Drug Survival in Cyclosporine Treatment for Moderate to Severe Atopic Dermatitis: Analysis of the Spanish Atopic Dermatitis Registry (BIOBADATOP). / Supervivencia de la ciclosporina en el tratamiento de la dermatitis atópica moderada-grave: Registro Español de Dermatitis Atópica (BIOBADATOP).

BACKGROUND: The past 5 years have seen a proliferation of new treatments for atopic dermatitis (AD). We analyzed recent drug survival data for cyclosporine in this setting. Because the Spanish National Healthcare system requires patients with AD to be treated with cyclosporine before they can be prescribed other systemic treatments, drug survival for cyclosporine may be shorter than in other diseases. MATERIAL AND METHOD: Multicenter, observational, prospective cohort study using data from the Spanish Atopic Dermatitis Registry (BIOBADATOP). Data from the Spanish Registry of Systemic Treatments in Psoriasis (BIOBADADERM) were used to create a comparison cohort. RESULTS: We analyzed data for 130 patients with AD treated with cyclosporine (median drug survival, 1 year). Median cyclosporine survival in the psoriasis comparison group (150 patients) was 0.37 years. Drug survival was significantly longer in AD than in psoriasis (P<.001). CONCLUSION: Drug survival of cyclosporine in the BIOBADATOP registry is similar to that described in other series of patients with AD and longer than that observed in the BIOBADADERM psoriasis registry.

Selection of Quality Indicators for the Certification of Dermato-Oncology Units: The CUDERMA Project Delphi Consensus Study. / Proyecto CUDERMA: Consenso Delphi de los indicadores de calidad para la certificación de las unidades de dermatología de atención en dermato-oncología.

Quality indicators are crucial for standardizing and guaranteeing the quality of health care practices. The Spanish Academy of Dermatology and Venereology (AEDV) launched the CUDERMA Project to define quality indicators for the certification of specialized units in dermatology; the first 2areas selected were psoriasis and dermato-oncology. The aim of this study was to achieve consensus on what should be evaluated by these indicators using a structured process comprising a literature review and selection of an initial list of indicators to be evaluated in a Delphi consensus study following review by a multidisciplinary group of experts. The selected indicators were evaluated by a panel of 28 dermatologists and classified as either «essential¼ or «of excellence¼. The panel agreed on 84 indicators, which will be standardized and used to develop the certification standard for dermato-oncology units.

Selection of Quality Indicators for the Certification of Psoriasis Units: The CUDERMA Project Delphi Consensus Study. / Proyecto CUDERMA: Consenso Delphi de los indicadores de calidad para la certificación de las unidades de dermatología de atención en psoriasis.

Defining quality indicators is a key strategy for ensuring the quality and standardization of health care. The CUDERMA project, an initiative of the Spanish Academy of Dermatology and Venerology (AEDV), was undertaken to define quality indicators for the certification of specialized units in dermatology; the first 2 areas selected were psoriasis and dermato-oncology. The aim of this study was to reach a consensus on what should be assessed by the indicators used to certify psoriasis units. The structured process used to do this comprised a literature review to identify potential indicators, the selection of an initial set of indicators to be evaluated by a multidisciplinary group of experts and, finally, a Delphi consensus study. A panel of 39 dermatologists evaluated the selected indicators and classified them as either "essential" or "of excellence". Consensus was finally reached on 67 indicators, which will be standardized and used to develop the certification standard for psoriasis units.

What Proportion of the Spanish Dermatology Caseload Corresponds to Pediatric Dermatoses? Results From the DIADERM National Random Sampling Survey. / ¿Cuánta carga asistencial suponen las dermatosis pediátricas en la actividad ambulatoria en la dermatología española? Resultados del muestreo aleatorio nacional DIADERM.

