Exploring the burden of actinic keratoses through development of a patient decision aid: a mixed methods study.

BACKGROUND: Actinic keratoses (AKs) present on sun-exposed sites and are considered precursors of cutaneous squamous cell carcinoma (cSCC). A better understanding of the experiences of patients with this condition may improve patient-provider relationships and guide the introduction of shared-decision making (SDM) to treatment decisions. OBJECTIVES: To develop a patient decision aid (PDA) for field treatment of multiple actinic keratoses in line with the International Patient Decision Aid Standards (IPDAS), by (i) characterising the burden and lived experiences of patients with multiple AKs, (ii) understanding the decisional needs of patients requiring field treatment and (iii) exploring clinician preferences regarding field treatment for multiple AKs. MATERIALS AND METHODS: This mixed methods study followed the most up-to-date guidelines set out by the IPDAS Collaboration; a voluntary body which aims to enhance the quality of PDAs by developing an evidence-based systematic process for the development of unbiased and effective PDAs. RESULTS: Multiple actinic keratoses have a psychosocial impact on patients. Patients feel supported through the integration of evidence-based information to guide SDM. CONCLUSIONS: We propose that the use of a PDA for multiple AKs provides a key role in supporting informed shared patient-provider decision making and empowers patient involvement in their prospective treatment strategy.

An open-label prospective study to assess short incubation time white LED light photodynamic therapy in the treatment of superficial basal cell carcinoma.

Artificial white LED light photodynamic therapy (awl-PDT) is an effective, pain-free treatment for actinic keratosis. The efficacy of awl-PDT in the treatment of superficial basal cell carcinoma (sBCC) has not been assessed. Patients with histologically confirmed sBCC underwent two treatments of awl-PDT 1 week apart. Lesions were incubated with methyl 5-aminolaevulinic acid for 30 min and then illuminated using the Maquet Power LED 500 theatre light (405-800nm, 140 000 lux) to deliver an equivalent red light dose of 75 J/cm2 at a rate of 55 mW/cm2 . Pain was measured using a visual analogue scale during treatment. Clinical response was assessed at day 28. Follow-up continued 3 months for 1 year. Cosmetic outcome was assessed at 3 months and 1 year. Twenty-eight patients with 36 lesions and a mean age of 63.64 (SD 2.62) were recruited. The median lesion size was 15 mm (IQR 8.75). The response rate at day 28 was 100%. Recurrence rates were 3/36 (8.3%) at 3 months, 6/36 (16.7%) at 6 months, 10/36 (27.8%) at 9 months and 11/36 (30.6%) at 1 year. Median pain scores were 0/100 (IQR 0) and 0/100 (IQR 5) during treatments one and two, respectively. Cosmetic outcome was excellent or good in the majority of cases. Although initially effective for sBCC at 28 days, 30.6% of lesions recurred 1 year after awl-PDT. Pain scores were negligible, and the cosmetic outcome was favourable. Further head-to-head studies with optimised protocols are required to determine if awl-PDT has a role in the treatment of sBCC.

The 'number needed to treat' metric: a further marker of the impact of COVID-19 on malignant melanomas.

We comment on a previous article, describing the number needed to treat metric as a further marker on the impact of COVID-19 on treatment of malignant melanomas.

High Levels of Psychological Distress, Sleep Disturbance, and Alcohol Use Disorder in Adults With Atopic Dermatitis.

BACKGROUND: The burden of illness associated with atopic dermatitis (AD) is significant and multidimensional, especially in those with moderate to severe disease. OBJECTIVE: Our objective was to evaluate the disease burden of patients with AD in relation to psychological distress, sleep disturbance, and alcohol misuse. METHODS: Patients with AD, attending 2 tertiary referral centers in Dublin, Ireland, were recruited. A series of validated questionnaires were used including the Patient-Oriented Eczema Measure, Dermatology Life Quality Index (DLQI), Center for Epidemiologic Studies-Depression Scale, Quality of Life in Atopic Dermatitis Questionnaire, Alcohol Use Disorders Identification Test, and Pittsburgh Sleep Quality Index. The Eczema Area and Severity Index was calculated contemporaneously with the questionnaire completion. RESULTS: One hundred patients completed the questionnaire, of whom 52% were female. Sixty-three percent of patients experienced impaired quality of life as measured by the DLQI. Higher DLQI scores correlated with decreasing age (r = 0.3277, P < 0.0009). Thirty percent were found to be at risk of clinical depression, and higher Center for Epidemiologic Studies-Depression Scale scores correlated with a younger age and eczema severity. Sleep disturbance was greater in those at risk of depression (mean = 10.40 vs 5.79, P < 0.0001). Patients with moderate to severe AD were more likely to score higher on the Alcohol Use Disorders Identification Test, and 25% met the criteria for alcohol use disorder. In relation to sleep, 73% of patients scored higher than 5 on the Pittsburgh Sleep Quality Index, which signifies poor sleep quality. CONCLUSIONS: Patients with AD endure a significant burden on health with regard to mental well-being, alcohol use, and sleep quality. Clinicians should consider screening patients for these comorbidities.

