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.

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.

Position statement on classification of basal cell carcinomas. Part 1: unsupervised clustering of experts as a way to build an operational classification of advanced basal cell carcinoma based on pattern recognition.

BACKGROUND: No simple classification system has emerged for 'advanced basal cell carcinomas', and more generally for all difficult-to-treat BCCs (DTT-BCCs), due to the heterogeneity of situations, TNM inappropriateness to BCCs, and different approaches of different specialists. OBJECTIVE: To generate an operational classification, using the unconscious ability of experts to simplify the great heterogeneity of the clinical situations into a few relevant groups, which drive their treatment decisions. METHOD: Non-supervised independent and blinded clustering of real clinical cases of DTT-BCCs was used. Fourteen international experts from different specialties independently partitioned 199 patient cases considered 'difficult to treat' into as many clusters they want (≤10), choosing their own criteria for partitioning. Convergences and divergences between the individual partitions were analyzed using the similarity matrix, K-mean approach, and average silhouette method. RESULTS: There was a rather consensual clustering of cases, regardless of the specialty and nationality of the experts. Mathematical analysis showed that consensus between experts was best represented by a partition of DTT-BCCs into five clusters, easily recognized a posteriori as five clear-cut patterns of clinical situations. The concept of 'locally advanced' did not appear consistent between experts. CONCLUSION: Although convergence between experts was not granted, this experiment shows that clinicians dealing with BCCs all tend to work by a similar pattern recognition based on the overall analysis of the situation. This study thus provides the first consensual classification of DTT-BCCs. This experimental approach using mathematical analysis of independent and blinded clustering of cases by experts can probably be applied to many other situations in dermatology and oncology.

Position statement on classification of basal cell carcinomas. Part 2: EADO proposal for new operational staging system adapted to basal cell carcinomas.

BACKGROUND: No simple staging system has emerged for basal cell carcinomas (BCCs), since they do not follow the TNM process, and practitioners failed to agree on simple clinical or pathological criteria as a basis for a classification. Operational classification of BCCs is required for decision-making, trials and guidelines. Unsupervised clustering of real cases of difficult-to-treat BCCs (DTT-BCCs; part 1) has demonstrated that experts could blindly agree on a five groups classification of DTT-BCCs based on five patterns of clinical situations. OBJECTIVE: Using this five patterns to generate an operational and comprehensive classification of BCCs. METHOD: Testing practitioner's agreement, when using the five patterns classification to ensure that it is robust enough to be used in the practice. Generating the first version of a staging system of BCCs based on pattern recognition. RESULTS: Sixty-two physicians, including 48 practitioners and the 14 experts who participated in the generation of the five different patterns of DTT-BCCs, agreed on 90% of cases when classifying 199 DTT-BCCs cases using the five patterns classification (part 1) attesting that this classification is understandable and usable in practice. In order to cover the whole field of BCCs, these five groups of DTT-BCCs were added a group representing the huge number of easy-to-treat BCCs, for which sub-classification has little interest, and a group of very rare metastatic cases, resulting in a four-stage and seven-substage staging system of BCCs. CONCLUSION: A practical classification adapted to the specificities of BCCs is proposed. It is the first tumour classification based on pattern recognition of clinical situations, which proves to be consistent and usable. This EADO staging system version 1 will be improved step by step and tested as a decision tool and a prognostic instrument.

What Proportion of the Caseload at Dermatology Outpatient Clinics in Spain Do Skin Tumors Account for? Results from the DIADERM National Random Sampling Project. / ¿Cuánta carga asistencial supone la enfermedad tumoral cutánea en la actividad ambulatoria en la Dermatología española? Resultados del muestreo aleatorio nacional DIADERM.

INTRODUCTION AND OBJECTIVE: A significant part of a dermatologist's activity involves the diagnosis and management of tumors. The aim of this study was to analyze the caseload at public and private dermatology outpatient clinics in Spain to determine the proportion of tumor diagnoses. MATERIAL AND METHOD: Observational cross-sectional study of diagnoses made in dermatology outpatient clinics during 2 data-collection periods in the DIADERM study, an anonymous survey of a random, representative sample of dermatologists across Spain. Diagnoses made during the 2 periods were coded according to the CIE-10. There were 165 tumor-related codes, classified into 24 groups. For the purpose of this study, these groups were then reduced to benign melanocytic lesions, malignant melanocytic lesions, benign nonmelanocytic lesions, and malignant nonmelanocytic lesions. RESULTS: Tumors accounted for 46.2% of all diagnoses; 18.5% of the tumors were malignant (a category that included in situ forms of keratinocyte cancers). Four of the 10 most common diagnoses were of malignant tumors: in situ keratinocyte cancers, basal cell carcinoma, melanoma, and squamous cell carcinoma. Significant differences were observed between malignant and benign tumors according to type of practice (public vs. private) and geographic region. CONCLUSION: Skin cancer accounts for a significant part of the dermatologist's caseload in Spain. Differences can be observed depending on the public/private healthcare setting and other factors.