BACKGROUND: Visits for skin conditions are very common in pediatric primary care, and many of the patients seen in outpatient dermatology clinics are children or adolescents. Little, however, has been published about the true prevalence of these visits or about their characteristics. MATERIAL AND METHODS: Observational cross-sectional study of diagnoses made in outpatient dermatology clinics during 2 data-collection periods in the anonymous DIADERM National Random Survey of dermatologists across Spain. All entries with an International Classification of Diseases, Tenth Revision code related to dermatology in the 2 periods (84 diagnoses) were collected for patients younger than 18 years and classified into 14 categories to facilitate analysis and comparison. RESULTS: In total, the search found 20 097 diagnoses made in patients younger than 18 years (12% of all coded diagnoses in the DIADERM database). Viral infections, acne, and atopic dermatitis were the most common, accounting for 43.9% of all diagnoses. No significant differences were observed in the proportions of diagnoses in the respective caseloads of specialist vs. general dermatology clinics or public vs. private clinics. Seasonal differences in diagnoses (January vs. May) were also nonsignificant. CONCLUSIONS: Pediatric care accounts for a significant proportion of the dermatologist's caseload in Spain. Our findings are useful for identifying opportunities for improving communication and training in pediatric primary care and for designing training focused on the optimal treatment of acne and pigmented lesions (with instruction on basic dermoscopy use) in these settings.

Nonvenereal Infections in Spanish Dermatology Clinics: Results of the DIADERM Study. / Enfermedades infecciosas no venéreas atendidas en consultas de Dermatología en España: resultados del estudio DIADERM.

BACKGROUND AND OBJECTIVE: The burden of nonvenereal infections in Spanish dermatology practice has not yet been evaluated. The aim of this study was to analyze the overall weight of these infections in outpatient dermatology caseloads. MATERIAL AND METHODS: Observational cross-sectional study of diagnoses made by a random selection of dermatologists from the Spanish Association of Dermatology and Venereology (AEDV) working in outpatient dermatology clinics. The data were obtained through the anonymous DIADERM survey. Diagnoses of infectious diseases were selected using codes from the International Classification of Diseases, Tenth Revision. After excluding sexually transmitted infections, the diagnoses were classified into 22 groups. RESULTS: Spanish dermatologists diagnosed an estimated 16190 (95% CI, 9338-23042) nonvenereal infections on average per week, a figure that accounted for 9.33% of the dermatology caseload. The most common diagnostic groups were nonanogenital viral warts (7475 diagnoses, 46.17% of nonvenereal infections), dermatophytosis (3336, 20.61%), and other viral infections (1592, 9.84%), which included Molluscum contagiosum infections. Nonvenereal infections were more common than noninfectious dermatologic conditions in private clinics (P<.0020) and adults (P<.00001). Patients with these infections were also more likely to be discharged than those with other conditions in both public (P<.0004) and private (P<.0002) practices. CONCLUSIONS: Nonvenereal infections are frequent in dermatology. They are the third most common reason for outpatient visits, behind actinic keratosis and nonmelanoma skin cancer. By enhancing the participation of dermatologists in the management of skin infections and encouraging interactions with other specialists, we will be able to carve out a niche in an area we have scarcely ventured into to date.

Tirbanibulin: review of its novel mechanism of action and how it fits into the treatment of actinic keratosis. / Tirbanibulina: revisión de su mecanismo de acción novedoso y de cómo encaja en el tratamiento de la queratosis actínica.

Actinic keratosis (AK) is a skin condition characterized by the proliferation of mutated keratinocytes that can develop into squamous cell carcinoma. Available therapies, although effective, are associated with a high frequency of severe local skin reactions. Tirbanibulin, one of the treatments for AK currently in development, is a new synthetic chemical entity with anti-proliferative and anti-tumor effects, both in vitro and in vivo, with proved efficacy in the treatment of AK, which has been recently demonstrated in two phase III clinical trials. In the present review, the tirbanibulin mechanism of action, based on the relevant literature and the results of several unpublished preclinical studies, is shown. In addition, the current scenario regarding the available treatments and how the novel tirbanibulin mechanism of action fits into the treatment of AK is raised.

Dermatology Care in Spanish Public Hospitals: A Mapping Study of Health Care Resources and Medical and Surgical Activity in Dermatology Departments in 2019. / Mapa asistencial dermatológico: descripción de los recursos estructurales y de la actividad médico-quirúrgica de los servicios de dermatología de los hospitales públicos españoles en 2019.