Metformin use in hidradenitis suppurativa.

Background: Hidradenitis suppurativa (HS) is a chronic debilitating inflammatory disease, associated with metabolic syndrome, obesity and insulin resistance. Metformin, an oral hypoglycaemic agent, may play an important role in delaying or preventing the onset of diabetes and metabolic syndrome. Metformin has been reported as having efficacy in HS. It may have a role in the treatment of HS and its associated co-morbidities.Objective: To evaluate metformin use, response and tolerability in a HS population.Methods: A retrospective chart review of patients attending a specialist Dermatology HS clinic over 12 months. All patients treated with metformin were included.Results: Fifty-three HS patients received metformin; 85% female; mean age was 37 years and mean weight was 102 kg. The mean duration of metformin was 11.3 months and mean dose was 1.5 g/days. The 6- and 12-month drug survival were 61% and 39%, respectively. Metformin was well tolerated. Gastrointestinal side effects were experienced by 11%. Subjective clinical response was seen in 68% (n = 36) with 19% (7/36) of these having quiescent disease with metformin monotherapy. 25% had no improvement. Insulin resistance was seen in 75%. Its presence did not predict clinical response to metformin.Conclusion: Metformin is an effective, well tolerated and inexpensive treatment that represents a viable treatment option for HS.Key message: Metformin is an effective; well tolerated and inexpensive treatment in the management of HS.

Understanding the role of cutaneous allergy testing in anogenital dermatoses: a retrospective evaluation of contact sensitization in anogenital dermatoses.

BACKGROUND: Patients with anogenital symptoms may delay before seeking medical attention. Attempted self-treatment with multiple topical preparations and excessive hygiene measures offer ideal conditions for sensitization. The aim of this study was to identify the common allergens detected on cutaneous allergy testing in patients presenting with anogenital symptoms. METHODS: A retrospective chart review of patients who underwent cutaneous allergy testing for perianal and/or genital symptoms over a 3-year period, January 2013 to December 2015, n = 99. Information was gathered from medical records, pretesting questionnaires, and cutaneous allergy testing records. RESULTS: At least one relevant allergen(s) was identified in 44/99 (45%) in our cohort, with allergic reactions to fragrances, Myroxylon pereirae, caine mix, sodium metabisulfite, and methylisothiazolinone most frequently observed. CONCLUSIONS: Cutaneous allergy testing is a useful investigation in patients presenting with anogenital symptoms, but advice regarding general skin care measures should not be omitted. The most commonly identified relevant allergens in our study were those present in over-the-counter cleansing and hemorrhoid preparations.

Evaluation of Immunophenotypic and Molecular Biomarkers for Sézary Syndrome Using Standard Operating Procedures: A Multicenter Study of 59 Patients.

Differentiation between Sézary syndrome and erythrodermic inflammatory dermatoses can be challenging, and a number of studies have attempted to identify characteristic immunophenotypic changes and molecular biomarkers in Sézary cells that could be useful as additional diagnostic criteria. In this European multicenter study, the sensitivity and specificity of these immunophenotypic and recently proposed but unconfirmed molecular biomarkers in Sézary syndrome were investigated. Peripheral blood CD4(+) T cells from 59 patients with Sézary syndrome and 19 patients with erythrodermic inflammatory dermatoses were analyzed for cell surface proteins by flow cytometry and for copy number alterations and differential gene expression using custom-made quantitative PCR plates. Experiments were performed in duplicate in two independent centers using standard operating procedures with almost identical results. Sézary cells showed MYC gain (40%) and MNT loss (66%); up-regulation of DNM3 (75%), TWIST1 (69%), EPHA4 (66%), and PLS3 (66%); and down-regulation of STAT4 (91%). Loss of CD26 (≥80% CD4(+) T cells) and/or CD7 (≥40% CD4(+) T cells) and combination of altered expression of STAT4, TWIST1, and DNM3 or PLS3 could distinguish, respectively, 83% and 98% of patients with Sézary syndrome from patients with erythrodermic inflammatory dermatoses with 100% specificity. These additional diagnostic panels will be useful adjuncts in the differential diagnosis of Sézary syndrome versus erythrodermic inflammatory dermatoses.

Diagnosis, prognosis and management of erythrodermic cutaneous T-cell lymphoma.

Erythroderma describes complete or near-complete skin surface erythema of any cause. Cutaneous T-cell lymphoma accounts for a minority of cases of erythroderma and consists of erythrodermic mycosis fungoides, Sézary syndrome. Both adult T-cell leukemia/lymphoma and T-cell prolymphocytic leukemia can also rarely present with erythroderma. Diagnosis may be extremely challenging because benign disorders may have overlapping features with those of lymphoma. Prognosis is poor with median survival of approximately 2 years. The evidence base for therapeutic approaches relies on cohorts and case series and more recently Phase II trials. Improved patient selection and identification of appropriate conditioning regimens for reduced intensity allogeneic hematopoetic transplant are likely to improve survival, although a significant number of patients may not be fit for transplant because of advanced age and comorbidities.