Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel.

BACKGROUND: A transition from a subtyping to a phenotyping approach in rosacea is underway, allowing individual patient management according to presenting features instead of categorization by predefined subtypes. The ROSacea COnsensus (ROSCO) 2017 recommendations further support this transition and align with guidance from other working groups. OBJECTIVES: To update and extend previous global ROSCO recommendations in line with the latest research and continue supporting uptake of the phenotype approach in rosacea through clinical tool development. METHODS: Nineteen dermatologists and two ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and management. Voting was electronic and blinded. RESULTS: Delphi statements on which the panel achieved consensus of ≥ 75% voting 'Agree' or 'Strongly agree' are presented. The panel recommends discussing disease burden with patients during consultations, using four questions to assist conversations. The primary treatment objective should be achievement of complete clearance, owing to previously established clinical benefits for patients. Cutaneous and ocular features are defined. Treatments have been reassessed in line with recent evidence and the prior treatment algorithm updated. Combination therapy is recommended to benefit patients with multiple features. Ongoing monitoring and dialogue should take place between physician and patients, covering defined factors to maximize outcomes. A prototype clinical tool (Rosacea Tracker) and patient case studies have been developed from consensus statements. CONCLUSIONS: The current survey updates previous recommendations as a basis for local guideline development and provides clinical tools to facilitate a phenotype approach in practice and improve rosacea patient management. What's already known about this topic? A transition to a phenotype approach in rosacea is underway and is being recommended by multiple working groups. New research has become available since the previous ROSCO consensus, necessitating an update and extension of recommendations. What does this study add? We offer updated global recommendations for clinical practice that account for recent research, to continue supporting the transition to a phenotype approach in rosacea. We present prototype clinical tools to facilitate use of the phenotype approach in practice and improve management of patients with rosacea.

Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel.

BACKGROUND: Rosacea is currently diagnosed by consensus-defined primary and secondary features and managed by subtype. However, individual features (phenotypes) can span multiple subtypes, which has implications for clinical practice and research. Adopting a phenotype-led approach may facilitate patient-centred management. OBJECTIVES: To advance clinical practice by obtaining international consensus to establish a phenotype-led rosacea diagnosis and classification scheme with global representation. METHODS: Seventeen dermatologists and three ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and severity evaluation. All voting was electronic and blinded. RESULTS: Consensus was achieved for transitioning to a phenotype-based approach to rosacea diagnosis and classification. The following two features were independently considered diagnostic for rosacea: (i) persistent, centrofacial erythema associated with periodic intensification; and (ii) phymatous changes. Flushing, telangiectasia, inflammatory lesions and ocular manifestations were not considered to be individually diagnostic. The panel reached agreement on dimensions for phenotype severity measures and established the importance of assessing the patient burden of rosacea. CONCLUSIONS: The panel recommended an approach for diagnosis and classification of rosacea based on disease phenotype.

Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel.

BACKGROUND: Rosacea is currently treated according to subtypes. As this does not adequately address the spectrum of clinical presentation (phenotypes), it has implications for patient management. The ROSacea COnsensus panel was established to address this issue. OBJECTIVES: To incorporate current best treatment evidence with clinical experience from an international expert panel and establish consensus to improve outcomes for patients with rosacea. METHODS: Seventeen dermatologists and three ophthalmologists reached consensus on critical aspects of rosacea treatment and management using a modified Delphi approach. The panel voted on statements using the responses 'strongly disagree', 'disagree', 'agree' or 'strongly agree'. Consensus was defined as ≥ 75% 'agree' or 'strongly agree'. All voting was electronic and blinded. RESULTS: The panel agreed on phenotype-based treatments for signs and symptoms presenting in individuals with rosacea. First-line treatments were identified for individual major features of transient and persistent erythema, inflammatory papules/pustules, telangiectasia and phyma, underpinned by general skincare measures. Multiple features in an individual patient can be simultaneously treated with multiple agents. If treatment is inadequate given appropriate duration, another first-line option or the addition of another first-line agent should be considered. Maintenance treatment depends on treatment modality and patient preferences. Ophthalmological referral for all but the mildest ocular features should be considered. Lid hygiene and artificial tears in addition to medications are used to treat ocular rosacea. CONCLUSIONS: Rosacea diagnosis and treatment should be based on clinical presentation. Consensus was achieved to support this approach for rosacea treatment strategies.

