Bioethical Conflicts in Current Dermatology: A Narrative Review. / Conflictos bioéticos en la dermatología actual: una revisión narrativa.

Both the functions and equipment of dermatologists have increased over the past few years, some examples being cosmetic dermatology, artificial intelligence, tele-dermatology, and social media, which added to the pharmaceutical industry and cosmetic selling has become a source of bioethical conflicts. The objective of this narrative review is to identify the bioethical conflicts of everyday dermatology practice and highlight the proposed solutions. Therefore, we conducted searches across PubMed, Web of Science and Scopus databases. Also, the main Spanish and American deontological codes of physicians and dermatologists have been revised. The authors recommend declaring all conflicts of interest while respecting the patients' autonomy, confidentiality, and privacy. Cosmetic dermatology, cosmetic selling, artificial intelligence, tele-dermatology, and social media are feasible as long as the same standards of conventional dermatology are applied. Nonetheless, the deontological codes associated with these innovations need to be refurbished.

Clinical and Epidemiological Characteristics of Patients Being Treated for Scabies in Spain: Opportunities for Improvement - A Multicenter Cross-Sectional CLINI-AEDV Study. / Características clínicas y epidemiológicas de pacientes diagnosticados de escabiosis en España: oportunidades de mejora. Estudio transversal multicéntrico CLINI-AEDV.

BACKGROUND: Several studies support the hypothesis that scabies is on the rise in Spain. There are also concerns about the possible development of resistance to treatment and an increase in atypical presentations. The aims of this study were to describe the demographic and clinical characteristics of patients with scabies seen by dermatologists in Spain, to identify the possible emergence of atypical forms of scabies, and to explore the frequency of treatment failures and associated risk factors. METHODS: We conducted an observational, cross-sectional, multicenter study of data collected prospectively in April and May 2023 using the CLINI-AEDVp platform created by the Spanish Academy of Dermatology and Venereology (AEDV). RESULTS: Participating dermatologists from 31 hospitals in 15 of Spain's autonomous communities recorded 186 cases of active scabies (51% in women) during the study period. A diagnostic certainty level of A, B or C as per the International Alliance for the Control of Scabies Consensus Criteria was required for diagnosis. Overall, 92% of patients had typical scabies and 66% had already been treated with a scabicide for the current episode. Of the treated patients, only 36% had received and completed adequate treatment (including the simultaneous treatment of all household members) and 50% had not received clear written recommendations. CONCLUSIONS: In a high proportion of the cases of scabies studied, the patient had already received treatment. In those cases, we observed several remediable shortcomings that could explain why some of these treatments had failed. Remedying these deficiencies should lead to better control of scabies and an improved assessment of the actual effectiveness of currently available scabicides.

[Translated article] Clinical and Epidemiological Characteristics of Patients Being Treated for Scabies in Spain: Opportunities for Improvement - A Multicenter Cross-Sectional CLINI-AEDV Study.

BACKGROUND: Several studies support the hypothesis that scabies is on the rise in Spain. There are also concerns about the possible development of resistance to treatment and an increase in atypical presentations. The aims of this study were to describe the demographic and clinical characteristics of patients with scabies seen by dermatologists in Spain, to identify the possible emergence of atypical forms of scabies, and to explore the frequency of treatment failures and associated risk factors. METHODS: We conducted an observational, cross-sectional, multicenter study of data collected prospectively in April and May 2023 using the CLINI-AEDVp platform created by the Spanish Academy of Dermatology and Venereology (AEDV). RESULTS: Participating dermatologists from 31 hospitals in 15 of Spain's autonomous communities recorded 186 cases of active scabies (51% in women) during the study period. A diagnostic certainty level of A, B or C as per the International Alliance for the Control of Scabies Consensus Criteria was required for diagnosis. Overall, 92% of patients had clinical features of classic scabies and 66% had already been treated with a scabicide for the current episode. Of the treated patients, only 36% had received and completed adequate treatment (including the simultaneous treatment of all household members) and 50% had not received clear written recommendations. CONCLUSIONS: In a high proportion of scabies cases, the patient has already received treatment. In those cases, we observe several remediable shortcomings that could explain why some of these treatments fail. Remedying these deficiencies should lead to better control of scabies and an improved assessment of the actual effectiveness of currently available scabicides.

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.

Artificial Intelligence in Dermatology: A Threat or an Opportunity? / Inteligencia artificial en dermatología: ¿amenaza u oportunidad?