BACKGROUND AND OBJECTIVE: No recent data on health care resources and medical and surgical activity in Spanish dermatology departments are available in the literature. The aim of this study was to compile this information for 2019. MATERIAL AND METHODS: Cross-sectional study based on an online survey sent to the heads of dermatology departments at public hospitals in Spain. RESULTS: Of the 162 department heads contacted, 59 answered the survey (participation rate, 36.4%). General findings included a shortage of staff, especially dermatologists, in hospitals of low and medium complexity. The main reason given for the shortage of dermatologists was a lack of interested applicants. Large hospital complexes had more infrastructure and equipment. Over 50% of the departments surveyed used a combination of in-person and virtual visits. Psoriasis units were the most common specialized care units. Approximately 75% of the hospitals had operating rooms with an anesthetist. More complex procedures such as sentinel lymph node biopsy and Mohs micrographic surgery were performed more often in large hospital complexes. Hospitalization and the presence of dermatology residents working call shifts were also more common in these hospitals. Teaching and research activity differed according to hospital complexity. CONCLUSIONS: We have mapped health care resource availability and medical and surgical activity in Spanish dermatology departments prior to the COVID-19 pandemic. Our findings could be useful for improving clinical management and defining future actions and areas for improvement.

What Proportion of the Spanish Dermatology Caseload Corresponds to Primarily Sexually Transmitted Infections and Other Anogenital Dermatoses? Results From the DIADERM National Random Survey. / ¿Cuánta carga asistencial suponen las infecciones de transmisión predominantemente sexual y otras dermatosis anogenitales en las consultas de Dermatología en España? Resultados del muestreo aleatorio nacional DIADERM.

BACKGROUND AND OBJECTIVE: Predominantly sexually transmitted infections (STIs) and infestations and other anogenital dermatoses are covered in the training of specialists in dermatology and venereology in Spain. This study aimed to analyze the proportion of the dermatology caseload these diseases account for within the public and private dermatological activity of the Spanish health system. MATERIAL AND METHODS: Observational cross-sectional study of time periods describing the diagnoses made in outpatient dermatology clinics, obtained through the anonymous DIADERM survey of a representative random sample of dermatologists. Based on diagnostic codes of the International Classification of Diseases, Tenth Revision, 36 related diagnoses were selected, and classified into 12 groups. RESULTS: Only 3.16% of diagnoses corresponded to STIs and other anogenital dermatoses. The most common diagnostic group was anogenital human papillomavirus infection, followed by molluscum contagiosum, and inflammatory anogenital dermatoses. Lesions with these diagnoses were usually the main reasons for first visits in the National Health Service. In private practice, the diagnoses usually came after referrals from other physicians. CONCLUSIONS: STIs and other anogenital dermatoses account for a very small proportion of the dermatology caseload in Spain, although the inclusion of molluscum contagiosum diagnoses overestimates these conditions. The fact that no STI centers or monographic STI consultations were included in the random sample of dermatology partly explains the under-representation of these areas of the specialty. A determined effort to support and promote monographic STI centres and clinics should be made.

Photoprotection of the future: challenges and opportunities.

The use of sunscreens is an important and essential component of photoprotection. Since their introduction during the first half of the last century, sunscreens have benefited enormously from major technological advances such as the development of novel UV filters; as a result, their efficacy in preventing UV-induced erythema is unequivocal. More recently, however, new challenges have appeared, which have prompted a robust discussion about the safety of sunscreens. These include topics directly related to photoprotection of human skin such as improved/alternative methods for standardization of assessment of the efficacy of sunscreens, but also many others such as photoprotection beyond UV, concerns about human toxicity and ecological safety, the potential of oral photoprotective measures, consequences of innovative galenic formulations. On a first glance, some of these might raise questions and doubts among dermatologists, physicians and the general public about the use sunscreens as a means of photoprotection. This situation has prompted us to critically review such challenges, but also opportunities, based on existing scientific evidence. We conclude by providing our vision about how such challenges can be met best in the future in an attempt to create the ideal sunscreen, which should provide adequate and balanced protection and be easy and safe to use.

European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications - field cancerization, photorejuvenation and inflammatory/infective dermatoses.

In addition to approved indications in non-melanoma skin cancer in immunocompetent patients, topical photodynamic therapy (PDT) has also been studied for its place in the treatment of, as well as its potential to prevent, superficial skin cancers in immune-suppressed patients, although sustained clearance rates are lower than for immune-competent individuals. PDT using a nanoemulsion of ALA in a daylight or conventional PDT protocol has been approved for use in field cancerization, although evidence of the potential of the treatment to prevent new SCC remained limited. High-quality evidence supports a strong recommendation for the use of topical PDT in photorejuvenation as well as for acne, refractory warts, cutaneous leishmaniasis and in onychomycosis, although these indications currently lack approvals for use and protocols remain to be optimized, with more comparative evidence with established therapies required to establish its place in practice. Adverse events across all indications for PDT can be minimized through the use of modified and low-irradiance regimens, with a low risk of contact allergy to photosensitizer prodrugs, and no other significant documented longer-term risks with no current evidence of cumulative toxicity or photocarcinogenic risk. The literature on the pharmacoeconomics for using PDT is also reviewed, although accurate comparisons are difficult to establish in different healthcare settings, comparing hospital/office-based therapies of PDT and surgery with topical ointments, requiring inclusion of number of visits, real-world efficacy as well as considering the value to be placed on cosmetic outcome and patient preference. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical photodynamic therapy in Dermatology prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.

