (5-60) seconds and 25 +/- 15 (20-30) watts. With an average follow-up of tachycardia or of ventricular preexcitation have been observed in the 40 patients. In addition, in 36 patients, electrophysiological control studies confirmed the initial result with absence of any disturbance of nodohisian conduction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Radiofrequency ablation of intranodal tachycardia]. / Traitement par radiofréquence des tachycardies intranodales.

The first radical approach to the treatment of atrioventricular nodal reentrant tachycardia was surgical dissection of the perinodal region. This technique has been replaced by the delivery of radiofrequency energy by an ablation catheter to the region of the atrioventricular node. The aim of this report is to describe the authors' experience of atrioventricular nodal application of radiofrequency current. The study comprised 53 cases (32 women and 21 men, mean age 46 +/- 17 years) with frequent attacks of reciprocating tachycardia. Endocavitary electrophysiological investigation confirmed the intranodal reentrant mechanism. The region of application of the radiofrequency current was located radiologically and then the precise site determined by the recording of nodal electrical activity. The appearance of junctional rhythm during the procedure was also used as a means of identification of the zone of ablation. Dual conduction persisted after ablation in 35 patients. However, no episode of tachycardia could be induced after the procedure. The AH interval increased during application of radiofrequency current in 3 cases but this abnormality regressed in the 2 months following the procedure. Recurrences of nodal reentrant tachycardia were observed in 14 cases (26%), 24 hours to 2 months after ablation. The rate of recurrence was significantly higher in patients who did not have a junctional rhythm during application of the radiofrequency current (62% vs 4%, p < 0.05). The number of recurrences was also greater in the group of patients with persistence of slow intranodal conduction after the radiofrequency ablation (p < 0.04). A second session of radiofrequency ablation was undertaken in 14 patients and a third session was required for 2 of them.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognosis and long-term development of arrhythmogenic dysplasia of the right ventricle]. / Pronostic et évolution à long terme de la dysplasie arythmogène du ventricule droit.

The authors studied the clinical, angiographic and electrophysiological features, and the long-term outcome of patients with arrhythmogenic right ventricular dysplasia (ARVD). The study was retrospective and involved 22 patients (3 women and 19 men) with an average age of 36 years at the time of their first documented ventricular tachycardia (VT) and admitted to hospital between 1971 and 1989. The diagnosis of ARVD was based on the association of monomorphic VT with a left bundle branch block morphology and right ventricular abnormalities on angiography. Fifteen patients were treated by antiarrhythmic drugs alone, 5 by antiarrhythmic drugs and tachycardia ablation and 2 by antiarrhythmic drugs and cardiac transplantation. An automatic defibrillator was implanted in one patient. After the first episode of VT, the beginning of follow-up, the criteria of evaluation were mortality, right heart failure and the evolution of the arrhythmia. The study population had the following characteristics. Familial forms or ARVD were observed in 18%. The mitral ventricular arrhythmia was often induced by exercises (45%). Twenty-one patients had a sustained VT and 1 patient had non-sustained VT. The resting ECG in sinus rhythm was abnormal in all cases. Thirty-two different VT morphologies were recorded. The abnormalities of the right ventricular wall motion on ventriculography were localised in 45% of cases and diffuse in 55% of cases. Seventy per cent of patients undergoing electrophysiological investigation had inducible sustained VT. The clinical outcome after an average of 10.7 years' follow-up was: 17 survivors, 3 sudden deaths and 4 cases of right ventricular failure. The 10 year actuarial survival rate was 75%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term results of implantable automatic defibrillator in 43 patients. Analysis of predictive factors of the first electric shock]. / Résultats à long terme du défibrillateur automatique implantable chez 43 patients. Analyse des facteurs de prévision du premier choc électrique.

In order to identify patients who will receive an electric shock after implantation of an automatic fibrillator, the relationship between the time to the first shock and clinical and paraclinical characteristics were studied in 43 patients treated at the Lyon Cardiological Hospital between July 1987 and September 1991. The age of the patients was 49.5 +/- 16 years (mean + SD). Eighty two percent of patients were men and the average left ventricular ejection fraction was 38.5 +/- 16.8%. Four patients died in the peri-operative period. The average follow-up of the survivors was 22 months. During this period, 21 patients (53.8%) received an appropriate electric shock. Three patients died. The causal role of a malignant ventricular arrhythmia is discussed in one case. A second patient, who never had automatic fibrillation, died of cardiac failure. Finally, the third patient died of non-cardiac pathology. The 22 month actuarial survival rate was 86%. The probability of receiving an appropriate electric shock was 60%. Analysis of clinical and paraclinical features identified left ventricular dysfunction (ejection fraction less than 38%) and cardiac symptoms (Stage III dyspnoea of the NYHA classification) as being associated with earlier electric shocks. This association was even more clear cut in the group of patients with previous myocardial infarction. Therefore, patients with implantable automatic defibrillators for malignant ventricular arrhythmias receive appropriate electric shocks in over 50% of cases. Patients with symptoms of cardiac failure and low ejection fraction are particularly exposed especially when they have previous myocardial infarction.

[Long-term course after electric ablation of the bundle of His in the treatment of supraventricular tachycardia]. / Evolution à long terme après ablation électrique du faisceau de His dans le traitement des tachycardies supraventriculaires.

The authors report the long term results of His bundle ablation for supraventricular tachycardia in a series of 49 patients. This retrospective study was based on a patient population of 27 men and 22 women with an average age of 59 at the time of ablation, between 1984 and 1993. The indication for His bundle ablation was invalidating supraventricular tachycardia resistant to antiarrhythmic therapy in all cases. One group of patients (Group I, n = 31 patients) underwent high energy electrical shock and the second group (Group II, n = 18 patients) recruited after 1991, underwent radiofrequency catheter ablation. Complete atrioventricular block was obtained in the first group in 1 to 4 sessions whereas 17 patients of Group II were treated in a single session. During a follow-up period of an average of 40 months, 2 patients were lost to follow-up and 6 died, 3 of cardiac failure, 1 of a cerebrovascular accident, 1 of pulmonary carcinoma and 1 of unknown cause. In Group I, atrioventricular conduction persisted in 1 patient (primary failure) and reappeared in one other patient, but, in Group II, complete atrioventricular block persisted even in the patient in whom the interruption was not obtained with a single session of radiofrequency ablation. The patients were generally physically improved and satisfied not to have any palpitations. A decrease in exercise capacity estimated by the NYHA classification was observed in 38% of patients without apparent cardiac disease who developed dyspnea. On the other hand, 43% of patients with cardiac disease and in NYHA class > or = 2 were improved.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemomediastinum caused by spontaneous rupture of the thoracic aorta]. / Hémomédiastin par rupture spontanée de l'isthme aortique.

The authors report the rare case of spontaneous rupture of the aortic isthmus in the absence of preexisting aortic aneurysm or dissection in a hypertensive woman presenting with chest pain and haemomediastinum. The history of trauma 30 years previously, could have been a predisposing factor. The diagnosis of this condition remains difficult and is often missed. The physiopathological, aetiological, clinical and diagnostic features are reviewed. Transoesophageal echocardiography showing an intraparietal haematoma confirmed the aortic origin of the haemomediastinum. Conventional angiography was of no value in the reported case because of the absence of rupture of continuity or of an intimal tear.