Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study).

BACKGROUND: Multiple questionnaires to screen for psoriatic arthritis (PsA) have been developed but the optimal screening questionnaire is unknown. OBJECTIVES: To compare three PsA screening questionnaires in a head-to-head study using CASPAR (the Classification Criteria for Psoriatic Arthritis) as the gold standard. METHODS: This study recruited from 10 U.K. secondary care dermatology clinics. Patients with a diagnosis of psoriasis, not previously diagnosed with PsA, were given all three questionnaires. All patients who were positive on any questionnaire were invited for a rheumatological assessment. Receiver operating characteristic (ROC) curves were used to compare the sensitivity, specificity and area under the curve of the three questionnaires according to CASPAR criteria. RESULTS: In total, 938 patients with psoriasis were invited to participate and 657 (70%) patients returned the questionnaires. One or more questionnaires were positive in 314 patients (48%) and 195 (62%) of these patients attended for assessment. Of these, 47 patients (24%) were diagnosed with PsA according to the CASPAR criteria. The proportion of patients with PsA increased with the number of positive questionnaires (one questionnaire, 19·1%; two, 34·0%; three, 46·8%). Sensitivities and specificities for the three questionnaires, and areas under the ROC curve were, respectively: Psoriatic Arthritis Screening Evaluation (PASE), 74·5%, 38·5%, 0·594; Psoriasis Epidemiology Screening Tool (PEST), 76·6%, 37·2%, 0·610; Toronto Psoriatic Arthritis Screen (ToPAS), 76·6%, 29·7%, 0·554. The majority of patients with a false positive response had degenerative or osteoarthritis. CONCLUSION: Although the PEST and ToPAS questionnaires performed slightly better than the PASE questionnaire at identifying PsA, there is little difference between these instruments. These screening tools identify many cases of musculoskeletal disease other than PsA.

Objective assessment of compliance with treatments in acne.

BACKGROUND: Acne occurs in prepubertal individuals, teenagers and adults, and can have a devastating effect on self-esteem and social relationships. Whether an acne sufferer will seek treatment often depends, apart from the severity, on cultural and social aspects, which play a significant role in the attitude of the individuals and how they cope with the condition. Compliance with treatment regimen is an essential element in overall effectiveness of therapy. OBJECTIVES: To assess patient compliance in acne vulgaris. METHODS: In an open prospective study at a dermatology outpatient clinic, patients with acne, and on isotretinoin or conventional therapies, were examined and completed a questionnaire consisting of: (i) a brief medical and social history, (ii) a compliance assessment sheet, and (iii) the Dermatology Life Quality Index (DLQI). Patients were re-examined after 3 months and their actual treatment usage was directly assessed and compared with expected use. The objective medication adherence (Med Ad) was calculated as (actual treatment use/expected treatment use) x 100. The interview (self-report) Med Ad was obtained by direct questioning. To avoid influencing the behaviour of the subjects, they were not informed of the specific aim of the study: the Local Research Ethics Committee gave approval for this approach. Patient attendance was recorded by referring to the outpatient clinic appointment charts. RESULTS: Of 687 patients seen who fulfilled the inclusion criteria, 403 completed the study. The mean +/- SD overall objective Med Ad was 64.7 +/- 24% (range 0-111%). The mean +/- SD DLQI was 17.7 +/- 8.1 (range 2-30). There was a highly significant negative correlation (r = -0.87) between DLQI scores and Med Ad. The correlation between age and Med Ad was significantly negative (P < 0.01). Being female, married, employed and not paying for prescriptions were characteristics associated with increased Med Ad and a lower DLQI. Med Ad was greater for isotretinoin therapy and for first time usage of isotretinoin. The major reasons for missing treatment given by the patients were being fed up, forgetful or too busy. Smoking cigarettes and drinking alcohol resulted in reduced Med Ad. The mean +/- SD interview Med Ad was 93.9 +/- 5% (range 85-100%). CONCLUSIONS: The study demonstrates that a range of disease-related and social factors may influence compliance with treatment in acne. The inverse relationship between DLQI and Med Ad probably reflects the profound interaction of physical and psychological factors as well as perceived treatment failure.

An evaluation of the role of a store-and-forward teledermatology system in skin cancer diagnosis and management.

There is currently much interest in the potential role of telemedicine in improving the delivery of dermatological care in the UK. The two teledermatology systems available at present are divided into live video and store-and-forward technology. We investigated the value of a store-and-forward teledermatology system in the diagnosis and management of lesions suspicious of skin cancer. A total of 163 store-and-forward referrals of patients with one lesion each were assessed independently by a Consultant and a third-year trainee dermatologist. The accuracy of diagnosis and appropriateness of management from these assessments was compared to a subsequent face-to-face consultation with the Consultant. Analysis of the Consultants' diagnoses showed that 48% were identical for teledermatology and conventional face-to-face consultations. A further 17% of teledermatology diagnoses included the actual clinical diagnosis as a possibility but 20% were either incorrect or a diagnosis could not be made. In the remaining 15% of cases the digital image was of insufficient quality for assessment. Of the trainee's reports, 44% were identical to the clinical diagnoses and another 20% included the clinical diagnosis as a possibility. The management plan was appropriate in 55% of the total teledermatology referrals assessed by the Consultants and in 52% assessed by the trainee when compared with the conventional consultation. This study illustrates that the store-and forward type telemedicine system has limited diagnostic accuracy for skin lesions. However, our results suggest that store-and-forward teledermatology may be suitable and safe for screening out clearly benign lesions but the study casts doubt on its efficiency.

Prediction of outcome in the treatment of onychomycosis.

Patients with toenail onychomycosis remain a therapeutic challenge despite the introduction of new systemic therapies. Around 20% of patients remain uncured even with optimal oral therapy, but the reasons for treatment failure are unclear. Thus far there are no data to suggest that treatment failures can be identified on the basis of their presenting features or progress during treatment. In a series of patients, we have attempted to identify clinical parameters that determine the patient response to 12 weeks of oral terbinafine for confirmed dermatophyte onychomycosis. As part of a dose-defining randomized multicentre study, 35 patients were followed for 48 weeks. The unaffected nail length, growth rate, hyperkeratosis, onycholysis and presence of a dermatophytoma were assessed prospectively. To confirm our findings, at the end of the study period we analysed retrospectively photographs that had been taken regularly throughout the trial. The average degree of hyperkeratosis was less severe in the group achieving a disease-free nail, meaning clinical and mycological cure. For mycological cure alone, no predictive factors could be identified.