[From dermabrasion to laser. Development of operative-interventional methods in aesthetic dermatology]. / Vom Schleifen zum Laser: Entwicklung operativ-interventioneller Methoden in der Kosmetik.

Many operative-interventional methods are available for aesthetic dermatology. The established high-speed dermabrasion as developed by Schreus has been replaced in many indications by newer approaches. Laser ablation can be effectively used for resurfacing of sun-damaged or scarred skin, but is associated with extensive side effects. Newer developments such as fractionated laser treatment are designed to fill the gap between ablative and non-ablative skin resurfacing. The side effects are much less severe, but the effectiveness must be confirmed in larger studies. Photorejuvenation with intense pulsed light (IPL) offers a wide variety of treatment parameters for a broad spectrum of skin changes. Both superficial and deep structures can be treatment in one session using IPL.

Stent migration necessitating surgical intervention.

BACKGROUND: Internal drainage with transhepatically or endoscopically placed endoprostheses has been used for many years as a temporary or definitive treatment for biliary tract obstruction. As a late complication, stent migration may occur. METHODS: We reviewed our records to identify patients who were operated on for a migrated endoprosthesis that was causing complications. In all, five such patients were identified. RESULTS: One patient had a large bowel perforation. Bowel penetration led to an interenteric fistula in one patient and to a biliocolic fistula formation in another. Small bowel distension was found in two patients. Surgical treatment consisted of local excision in three patients, segmental resection in one patient, and a bypass operation in the patient with biliocolic fistula. Postoperatively, four patients recovered without problems, but one patient died during a complicated postoperative course. CONCLUSION: If a stent becomes stuck in the gastrointestinal tract and is not accessible for endoscopic removal, early operative revision is mandatory to prevent further complications.

[Surgical therapy of hemorrhage after endoscopic sphincterotomy. Indications and technique]. / Chirurgische Therapie von Blutungen nach endoskopischer Sphincterotomie. Indikation und Technik.

Postinterventional bleeding occurs in 2.5% after endoscopic sphincterotomy (EST). It is the most frequent complication of this technique. According to the world literature the mortality of post-EST-bleeding averages 10%. According to a review of the world literature patients are often operated upon too rarely and too late. Direct surgical interventions at the Vaterian papilla should be omitted because of the danger of post-operative pancreatitis. From our point of view laparotomy and ligation of the gastroduodenal artery are recommended if periampullary injection of epinephrine fails to control the bleeding. The cessation of the bleeding should be controlled by intraoperative endoscopy. During the same surgical intervention the underlying disease for EST, e.g. common bile duct stones, ought to be treated surgically to prevent a new bleeding episode. If the underlying disease was already cured or in case of inoperability, selective embolization of the gastroduodenal artery presents an alternative option.

[Elective lymph node dissection in malignant melanoma--status of color Doppler findings]. / Elektive Lymphknotendissektion (ELND) beim Malignen Melanom--Stellenwert des Farbdopplerbefundes.

Since there is still a controversial discussion about the ELND in melanoma patients, the purpose of this prospective study was to optimize the indication concerning ELND by ultrasound examinations. 144 patients with primary melanomas were checked every 3 months after excision. Echomorphologic pattern and intranodal vascularisation in the color-flow Doppler modus provide essential information for differential diagnosis. We found 47 patients (32.6%) with suspicious ultrasound lesions. 50% of these patients had no pathological clinical findings, the histological findings of excised lymph nodes were positive in all cases. It must be emphasized, however, that the group with lymph node metastases included 12 patients with low-risk-melanomas (2 x Tis, 10 x T1 < 1 mm tumor thickness). In comparison with a historical control group (141 patients), where ELND was performed routinely in high-risk-patients ( > T2), the incidence of ELND in our hospital decreased more than 50%; at the same time the percentage of detected lymph node metastases increased (twice).

[Indications, findings and complications of ERCP in pediatrics]. / Indikationen, Befunde und Komplikationen der ERCP in der Pädiatrie.

