A review of the selection process and decontamination methods with the use of face shields in UV phototherapy during the SARS-CoV-2 pandemic.

Targeted ultraviolet (UV) phototherapy has been used in the management of a wide variety of dermatological clinical conditions including moderate to severe psoriasis unresponsive to topical therapies, vitiligo, severe atopic dermatitis and lymphoproliferative disorders. To date there are no uniform, standardised guidelines for the selection and decontamination process for UV personal protective equipment (PPE) and facial shields used in phototherapy. In the current climate, Coronavirus 2019 (COVID-19) pandemic, standards regarding all decontamination and disinfection processes are under significant scrutiny. In terms of the UV-PPE and facial shields used in phototherapy, careful disinfection procedures need to be implemented to ensure that the decontamination practice is effective enough to neutralise the virulent virus whilst maintaining maximal protection to the user from UV-rays and safeguard the equipment from damage during the cleaning process. The aim of this report is to provide an evidence based review of the current and international practice standards guiding the selection, use and decontamination processes of UV facial shields in phototherapy. The complications and concerns that the COVID-19 pandemic has had on this practice is highlighted. As such, we performed a comprehensive evaluation of the literature to provide recommendations as to the most effective, time efficient and safest practices for disinfection and decontamination of UV facial shields used in phototherapy during these unprecedented times.

Declining incidence of keratinocyte carcinoma in organ transplant recipients.

BACKGROUND: All organ transplant populations are predisposed to increased rates of keratinocyte carcinoma (KC). Since this increased risk was first appreciated, immunosuppressive regimens have changed and organ transplant recipients (OTRs) have been aggressively screened for KC. There is a perception that these measures have impacted on KC incidence but there is a paucity of population-based studies on post-transplant rates of basal cell carcinoma (BCC). OBJECTIVES: To identify trends in incidence rates for KC following solid organ transplantation over the past two decades. METHODS: This nationwide, population-based study included all solid OTRs transplanted between 1994 and 2014. Patient data were matched to national cancer registry data to determine the standardized incidence ratio (SIR) of KC in solid OTRs compared with the general population. RESULTS: In total 3580 solid OTRs were included. The total follow-up time was 28 407 person-years (median follow-up 7·11 years). The overall SIRs for squamous cell carcinoma (SCC) and BCC were 19·7 and 7·0, respectively. Our study documents a progressive fall in the SIRs for SCC and BCC from peak SIRs (95% confidence intervals) in 1994-1996 of 26·4 (21·5-32·4) and 9·1 (7·4-11·3) to 6·3 (2·3-16·7) and 3·2 (1·4-7·1) in 2012-2014, respectively. The ratio of SCC to BCC has remained at 3 to 1 over the last two decades. CONCLUSIONS: Our study is the first to demonstrate a significant reduction over the past two decades in the incidences of both SCC and BCC following solid organ transplantation. The SCC-to-BCC ratio was maintained, demonstrating that both are reducing equally. This trend coincided with temporal changes in immunosuppressive protocols and the introduction of skin cancer prevention programmes. What's already known about this topic? Prior studies have shown that the risk of cutaneous squamous cell carcinoma (SCC) has declined over recent decades following solid organ transplantation. It is not known whether the risk of basal cell carcinoma (BCC) has reduced in line with this. What does this study add? Our study documents a progressive fall in the risk of SCC and BCC following solid organ transplantation over the last two decades. The SCC-to-BCC ratio was maintained, demonstrating that both are reducing equally. The trends observed in our study coincided with temporal changes in immunosuppressive protocols and the introduction of cancer prevention programmes, suggesting that these factors have positively impacted on the risk of keratinocyte carcinoma in this cohort.

Increased non-melanoma skin cancer risk in young patients with inflammatory bowel disease on immunomodulatory therapy: a retrospective single-centre cohort study.

BACKGROUND: Recent studies report an increased risk of non-melanoma skin cancer (NMSC) in immunosuppressed patients with inflammatory bowel disease (IBD). Concurrently, paediatric IBD incidence is rising, with more patients now exposed to immunomodulators from a younger age. OBJECTIVES: To investigate NMSC incidence and to examine the risk associated with immunomodulators in the development of NMSC in patients with IBD. METHODS: This was a retrospective single-centre cohort study. Patients with IBD attending a tertiary adult hospital from 1994 to 2013 were included. Skin cancer incidence was compared with population data from the National Cancer Registry of Ireland (NCRI) to calculate standardized incidence ratio (SIR). Logistic regression was utilized for risk factor analysis. RESULTS: Two thousand and fifty-three patients with IBD were studied. The SIR for NMSC in patients with IBD taking immunomodulators overall was 1.8 (95% CI: 1.0-2.7) with age-specific rates significantly elevated across certain age categories. Exposure to thiopurines (OR: 5.26, 95% CI: 2.15-12.93, P < 0.001) and in particular thiopurines and/or tumour necrosis factor alpha (TNF-α) inhibitors (OR: 6.45, 95% CI: 2.69-15.95, P < 0.001) was significantly associated with NMSC. The majority (82%) of those exposed to a TNF-α inhibitor also had thiopurine exposure. CONCLUSIONS: Compliance with skin cancer preventative measures should be highlighted to all patients with IBD. There should be a low threshold for dermatology referral for immunosuppressed patients, particularly those with a history of exposure to dual immunomodulators from a young age.

Renal dysfunction in patients taking fumaric acid esters - a retrospective cross-sectional study.

