Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus.

BACKGROUND: Long-term sequelae are frequent and often disabling after epidermal necrolysis (Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)). However, consensus on the modalities of management of these sequelae is lacking. OBJECTIVES: We conducted an international multicentric DELPHI exercise to establish a multidisciplinary expert consensus to standardize recommendations regarding management of SJS/TEN sequelae. METHODS: Participants were sent a survey via the online tool "Survey Monkey" consisting of 54 statements organized into 8 topics: general recommendations, professionals involved, skin, oral mucosa and teeth, eyes, genital area, mental health, and allergy workup. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). Results were analyzed according to the RAND/UCLA Appropriateness Method. RESULTS: Fifty-two healthcare professionals participated. After the first round, a consensus was obtained for 100% of 54 initially proposed statements (disagreement index < 1). Among them, 50 statements were agreed upon as 'appropriate'; four statements were considered 'uncertain', and ultimately finally discarded. CONCLUSIONS: Our DELPHI-based expert consensus should help guide physicians in conducting a prolonged multidisciplinary follow-up of sequelae in SJS-TEN.

A digital therapeutic for management of psychosocial aspects of psoriasis: A pre-post proof of concept study.

Background: Despite the psychosocial challenges of living with psoriasis many patients may not be able to access appropriate services to manage these challenges. Mobile health interventions may be helpful as a means to support patients in managing the impact of their condition. Objective: To conduct a preliminary examination of the feasibility and acceptability of a bespoke psoriasis-specific digital therapeutic solution (hereafter termed Allay), and to provide initial data on psychological changes pre-post. Methods: Phase one proof of concept pre-post study. Eligible patients were provided with Allay on their smartphone and assessed at baseline and at 12 weeks on a range of indices of well-being. Participants experiences on usability were collected by telephone interview at 4 weeks, 8 and 12 weeks. Results: Out of 66 participants recruited, 59 persisted in using Allay after the familiarisation phase, and 34 participants completed the 12 weeks programme. Participants showed a statistically significant improvement between induction and the end of the 12 weeks programme on Quality of life, Resilience, Perceptions of 'Overall impact' of psoriasis, and 'Emotional impact'. There was a significant change over the course of using Allay for symptoms of depression but not anxiety. While there was an interaction effect of changes in severity of psoriasis symptoms over the course of the study for dermatology-specific measures, there was no interaction between such changes in psoriasis symptoms and changes in depression, resilience or beliefs in emotional impact. Conclusions: Study results suggest that the use of Allay as an adjunct to medical management of psoriasis may help patients improve resilience, mood, beliefs about their condition and enhance their quality of life. Given that this is a phase one proof of concept study, and our rates of attrition further research is necessary to examine comparative effectiveness and stability of these findings.

A retrospective review of pregnancies on biologics for the treatment of dermatological conditions.

Psoriasis often first presents in young adulthood, with the average age of diagnosis in women being 28 years, thus in the prime reproductive years. In addition, approximately 50% of pregnancies worldwide are unplanned. Although biologic therapies have revolutionized the treatment of moderate-to-severe psoriasis, there are no controlled studies of biologics in pregnant women. The increasing use of these agents in women of childbearing age highlights the need to further assess their safety during pregnancy. Postmarketing experience regarding the safety of these drugs is accumulating and being published, with largely reassuring results. We present our real-world experience of 17 pregnancies occurring in women on treatment with biologic agents for dermatological conditions to further add to the body of knowledge.

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic.

CLINICAL SCENARIO: A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful. MANAGEMENT QUESTION: What are the psychological impacts of SJS/TEN on this man's life? BACKGROUND: SJS and TEN have devastating outcomes for those affected. OBJECTIVES: To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario. METHODS: Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age. RESULTS: Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression. DISCUSSION AND RECOMMENDATION: The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

Planning, guidance, and quality assurance of pelvic screw placement using deformable image registration.

Percutaneous pelvic screw placement is challenging due to narrow bone corridors surrounded by vulnerable structures and difficult visual interpretation of complex anatomical shapes in 2D x-ray projection images. To address these challenges, a system for planning, guidance, and quality assurance (QA) is presented, providing functionality analogous to surgical navigation, but based on robust 3D-2D image registration techniques using fluoroscopy images already acquired in routine workflow. Two novel aspects of the system are investigated: automatic planning of pelvic screw trajectories and the ability to account for deformation of surgical devices (K-wire deflection). Atlas-based registration is used to calculate a patient-specific plan of screw trajectories in preoperative CT. 3D-2D registration aligns the patient to CT within the projective geometry of intraoperative fluoroscopy. Deformable known-component registration (dKC-Reg) localizes the surgical device, and the combination of plan and device location is used to provide guidance and QA. A leave-one-out analysis evaluated the accuracy of automatic planning, and a cadaver experiment compared the accuracy of dKC-Reg to rigid approaches (e.g. optical tracking). Surgical plans conformed within the bone cortex by 3-4 mm for the narrowest corridor (superior pubic ramus) and >5 mm for the widest corridor (tear drop). The dKC-Reg algorithm localized the K-wire tip within 1.1 mm and 1.4° and was consistently more accurate than rigid-body tracking (errors up to 9 mm). The system was shown to automatically compute reliable screw trajectories and accurately localize deformed surgical devices (K-wires). Such capability could improve guidance and QA in orthopaedic surgery, where workflow is impeded by manual planning, conventional tool trackers add complexity and cost, rigid tool assumptions are often inaccurate, and qualitative interpretation of complex anatomy from 2D projections is prone to trial-and-error with extended fluoroscopy time.