The worldwide explosion of interest in artificial intelligence (AI) has created a before-and-after moment in our lives by generating great improvements in such sectors as the automotive and food production industries. AI has even been called the fourth industrial revolution. Machine learning through AI is helping to improve professional processes and promises to transform the health care sector as we know it in various ways: 1) through applications able to promote health in the general population by providing high-quality information and offering advice for different segments of the population based on prediction models; 2) by developing prediction models based on anonymized clinical data, for preventive purposes in primary care; 3) by analyzing images to provide additional decision-making support for health care providers, for improving specialist care at the secondary level; and 4) through robotics applied to processes that promote health and well-being. However, the medical profession harbors doubts about whether this revolution is a threat or an opportunity owing to a lack of understanding of AI technology and the methods used to validate its applications. This article outlines basic aspects of AI as it is applied in dermatology and reviews the main advances achieved in the last 5 years.

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.

Dermoscopy of inverted follicular keratosis: study of 12 cases.

BACKGROUND: Inverted follicular keratosis (IFK) is an uncommon benign tumour of the follicular infundibulum, which is often misdiagnosed clinically as other keratinizing tumours, and commonly diagnosed correctly by histopathology. There are few reports about the dermoscopic findings of this lesion. AIM: To evaluate the dermoscopic features of IFK. METHODS: The dermoscopic structures and patterns in digital dermoscopic images of 12 histopathologically confirmed cases of IFK collected from 5 hospitals in Spain were evaluated. RESULTS: A keratoacanthoma (KA)-like pattern composed of central keratin surrounded by hairpin vessels in a radial arrangement was the most common pattern in IFK (58.3%). The second most common pattern was composed of a yellowish-white amorphous central area surrounded by vascular structures in a radial arrangement (33.3%). The remaining case showed a pattern composed of a yellowish-white amorphous central area with milky red globules. Vascular structures were present in all cases, with a monomorphic pattern in seven cases and a polymorphic pattern in five, mainly with radial arrangement. Arborizing vessels, linear irregular vessels, corkscrew vessels and milky red globules were present in some cases. CONCLUSIONS: We describe the two main patterns of IFK. Lesions with a KA-like pattern are clinically and dermoscopically undistinguishable from KA and squamous cell carcinoma. Cases with a polymorphic vascular pattern could be confused with malignant tumours, including basal cell carcinoma and amelanotic melanoma.

e-Dermatology: social networks and other web based tools.

The use by patients of social networking sites and the Internet to look for health related information has already become an everyday phenomenon. If, as dermatologists, we want to be part of this new conversation and provide quality content, we will have to adapt to digital media and find new ways of communicating with both our patients and our colleagues. Dozens of Spanish dermatologists have already ventured into the online space and have begun to provide important content through blogs, which they also disseminate via the social media. However, the use of these new technologies can also pose certain risks from the standpoint of ethics and our codes of practice and even place an individual's digital reputation in jeopardy. Another aspect of this new situation is that the Internet produces information saturation, and the appropriate use of certain tools can help to improve our productivity and prevent such information overload or infoxication.

Safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and chronic viral hepatitis B or C: a retrospective, multicentre study in a clinical setting.

BACKGROUND: Both the safety and efficacy of biologic therapy may be affected in the presence of highly prevalent chronic viral hepatitis. OBJECTIVE: To evaluate the safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and concomitant chronic viral hepatitis. METHODS: This was a retrospective, multicentre study. Twenty-five patients with psoriasis and concurrent hepatitis C virus (HCV) (20 patients) or hepatitis B virus (HBV) (five patients) infection who had received at least one biologic agent (etanercept, 21 treatments; adalimumab, four; ustekinumab, four; infliximab, two) were included. Clinical, imaging and laboratory data were recorded. RESULTS: In the case of HCV infection, the majority of the patients did not exhibit increases in their viral load or serum liver tests. Aspartate aminotransferase, alanine aminotransferase and gamma glutamyl transpeptidase were doubled from the baseline measurement in only one patient treated with etanercept. Two other cases exhibited viral load increases during the follow-up period. In total, 18 of the 26 treatments achieved a 75% improvement in their Psoriasis Area and Severity Index (PASI 75) score during the follow-up period. Two patients treated with etanercept were diagnosed with hepatocellular carcinoma. In the case of HBV infection, all of the patients were being treated with antiviral therapy, and none presented significant variations in viral load or serum liver enzymes. All patients achieved a PASI 75 during follow-up. CONCLUSIONS: Biologic therapy was effective and safe for the majority of our patients with HCV and HBV infection, although there may be a risk of reactivation or aggravation. We describe the first cases to receive ustekinumab. The use of biologics should be limited to those cases in which the risk-benefit ratio is justified.