Risk Perception Plays Minimal Role in Sun Exposure Behaviours.

Despite decades of public health campaigns, tanning and sunburn still occur at unacceptably high rates. Skin cancer prevention campaigns predominately focus on increasing awareness of the risk of excessive sun exposure. This study sought to assess the efficacy of this approach, by interrogating correlations between risk perception and sun exposure behaviour. A 31-item questionnaire assessing skin cancer risk factors, tanning attitudes, sunburn and tanning behaviour was undertaken by individuals who attended a workplace skin check. Validated questions were included to assess cognitive and affective risk perception and to frame risk as absolute, comparative and conditional. One hundred sixty-seven respondents completed the questionnaire. No aspects of risk perception (absolute cognitive, affective or conditional) significantly correlated with protective sun exposure behaviour, with the exception of perceived comparative severity of skin cancer. Instead, positive tanning attitudes were far more significantly correlated with sun exposure behaviour. Actual risk and risk perception have very limited impact on sun exposure behaviour. Instead, sun exposure behaviour was significantly linked with positive tanning attitudes. It is suggested, therefore, that campaigns focussing solely on education regarding risk factors appear to have been ineffective in behaviour mitigation, and innovative approaches, aimed at influencing tanning norms, might complement the existing educational campaigns.

Proportion of Potentially Avoidable Referrals From Primary Care to Dermatologists for Cystic Lesions or Benign Neoplasms in Spain: Analysis of Data From the DIADERM Study. / Análisis de la proporción de derivaciones potencialmente evitables desde Atención Primaria a Dermatología por lesiones quísticas o tumorales benignas en España. Datos del estudio DIADERM.

BACKGROUND AND OBJECTIVE: Skin lesions are a common reason for consulting a primary care physician. Current legislation in Spain states that purely aesthetic skin problems that do not pose a health problem are not to be treated within the National Health Service. The aim of this study was to estimate the proportion of referrals from primary care physicians to dermatologists that were for cystic lesions or benign tumors and could potentially have been avoided. MATERIAL AND METHODS: We consulted cases registered in the DIADERM study dataset, which is representative of dermatology practice in Spain, and collected the main diagnoses given on referring patients from primary care. A referral diagnosis was classified as potentially avoidable if it corresponded to one of the primary care discharge diagnoses listed in a consensus paper of the Andalusian section of the Spanish Academy of Dermatology and Venereology (AEDV). RESULTS: We collected 2171 main reasons for first-visit referrals to dermatologists; 686 of them (31.6%) were for cystic lesions or benign tumors and classified as potentially avoidable. In 478 cases (22%) the patients were discharged on the first visit. The most frequent diagnoses in such cases were seborrheic keratosis (9.3%) and melanocytic nevus (8.6%). CONCLUSIONS: Nearly a third of referrals from primary care to a dermatologist were for cystic lesions and benign tumors and could have been avoided. A clearer understanding of our caseload can be useful for improving planning, training, and health care system management.

Do Dermatologic Diagnosis Change in Hot vs. Cold Periods of The Year? A Sub-Analysis of the DIADERM National Sample (Spain 2016). / ¿Existe variación en los diagnósticos dermatológicos entre la temporada de frío vs. calor? Un subanálisis del estudio DIADERM (España 2016).

BACKGROUND: Knowledge of seasonal variation of cutaneous disorder may be useful for heath planning and disease management. To date, however, descriptions of seasonality including all diagnoses in a representative country sample are very scarce. OBJECTIVES: To evaluate if clinical dermatologic diagnosis in Spain change in the hot vs. cold periods. MATERIALS AND METHODS: Survey based on a random sample of dermatologists in Spain, stratified by area. Each participant collected data during 6 days of clinical activity in 2016 (3 in the cold period of the year, 3 in the hot period). Clinical diagnoses were coded using ICD-10. RESULTS: With a 62% response proportion, we got data on 10999 clinical diagnoses. ICD-10 diagnostic groups that showed changes were: other benign neoplasms of skin (D23), rosacea (L71) and other follicular disorders (L73), which were more common in the hot period and acne (L70) which was more frequent in the cold period. We describe differences in the paediatric population and in private vs. public practice. Some of these differences might be associated to differences in the population demanding consultations in different periods. CONCLUSIONS: The frequency of most clinical diagnosis made by dermatologists does not change over the year. Just a few of the clinical diagnoses made by dermatologists show a variation in hot vs. cold periods. These variations could be due to the diseases themselves or to seasonal changes in the demand for consultation.