BACKGROUND: Fumaric acid esters (FAE) have been used for over 30 years in the management of psoriasis. There have been a number of case reports linking the use of FAE with nephrotoxicity, including acute renal injury and Fanconi syndrome. However, one large multicentre retrospective trial showed no evidence of renal dysfunction with FAE. OBJECTIVES/AIMS: The aim of this study was to determine the number of patients in our institution being treated with FAE who developed significant proteinuria or renal dysfunction. METHODS: This was a single-centre retrospective study assessing all patients on FAE who attended for follow-up during an 18-week period between February and June 2015. Demographics, comorbidities, duration and dose of treatment with FAE, proteinuria, renal function and other biochemical serum abnormalities were recorded. RESULTS: One hundred and twenty-seven patients were included in the study. Eighty-two patients had proteinuria detected at some stage during treatment with FAE, and 18 of these had persistent proteinuria (positive in at least three consecutive specimens, 12 weeks apart). Six patients (five female) developed proximal tubular dysfunction (PTD). The risk factors for the development of PTD appear to be lower bodyweight (P = 0.03), higher dose per weight (P = 0.03) and longer duration of treatment (P = 0.03). Renal dysfunction improved on discontinuation or dose reduction in FAE. CONCLUSION: Fumaric acid esters are frequently associated with transient or persistent proteinuria. Significant renal dysfunction is rare and usually reversible on dose reduction or discontinuation of FAE. This study highlights the importance of screening for proteinuria. Higher doses per weight of treatment and longer duration of FAE therapy are likely risk factors for PTD.

The efficacy of PUVA and narrowband UVB phototherapy in the management of generalised granuloma annulare.

Generalised granuloma annulare (GGA) is a significant cosmetic issue for patients but evidence is lacking to guide optimum treatment. We reviewed our patients with GGA treated with PUVA and narrowband UVB (NBUVB). A telephone questionnaire obtained the patients' perspective in terms of treatment response, remission and overall satisfaction. Twenty patients, all female, were treated. Twelve patients had 15 courses of PUVA therapy (10 oral, 5 bath PUVA) and 10 had 12 courses of NB UVB (two patients had both). There was clearance or minimal residual disease (MRD) on clinical examination in eight of 12 patients after PUVA. Remission was for six months in seven patients extending to one year or more in five patients. Nine patients were contactable after PUVA therapy. They reported their satisfaction as excellent (n = 1), very good (n = 2) or good (n = 4), and two were disappointed. There was clearance or MRD in seven patients treated with NBUVB. Remission was for six months in at least three patients and greater than 1 year in at least 2 patients. Eight patients were contactable and reported satisfaction as excellent (n = 1) or good (n = 5) and two were disappointed. PUVA and NBUVB were effective in at least half of patients and they achieved satisfactory remission. Patients' perceptions of the improvement after phototherapy were lower compared with their dermatologists' assessment.

Drug survival of fumaric acid esters for psoriasis: a retrospective study.

BACKGROUND: Fumaric acid esters (FAEs) have been used for over 30 years in the management of psoriasis. OBJECTIVES: To determine drug survival of FAEs in patients with psoriasis, treatment-limiting adverse drug events and the range of effective drug doses. METHODS: A retrospective, single-centre study assessing all patients commenced on FAEs between October 2003 and July 2012. Demographic data, length of treatment, reasons for discontinuation of FAEs, side-effects and range of doses were recorded. RESULTS: Two hundred and forty-nine patients [160 (64%) male] were included. The mean age at which FAEs were commenced was 44·5 years (range 17-82 years). The mean length of treatment was 28 months (range 1 week to 106 months). In patients who were commenced on FAEs ≥ 4 years before inclusion in this study, the 4-year drug survival was 60% (64/107). FAEs were discontinued in 146/249 patients (59%); this was due to lack of efficacy in 59/146 (40%) and gastrointestinal upset in 39/146 (27%). A very low dose of FAEs (< 240 mg daily) was successful in maintaining control of psoriasis in 26 (10%) patients. The mean treatment duration of these patients was 64 months (range 32-106 months). CONCLUSIONS: Fumaric acid esters have a 4-year drug survival rate of 60%, which compares favourably with reported 4-year survival rates of 40% for etanercept and adalimumab and 70% for infliximab. Longer drug survival is more likely in the significant subgroup of patients in whom a very low dose of FAEs is sufficient to control disease. The reasons for this are unclear.

Is universal screening for hepatitis C infection prior to commencing antitumour necrosis factor-α therapy necessary?

BACKGROUND: Screening for hepatitis C virus (HCV) prior to the commencement of antitumour necrosis factor (anti-TNF)-α therapies for dermatological disease is recommended for all patients. OBJECTIVES: To determine the incidence of HCV infection among dermatology patients who were screened for HCV infection prior to commencing anti-TNF-α therapies. METHODS: We reviewed the HCV infection status of all patients attending our dermatology department who had been tested for evidence of HCV infection between January 2005 and November 2012. We identified patients who had been tested as part of routine screening prior to commencing anti-TNF-α therapy using dermatology departmental records. RESULTS: In total, 215 patients were screened for HCV infection prior to commencing anti-TNF-α therapies. Among this group, 143 patients (66·5%) were male and 72 (33·5%) were female. None of these patients tested positive for active HCV infection. One patient tested positive for HCV antibody with negative HCV antigen and HCV RNA. This indicated previous HCV infection that had cleared. This patient had abnormal liver function tests and a history of alcohol excess. CONCLUSIONS: There were no cases of active HCV infection diagnosed through pretreatment anti-TNF-α screening in our department, which is located in a low-prevalence area for HCV infection. In view of the lack of evidence of harm associated with anti-TNF-α use in HCV-infected patients, we propose that screening for HCV infection in low-prevalence areas should be targeted to those with pre-existing risk factors. This is consistent with current guidelines from the Royal College of General Practitioners. Targeted screening rather than universal screening may be a safe and cost-effective option among patients being evaluated for anti-TNF-α therapies.