European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 1: treatment delivery and established indications - actinic keratoses, Bowen's disease and basal cell carcinomas.

Topical photodynamic therapy (PDT) is a widely approved therapy for actinic keratoses, Bowen's disease (squamous cell carcinoma in situ), superficial and certain thin basal cell carcinomas. Recurrence rates when standard treatment protocols are used are typically equivalent to existing therapies, although inferior to surgery for nodular basal cell carcinoma. PDT can be used both as lesional and field therapies and has the potential to delay/reduce the development of new lesions. A protocol using daylight to treat actinic keratoses is widely practised, with conventional PDT using a red light after typically a 3-h period of occlusion employed for other superficial skin cancer indications as well as for actinic keratoses when daylight therapy is not feasible. PDT is a well-tolerated therapy although discomfort associated with conventional protocol may require pain-reduction measures. PDT using daylight is associated with no or minimal pain and preferred by patient. There is an emerging literature on enhancing conventional PDT protocols or combined PDT with another treatment to increase response rates. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical PDT in dermatology, prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.

Methyl aminolevulinate photodynamic therapy for onychomycosis: a multicentre, randomized, controlled clinical trial.

BACKGROUND: Onychomycosis is a common fungal nail infection that responds poorly to antifungals. OBJECTIVE: To investigate the efficacy and safety of methyl aminolevulinate (MAL) photodynamic therapy (PDT) in the treatment of onychomycosis. METHODS: A multicentre (3), randomized, placebo-controlled clinical trial compared the effects of three sessions of urea (40%) plus conventional MAL-PDT with urea (40%) plus placebo (red light) photodynamic therapy (pPDT) in onychomycosis patients. Efficacy, both clinical (onychomycosis severity index, OSI) and microbiological, was blindly evaluated after 36 weeks of follow-up. RESULTS: Forty patients were analysed in the trial. Twenty-two received MAL-PDT and 18 pPDT. A complete response (OSI = 0) was observed for four patients (18.18%) in the MAL-PDT group and one (5.56%) in the pPDT group (NTT 7.92, 95% CI: 2.98-9.69, P = 0.23). A decrease in OSI score of over 75% (OSI75) was achieved by 40.91% of the patients in the MAL-PDT group and 16.67% in the pPDT group (P = 0.096). Microbiological cure was achieved by seven patients (31.82%) in the MAL-PDT group and two (11.11%) in the pPDT group (P = 0.178). MAL-PDT resulted in better rates of clinical response [OSI >75%: 53.85% vs. 18.75% (P =0.048)] and microbiological cure [41.56% vs. 7.14% (P = 0.037)] in non-dystrophic vs. dystrophic onychomycosis patients. No significant side-effects were reported. The limitations of the study were the reduced sample size and the unexpected efficacy of the control treatment, which was attributed to the 40% urea pre-treatment. CONCLUSION: This study did not show significant differences between urea 40% + MAL-PDT and urea 40% + pPDT in the treatment of onychomycosis. However, some results suggest that this treatment may constitute an alternative for dermatophyte and non-dermatophyte mould onychomycosis in patients not eligible for systemic treatment, particularly in the absence of total nail dystrophy.

Neuropeptide Y expression in primary cutaneous melanoma.