Vitiligo-like depigmentation in oncology patients treated with immunotherapies for nonmelanoma metastatic cancers.

Vitiligo-like depigmentation (VLD) is a characteristic cutaneous event described in patients with metastatic malignant melanoma receiving treatment with immune checkpoint inhibitors. We report the onset of VLD in three patients with other cancer types (cholangiocarcinoma, renal cell carcinoma and squamous cell carcinoma) following treatment with immunotherapy (combination pembrolizumab and nivolumab for the first, and pembrolizumab for the other two cancer types). Cases of VLD have not been reported previously in patients treated for any of these cancers, to our knowledge. Pembrolizumab and nivolumab are monoclonal antibodies targeting programmed cell death (PD)-1 receptors, while ipilimumab targets cytotoxic T-lymphocyte antigen-4. Our clinical finding challenges the current understanding of VLD as a malignant melanoma-specific immunotherapy-related adverse event.

Referral of Patients to Dermatology and Teledermatology Consultations in Spain. DIADERM Study. / Derivación de pacientes en consulta de dermatología y de teledermatología en España. Estudio DIADERM.

BACKGROUND AND OBJECTIVES: Understanding the origin and referral routes of patients seen in teledermatology and in-person dermatology consultations in Spain is of interest from the perspective of health care management. The objective of this study was to describe the referral routes and the frequency and characteristics of teledermatology consultations in Spain. MATERIAL AND METHODS: We performed a descriptive cross-sectional study of data collected over 6 days from the DIADERM study sample, which included the outpatients diagnosed by 80 Spanish dermatologists, selected by means of stratified random sampling. We studied the source and destination of patients based on funding, type of consultation, and age of the patients. We reported the frequency of teledermatology consultations, their origin and destination, type of funding, age of the patients, and most common diagnoses, and compared them with the same characteristics for in-person consultations. RESULTS: In private consultations, most patients were direct clients, whereas the most frequent source in public consultations was primary care and the dermatologist. Sixty-six percent of patients were referred to dermatology and 27% were discharged. No differences in these percentages were found between public and private consultations. The ratio of follow-up to initial visits was 0.8 for public consultations and 0.2 for private consultations. Teledermatology accounts for 1% of consultations. Eighty percent of these come from primary care and 17% are direct visits. Thirty-three percent of these visits are referred to primary care - a greater proportion than in in-person consultations. Galicia, Andalusia, and Catalonia are the regions with the highest percentage of consultations. CONCLUSIONS: The results suggest that dermatologists in Spain have a considerable ability to resolve cases. Teledermatology accounts for a small percentage of consultations and access to these consultations is direct in a large percentage of cases.

Difficulties Coding Dermatological Disorders Using the ICD-10: The DIADERM Study. / Problemas de la CIE-10 para la codificación de diagnósticos dermatológicos. Estudio DIADERM.

BACKGROUND AND OBJECTIVES: The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) has some shortcomings when it comes to coding certain dermatological disorders. To overcome these shortcomings, a compatible version of the ICD-10 specifically adapted to dermatology was produced in Spain in 1999. The recent DIADERM study recorded 10 999 dermatological diagnoses using a representative sample of dermatologists working at outpatient clinics in Spain. The aims of the current study were to identify diagnoses from the DIADERM study that could not be coded using the adapted ICD-10, determine why, and check if they could be coded using the draft ICD-11. MATERIAL AND METHODS: We included all dermatological diagnoses from the DIADERM study that could not be assigned a code from the adapted ICD-10. We then quantified and recorded all the diagnoses that could not be coded using either the adapted ICD-10 or the draft ICD-11. RESULTS: Of the 10 999 diagnoses analyzed, 41 had not been assigned a code. Of these, 19 were assigned an adapted ICD-10 code on reassessment. However, the adapted ICD-10 and the draft ICD-11 lacked specific codes for 22 and 17 diagnoses, respectively. CONCLUSIONS: The adapted ICD-10 can be used to correctly code the vast majority of dermatological diagnoses seen in routine clinical practice. Nevertheless, the system does have some minor shortcomings when it comes to coding certain diseases, particularly newly discovered and emerging diseases. Some of these problems, however, were resolved with the new ICD-11. Based on our findings, we propose some modifications to the ICD-11.