Endoscopic retrograde cholangio-pancreatography presents the only method which not only produces exact results concerning the morphology of the pancreatic and biliary ducts but also enables therapeutic access to these structures. In childhood ERCP is indicated if other non invasive diagnostic procedures do not help to establish a diagnosis or if further informations concerning indication or planning of an operation can be expected. In 25 children and 13 adolescents ERCP established the correct diagnosis in 95%. The success rate in newborns after the second month reaches 90%. For children before the age of 2 months a pediatric duodenoscope with a diameter of 7-9 mm is necessary. In obstructive jaundice, after trauma of the upper abdomen and especially in pancreatitis of unknown origin ERCP should be performed liberally, because a lot of exploratory laparotomies can be prevented, and significant findings for operative intervention can be collected. Moreover the causes of pancreatitis can be evaluated and treated definitely. With EST impressive improvements in the clinical course of obstructive jaundice, cholangitis and acute pancreatitis even in children and adolescents can be reached. In our own series 9 children (3 acute biliary pancreatitis, 3 chronic obstructive pancreatitis, 1 acute pancreatitis, 2 biliary duct stones with cholangitis or ampullary stenosis) were treated successfully without any significant complications. In acute pancreatitis an ERCP should be performed as early as possible (during 24-48 hours after onset of symptoms) because only in this instance the etiologic factors can be evaluated reliably and using endoscopic sphincterotomy of the sphincter proprius choledochi and/or the sphincter proprius pancreatis be treated adequately and with the lowest risk in time.(ABSTRACT TRUNCATED AT 250 WORDS)

[Therapeutic problems of cancers of the gallbladder]. / Problèmes thérapeutiques posés par les cancers de la vésicule biliaire.

Data of 32 patients who were operated for gallbladder carcinoma were evaluated in a retrospective meta-analysis. Results were compared with endoscopic retrograde cholangio-drainage (ERCP) using large size 12/14-French gauge endo-prostheses with side flaps to prevent migration. According to the TNM classification 84% of patients were classified as stage IV, 12.5% were in a stage III and 3% were in a stage II. Only 22% of cases were operated for cure (cholecystectomies, lymphadenectomy, wedge resection of the liver). All patients died in between one year on cancer, average survival was 158 days in TNM stage II, 183 days in stage III and 75 days in stage IV. Early complication rate was in stage III and 75 days in stage IV. Early complication rate was at 28% due to cardiac and pulmonary complications. No one died as a result of the operation. Endoscopic bile duct drainage (ERCP) for gallbladder carcinoma (n = 21) was shown to be superior to surgical results with an average survival of 160 days. Early complication rate (30 day interval) was at 5.6% (n = 1014), mostly due to tube occlusion with cholangitis; clinical mortality was 2.6% only (n = 393). Occlusion of the endoscopic 12/14-French gauge tube was seen after 213 days in average. Endoscopic therapy was shown to represent an independent way in gallbladder cancer treatment not only for patients defined as not suitable for operation. All own results were compared to the literature, therapeutic regimen in gallbladder carcinoma is summarized as an organigramm.

[More successful and cost effective--the non-transendoscopic method of TPCD]. / Erfolgreicher und kostensparender--die nicht-transendoskopische Methode der TPCD.

With TPCD best results are gained with large diameter endoprostheses. In this instance special duodenoscopes with a working channel of 3.2 or 4.2 mm are needed for the implantation of 10 or 12 French endoprostheses. Alternatively, using the non-transendoscopic technique large diameter endoprostheses of 14 or more French can be implanted independently from the diameter of the working channel with conventional endoscopes. We have used this method developed at our institution in 1204 patients since 1982 and compared its results with 192 patients in whom the transendoscopic technique with 7-10 French endoprostheses was administered. The success-rate (non-transendoscopic technique 94 vs transendoscopic technique 79%), early complications (5 vs 11%), method-specific mortality (0.3 vs 1%), in-hospital mortality (3.6 vs 21%) and late complications (19 vs 33%) are clearly in favour of the non-transendoscopic approach. The higher rate of early complications and consecutively higher in-hospital mortality of the transendoscopic method with 7-10 French endoprostheses was mainly due to frequent episodes of early cholangitis due to insufficient biliary drainage. The higher success-rate of the non-transendoscopic approach is method specific ("Prothesenleger" guidable). A change of the endoscope is not necessary in contradiction to the transendoscopic method. Additional costs of special duodenoscopes that can be used neither for ERCP nor sphincterotomy are superfluous.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical aspects, diagnosis and therapy of genuine bile duct cysts]. / Klinik, Diagnostik und Therapie genuiner Gallengangszysten.

During an eight-year period eight patients with intra- or extrahepatic bile duct cysts were treated at our institution. One patient belonged to Type I, four to Type IV and three to Type V according to the classification by Alonso-Lej/Todani. The main symptom among the Type IV patients was jaundice, among the Type V patients abdominal pain. The correct diagnosis could be established by ERCP in seven of eight cases. Two type V patients with disease mainly confined to one lobe of the liver could be resected, one patient was treated endoscopically, the others underwent biliary drainage procedures.