BACKGROUND: Neuropeptide Y (NPY) is involved in the carcinogenesis of different tumours, especially neural crest-derived tumours. OBJECTIVE: The aim of our study is to investigate the expression of NPY on melanoma and its relation with prognostic histological parameters and survival. METHODS: This is a retrospective observational study of two independent series, with a total of 79 primary melanomas, diagnosed in two independent University Hospitals in Spain, from January 2000 to December 2004. RESULTS: We found a significant higher expression of NPY on superficial spreading melanoma and lentigo maligna (40%) (P = 0.030). Thinner tumours were associated with higher NPY expression (Clark level, P = 0.003; Breslow level, P = 0.012). Melanomas with low NPY expression were associated with intense cell proliferation (Ki-67, P = 0.034), high density of peritumoral mast cell infiltrates (P = 0.033) and low E-cadherin expression (P = 0.031). Melanomas with high NPY expression exhibited significant differences in terms of relapse time (median: 114 vs. 68 months, P = 0.008) and overall survival (114 vs. 74 months, P = 0.004). CONCLUSION: High expression of NPY was associated with better prognostic histological parameters, low peritumoral mast cells density, presence of adhesion proteins and better outcome.

Acquired perforating dermatosis: clinicopathological study of 31 cases, emphasizing pathogenesis and treatment.

BACKGROUND: Acquired perforating dermatosis (APD) is a rare group of skin disorders of unknown aetiology and pathogenesis and is associated with several systemic diseases. OBJECTIVE: We review the clinicopathological features, associated systemic diseases and treatment response in a series of APD patients. METHODS: We conducted a retrospective observational study of all patients histologically diagnosed with APD in Hospital San Jorge (Huesca, Spain) between 2002 and 2014. Demographic and clinical features were collected from medical records. Statistical analyses were carried out using SPSS software (version 20.0; IBM Corp, Armonk, NY, USA). RESULTS: The study population consisted of 31 patients (19 women and 12 men), with a mean age of 54 years. Reactive perforating collagenosis (n = 15, 45%) was the most common histopathologic type. The most frequently affected area was the lower limbs (66.6%, n = 22), and pruritus was present in 19 patients (61.3%, P = 0.005). Arterial hypertension (30.3%) was the most common associated condition. Five patients were receiving treatment with infliximab when diagnosed with APD. Most patients responded to topical steroids and oral antihistamines (n = 15). LIMITATIONS: This study is retrospective, and the sample size is limited. CONCLUSION: Acquired perforating dermatosis is an underdiagnosed dermatosis frequently associated with systemic disorders. Its pathogenesis may involve vascular damage, not only in patients with diabetes, but also in those with arterial hypertension and chronic venous insufficiency. Control of pruritus and underlying extracutaneous disorders, as well as discontinuation of the treatment with biologics, are important aspects of the management of this dermatosis.

Mycobacterium fortuitum infection after acupuncture treatment.

Actinic keratoses are cutaneous lesions that appear as the result of the proliferation of atypical keratinocytes. These lesions are considered pre-malignant and they can progress to squamous cell carcinoma. Ingenol mebutate has been approved as an effective treatment for AK on the face and trunk. We studied the local skin reactions to this therapy. Data about local skin reactions were collected in a series of 5 patients with photographic documentation, a visual analog scale, and a ranking of satisfaction of the patient. Moderate to severe reactions were reported in most of patients, but only one stopped treatment early. The short duration of treatment contributes to high adherence to the therapy.

Photodynamic Therapy With Methylene Blue for Skin Ulcers Infected With Pseudomonas aeruginosa and Fusarium spp. / Terapia fotodinámica con azul de metileno en úlceras cutáneas infectadas con Pseudomonas aeruginosa y Fusarium spp.

Photodynamic therapy (PDT) is a therapeutic modality with significant antimicrobial activity. We present 2 cases of chronic lower limb ulcers in which fungal and bacterial superinfection complicated management. PDT with methylene blue as the photosensitizer led to clinical and microbiological cure with no significant adverse effects. PDT with methylene blue is a valid option for the management of superinfected chronic ulcers, reducing the use of antibiotics and the induction of resistance.

Resistance of Nonmelanoma Skin Cancer to Nonsurgical Treatments. Part I: Topical Treatments. / Resistencias al tratamiento no quirúrgico en cáncer cutáneo no melanoma. Parte I: tratamientos tópicos.

A wide range of treatments is now available for nonmelanoma skin cancer (NMSC), including 5-fluorouracil, ingenol mebutate, imiquimod, diclofenac, photodynamic therapy, methotrexate, cetuximab, vismodegib, and radiotherapy. All are associated with high clinical and histologic response rates. However, some tumors do not respond due to resistance, which may be primary or acquired. Study of the resistance processes is a broad area of research that aims to increase our understanding of the nature of each tumor and the biologic features that make it resistant, as well as to facilitate the design of new therapies directed against these tumors. In this article we review resistance to the authorized topical treatments for NMSC.