Patient perceptions of clear/almost clear skin in moderate-to-severe plaque psoriasis: results of the Clear About Psoriasis worldwide survey.

BACKGROUND: Therapeutic advances have made the achievement of clear/almost clear skin possible for many patients with moderate-to-severe plaque psoriasis. OBJECTIVE: To determine patient perceptions of the impact of psoriasis and of attaining clear/almost clear skin. METHODS: Global survey of patients with moderate-to-severe psoriasis. RESULTS: A total of 8338 patients from 31 countries participated. The majority (57%) had not achieved self-assessed clear/almost clear skin with their current therapy, and 56% of those who had not met this goal believed it would be impossible to do so. Among the patients who had clear/almost clear skin, 73% had not initiated their current treatment until >1 year after psoriasis diagnosis, and 28% had to wait >5 years. Eighty-four percent of all respondents experienced discrimination and/or humiliation due to psoriasis, and many reported negative effects on work, intimate relationships, sleep and mental health. Patients without clear/almost clear skin reported that such achievement would open new possibilities, such as swimming (58%), a wider choice of clothing (40%), and meeting new people (26%). A limitation of this study, as with any survey-based research, is that selection and recall bias may have been present. Additionally, respondent definitions of clear/almost clear skin were subjective and may have varied. CONCLUSION: Despite the importance of clear/almost clear skin to psoriasis patients, most are still not achieving it, and many are unaware it is possible.

Outpatient Dermatological Diagnoses in Spain: Results From the National DIADERM Random Sampling Project. / Análisis de los diagnósticos realizados en la actividad ambulatoria dermatológica en España: muestreo aleatorio nacional DIADERM.

INTRODUCTION: Dermatologists perform most of their work in outpatient or private clinics. Data on the diagnoses made by dermatologists in these settings are lacking, however, as outpatient activity, unlike hospital activity, is difficult to code. The aim of this study was to analyze the diagnoses made by members of the Spanish Academy of Dermatology and Venereology (AEDV) at dermatology clinics in Spain. METHODOLOGY: We selected a random sample of AEDV dermatologists drawn from the AEDV list and stratified by geographic area. The selected dermatologists received instructions on how to collect the data required. Each participant recorded the diagnosis reached and other data for patients seen during 2 specified periods: 3 days in January and 3 days in May. The diagnoses were subsequently coded by a dermatologist expert in applying the International Classification of Diseases (10th revision). In view of the complex nature of the sample, data were analyzed with standard error and finite population corrections. RESULTS: The sample consisted of 124 dermatologists. Of these, 65% participated in the first phase of the study and 59% in the second. An estimated 621 562 patients (95% CI, 368 130-874 995) visit the dermatologist every month in Spain. This is the equivalent of 28 (25-31) patients per day per clinic. The most common diagnosis recorded was actinic keratosis, followed by basal cell carcinoma and melanocytic nevus. The vast majority of visits took place at the clinic, but 1% of patients (0.3%-3%) were assessed using teledermatology. CONCLUSIONS: This is the first study in Spain to analyze diagnoses made by AEDV members at outpatient dermatology clinics. Our findings show a high volume of activity and will be useful for guiding health care planning, resource use, and future studies.

Towards global consensus on core outcomes for hidradenitis suppurativa research: an update from the HISTORIC consensus meetings I and II.

BACKGROUND: A core outcomes set (COS) is an agreed minimum set of outcomes that should be measured and reported in all clinical trials for a specific condition. Hidradenitis suppurativa (HS) has no agreed-upon COS. A central aspect in the COS development process is to identify a set of candidate outcome domains from a long list of items. Our long list had been developed from patient interviews, a systematic review of the literature and a healthcare professional survey, and initial votes had been cast in two e-Delphi surveys. In this manuscript, we describe two in-person consensus meetings of Delphi participants designed to ensure an inclusive approach to generation of domains from related items. OBJECTIVES: To consider which items from a long list of candidate items to exclude and which to cluster into outcome domains. METHODS: The study used an international and multistakeholder approach, involving patients, dermatologists, surgeons, the pharmaceutical industry and medical regulators. The study format was a combination of formal presentations, small group work based on nominal group theory and a subsequent online confirmation survey. RESULTS: Forty-one individuals from 13 countries and four continents participated. Nine items were excluded and there was consensus to propose seven domains: disease course, physical signs, HS-specific quality of life, satisfaction, symptoms, pain and global assessments. CONCLUSIONS: The HISTORIC consensus meetings I and II will be followed by further e-Delphi rounds to finalize the core domain set, building on the work of the in-person consensus meetings.