Spanish evidence-based guidelines on the treatment of psoriasis with biologic agents, 2013. Part 1: on efficacy and choice of treatment. Spanish Psoriasis Group of the Spanish Academy of Dermatology and Venereology.

Biologic therapy is a well-established strategy for managing moderate and severe psoriasis. Nevertheless, the high cost of such therapy, the relatively short span of clinical experience with biologics, and the abundance of literature now available on these agents have made evidence-based and consensus-based clinical guidelines necessary. The ideal goal of psoriasis treatment is to achieve complete or nearly complete clearing of lesions and to maintain it over time. Failing that ideal, the goal would be to reduce involvement to localized lesions that can be controlled with topical therapy. Although current evidence allows us to directly or indirectly compare the efficacy or risk of primary or secondary failure of available biologics based on objective outcomes, clinical trial findings cannot be directly translated to routine practice. As a result, the prescribing physician must tailor the treatment regimen to the individual patient. This update of the clinical practice guidelines issued by the Spanish Academy of Dermatology and Venereology (AEDV) on biologic therapy for psoriasis incorporates information from the most recent publications on this topic.

[Cutaneous tuberculosis in an area of Mallorca (2003-2011)]. / Tuberculosis cutánea en una zona de Mallorca (2003-2011).

BACKGROUND AND OBJECTIVE: Tuberculosis is an important health care problem, even in our setting. The objective of this study is to describe clinic and epidemiological features of cutaneous tuberculosis in our area. PATIENTS AND METHODS: A retrospective study was performed of all patients diagnosed of cutaneous tuberculosis in a hospital in Mallorca (Spain) from January 2003 to July 2011. The clinical forms, diagnostic methods used, treatment used and clinical course were recorded. RESULTS: Twenty-eight cases of cutaneous tuberculosis were diagnosed (5.9% of the tuberculosis cases diagnosed in this period), 15 with classic cutaneous tuberculosis (14 scrofuloderma, 1 empyema necessitatis) and 13 patients with tuberculids (8 erythema induratum of Bazin disease and 5 erythema nodosum). Scrofulodermas came from lymph nodes in 10 of the patients, infected bone in 4 and pleural in one case; 13/28 patients came from other continents. Most of the patients were treatment with 3-4 tuberculostatic drugs, with favorable course. CONCLUSIONS: Cutaneous tuberculosis is not uncommon in our setting. In classic cutaneous tuberculosis culture is the gold standard diagnostic method while tuberculids are most commonly diagnosed by histology.

[Multiplatform application to determine presence of metabolic syndrome and cardiovascular risk in patients with psoriasis]. / Calculadora multiplataforma para síndrome metabólico y riesgo cardiovascular en pacientes con psoriasis.

Traditionally, psoriasis was considered to be a purely cutaneous disease affecting otherwise healthy patients (except for joint involvement). Recent studies have, however, shown a relationship between psoriasis and cardiovascular disease, with increased mortality in patients who have severe forms of psoriasis. Dermatologists are thus in a position to play an important role in identifying patients at greater risk of cardiovascular disease and detecting potential risk factors that are, for the most part, manageable and avoidable. To this end, we designed a multiplatform application that provides a simple and intuitive tool to determine body mass index, whether or not metabolic syndrome is present, and cardiovascular risk. The application runs on iOS, Android, and the webpage of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (AEDV).

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.

[Digital photograph storage systems in clinical dermatology]. / Sistemas de almacenamiento en fotografía clínica dermatológica.

In recent years, digital photography has consolidated its role in clinical dermatology. In view of the quality and low cost of current equipment and the simplicity of digital storage, almost all dermatologists now use digital photography, which is also extremely versatile and readily applicable to teaching. However, to maximize its full potential, image retrieval must be available at any time and with the patient present. This requires a suitable storage system that may vary according to the characteristics of each center. Dermatologists must also find time to maintain and organize the digital archives. The present article describes current options in digital image storage and retrieval, ranging from multidepartmental picture archiving and communication systems at one end to image management freeware at the other, and also including dedicated dermatology software.

[Dermatology service utilization and reasons for consultation by Spanish and immigrant patients in the region served by Hospital Son Llàtzer, Palma de Majorca, Spain]. / Motivos de consulta dermatológicos en la población inmigrante y española del área de salud del Hospital Son Llàtzer (Mallorca).