[Arguments for a revised concept in the therapy of acute pancreatitis. On the indications for conservative, endoscopic and surgical procedures]. / Argumente für ein abgewandeltes Konzept in der Therapie der akuten Pankreatitis. Zur Indikation konservativer, endoskopischer und chirurgischer Verfahren.

From January 1, 1973 to October 31, 1987 we treated 271 patients suffering from acute pancreatitis at the Department of General Surgery at the University Münster, Westphalia. 159 (58.7%) presented with stage I, 75 (27.7%) with stage II, and 39 (13.6%) with stage III disease according to the Mainz classification for acute pancreatitis. In 147 cases an endoscopic sphincterotomy (EST) was performed. At a low method-specific morbidity (5.4%) we observed a mortality rate of 0% for stage I, 8% for stage II, and 22% for stage III. Altogether, a mortality rate of 13.3% was calculated for the necrotizing forms of acute pancreatitis after EST, compared to 36.5% for a conventionally (conservative therapy, operation) treated group.

[Endoscopy in diseases of the bile ducts and pancreas]. / Endoskopie bei Erkrankungen von Gallenwegen und Pankreas.

The results of endoscopic therapeutic methods (EST, TPCD), which changed the therapy of the frequent biliary duct and of the diseases of the pancreas, are discussed and the literature and treatment of our own patients are discussed. The choice of optimal therapy for the patient is possible only if endoscopic methods are part of a combined endoscopic-surgical concept of therapy selected in close cooperation with the surgeon. The therapy of cholelithiasis and acute pancreatitis are used as examples.

[Long-term results of endoscopic sphincterotomy in patients with gallbladder in situ]. / Langzeitergebnisse nach endoskopischer Sphinkterotomie bei Patienten mit Gallenblase in situ.

The place of endoscopic sphincterotomy (EST) as primary and sole invasive treatment was retrospectively analysed in 185 patients who had the procedure performed because of choledocholithiasis and/or stenosis of the papilla. EST was successful in 99.5%, with an early complication rate of 3.8%, an early mortality rate of 0.5% and an emergency operation rate of 0.5%. Freedom from stone in the choledochal duct or adequate bile flow was achieved in 94.1%. Late complications, on average 36.5 (6-75) months after the procedure, was 16.9%, late mortality 2.8% and operation rate for complications 5.6%. Even without stones in it the gallbladder was the cause of late complications in over 60% of cases. Comparison of results between operative treatment and EST indicated advantages of the former up to the age of 60 years, combined cholecystectomy and EST up to 70 years, while EST alone seems justified in older patients.

[Value of diagnostic procedures in pancreatic cancer]. / Die Wertigkeit diagnostischer Verfahren beim Pankreaskarzinom.

At the Surgical Department of Münster University in-patient treatment was applied to 320 patients for pancreas carcinoma, between 1977 and 1984. These cases were concomitantly studied for informative potentials of computed tomography (CT), sonography (Sono), and endoscopic retrograde cholangiopancreatography (ERCP). CT was performed on 163 patients (50.3 per cent), Sono on 180 (56.3 per cent), and ERCP on 90 (28.1 per cent). Highest sensitivity was recorded from ERCP, with 91.1 per cent of correctly positive diagnoses. CT gave correct positive findings in 70.5 per cent of all cases and Sono in 61.1 per cent. Resection rates were not increased by introduction of these new techniques, but the rate rather stayed at 14.8 per cent. While the period between hospitalisation and operation was slightly reduced, surgical intervention was too late for curative resection in most cases. In some highly advanced cases with distant metastases but absence of symptoms on the basis of CT findings, exploratory laparotomy was abandoned. The new methods have improved diagnostic accuracy rather than prognosis of pancreas carcinoma.

Transpapillary bile duct drainage with a large-caliber endoprosthesis.

A new method for transpapillary bile duct drainage by means of a large-caliber endoprosthesis is described. It facilitates the transpapillary introduction of endoprostheses with an internal diameter of 3.5 to 5 mm irrespective of the actual diameter of the duodenoscope instrument channel. The method has been successfully employed in 6 out of 8 patients with malignant obstructive jaundice, uncomplicated by cholangitis. It offers an acceptable alternative to palliative surgical biliodigestive anastomosis.