INTRODUCTION: Spain has come to be one of the main European destinations for immigrants from countries with low per capita incomes. The Balearic Islands have the second largest proportion of immigrants in a Spanish autonomous community. The aim of this study was to describe the dermatology service utilization by immigrant and Spanish populations at Hospital Son Llàtzer in Palma de Majorca, Spain. PATIENTS AND METHODS: A longitudinal, descriptive study was undertaken to analyze first visits to the dermatology department of Hospital Son Llàtzer between July 10, 2007 and July 9, 2008. RESULTS: Of the 6699 first visits, 13. 2% were by non-Spanish patients, originating from 64 different countries, with Argentina, Ecuador, and Columbia the most common. Spanish patients consulted more frequently than non-Spanish patients. Patients from outside the European Union consulted most often for inflammatory conditions, whereas patients from Spain and other countries of the European Union mainly consulted for benign tumors. Consultations were for sexually transmitted disease in 2% of visits. The reason for the visit was classified as cosmetic in 14. 1% of patients. CONCLUSIONS: The dermatology service utilization by the immigrant population was lower than by Spanish patients, although with differences according to the country of origin.

[Guidelines on the use of methotrexate in psoriasis]. / Metotrexato: guía de uso en psoriasis.

Psoriasis, a chronic multifactorial inflammatory disease that develops in genetically predisposed individuals, affects approximately 1.5% of the Spanish population. This disease has a negative impact on patients' quality of life, and long-term therapy is often required to control the symptoms. In addition to the classical systemic treatments (methotrexate, acitretin, cyclosporine, and ultraviolet light), the group of drugs known as biologics (etanercept, infliximab, adalimumab, and ustekinumab) provides the dermatologist with an expanded therapeutic armamentarium, thereby improving the likelihood of controlling psoriasis in patients with severe and/or extensive disease. Methotrexate, a classic antipsoriatic drug, is still very useful either as single-drug therapy or in combination with other systemic drugs, particularly as a rescue therapy or combined with biologics. This article aims to establish the role of methotrexate in the treatment of psoriasis. We considered it of interest to develop guidelines for using methotrexate in the management of psoriasis with a view to ensuring the safe and proper use of this drug in the management of psoriasis. This document was developed by consensus among members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology.

Guidelines on the Use of Methotrexate in Psoriasis. / Metotrexato: guía de uso en psoriasis.

Psoriasis, a chronic multifactorial inflammatory disease that develops in genetically predisposed individuals, affects approximately 1.5% of the Spanish population. This disease has a negative impact on patients' quality of life, and long-term therapy is often required to control the symptoms. In addition to the classical systemic treatments (methotrexate, acitretin, cyclosporine, and ultraviolet light), the group of drugs known as biologics (etanercept, infliximab, adalimumab, and ustekinumab) provides the dermatologist with an expanded therapeutic armamentarium, thereby improving the likelihood of controlling psoriasis in patients with severe and/or extensive disease. Methotrexate, a classic antipsoriatic drug, is still very useful either as single-drug therapy or in combination with other systemic drugs, particularly as a rescue therapy or combined with biologics. This article aims to establish the role of methotrexate in the treatment of psoriasis. We considered it of interest to develop guidelines for using methotrexate in the management of psoriasis with a view to ensuring the safe and proper use of this drug in the management of psoriasis. This document was developed by consensus among members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology.

Incidental Skin Cancer Detection in a Hospital Department: A Prospective Study. / Evaluación de la tasa de detección incidental de cáncer cutáneo: estudio prospectivo en un servicio hospitalario.

BACKGROUND AND OBJECTIVES: Skin cancer is a common cause for referral to dermatology, but it may also be an incidental finding during examination of patients referred for other reasons. The objective of the study was to compare the characteristics of skin cancer lesions (squamous skin carcinoma, basal cell carcinoma, melanoma) diagnosed at a dermatology department over 1 year between patients referred for suspected skin cancer and those referred for another reason but in whom skin cancer was detected as an incidental finding. Pearson's χ2 test was used to compare different study variables between the 2 groups. RESULTS: Data were collected from 433 patients with a mean age of 72 years; 233 (51.3%) of the patients were female. The most common skin types were Fitzpatrick types II and III. Basal cell carcinoma was the most frequent cancer in all the analyses and accounted for 68.4% of all cancers diagnosed (296/433). Twenty-six percent of the malignant skin tumors were detected incidentally. Statistical analysis revealed that these tumors tended to be located in nonvisible areas and were smaller and of more recent onset than tumors initially suspected to be malignant. CONCLUSIONS: The high rate of skin cancer diagnosed incidentally by dermatologists highlights the need to carry out thorough examinations of patients in order to facilitate early detection and treatment.