Melanoma diagnosis and management after the introduction of a pigmented lesion clinic in the Mid-West of Ireland.

BACKGROUND: A pigmented lesion clinic (PLC) was introduced and Consultant Dermatology posts were increased in the Mid-West of Ireland with the aim of improving early detection of melanoma. METHODS: We analysed retrospectively the invasive melanomas excised in the Mid-West of Ireland over a 2-year period prior to (2010-2011) and after (2013-2014) the advent of the PLC. RESULTS: The number of melanomas excised almost doubled from 54 (2010-2011) to 107 (2013-2014). There was a significant rise in the rate of excision biopsies performed by Dermatologists compared to non-dermatology clinicians from 19 to 56% (p < 0.0001). There was a significant difference in the diagnostic accuracy of excised melanomas by Dermatologists compared to non-dermatology clinicians during both time periods (2010-2011: p = 0.001; 2013-2014: p < 0.0001). There was a non-significant decrease in the median Breslow thickness of melanomas from 1.3 mm (0.6-2.6) (2010-2011) to 1.0 mm (0.5-2.3) (2013-2014) (n = 145, p = 0.48). CONCLUSION: The PLC has led to an increase in the number of melanomas excised by Dermatologists in the Mid-West of Ireland which has led to higher diagnostic accuracy.

An analysis of inpatient dermatologic consultations at University Hospital Limerick: inadequate infrastructure leads to acute skin failure.

BACKGROUND: Approximately 15-20 % of the general population have skin diseases and it is therefore clear that inpatients can also present with various skin conditions that require dermatology input and in some cases the primary reason for admission to hospital. Inpatient hospital care is more expensive than outpatient care. Recent trends are moving towards outpatient care, as there is huge pressure on hospital bed availability. AIMS: The main aim of this study was to analyse patients referred with dermatological complaints and how soon after admission, were patients assessed by the dermatology team. Most dermatologic work is outpatient based and inpatient workload can be underestimated. METHODS: We retrospectively reviewed our inpatient consultations with a total of 220 consultations (males 113, females 107) between August 2014 and April 2015, to document this significant area of work over an eight-month period. RESULTS: The services requesting consultations were mostly general medicine 45.9 % (101/220), surgery 25.4 % (56/220) and paediatrics 24 % (53/220). Dermatologist's diagnosis was different from the referral team diagnosis in 60 % (132/220) of consults, with prompt inpatient assessment by the dermatologist within 24 h of admission. Most common dermatoses diagnosed included eczema 21.8 % (48/220) and psoriasis 7.3 % (16/220). CONCLUSION: Timely diagnosis and inpatient care has important implications on appropriate treatment, duration of hospital stay and patient outcome.

Assessment of psoriatic plaque in vivo with correlation mapping optical coherence tomography.

BACKGROUND/PURPOSE: Vascular abnormalities play an acute role in the pathogenesis of psoriasis. In order to characterize vascular involvement in psoriasis and its regular clinical assessment in vivo, non-invasive high speed imaging with high resolution and high sensitivity is needed. METHODS: The correlation mapping optical coherence tomography (cmOCT) technique was used for in vivo microcirculation imaging of human forearm under normal and psoriatic conditions. The cmOCT technique developed by our group uses dense scanning OCT image acquisition and post-processing software based on correlation statistics. The frequency domain OCT system was used for imaging which acquires a 3D volume of 1024 × 1024 A-scans, each of 512 pixels deep in approximately 70 s. The cmOCT technique processes the resulting OCT volume within 116 s using a 7 × 7 kernel. RESULTS: 3D structural and functional (microcirculation) maps of the healthy tissue and the psoriatic plaque were obtained using the cmOCT technique. The presented results indicate that cmOCT allows not only the identification of the microvessels, but also produces more detailed microvascular networks showing how the blood vessels relate to each other in healthy tissue and within the plaque. The microcirculation pattern within the plaque is totally different from the healthy tissue. The distinct changes are also observed in vessel density, tortuosity, and orientation. CONCLUSION: The cmOCT provides high sensitivity and imaging speed for in vivo microcirculation imaging within the human skin under normal and diseased conditions.

Pyoderma gangrenosum associated with subcorneal pustular dermatosis and IgA myeloma.

We report a 57-year-old woman with a 12-year history of ulcerative pyoderma gangrenosum (PG). Five years after the onset of PG, she developed subcorneal pustular dermatosis (SPD) and biclonal IgA and IgG gammopathy. She developed PG at two bone-marrow biopsy sites, showing pathergy. Finally, she developed multiple myeloma. Although PG and SPD may occur without associated underlying malignancy, these patients should be followed up for any prospective malignancy because of the association between these disorders.

Analysis of inpatient dermatologic referrals: insight into the educational needs of trainee doctors.

AIM: To analyse inpatient consultation referrals to the Dermatology Department and to identify the educational needs of junior/trainee doctors. METHODS: Consultation data of inpatients referred to the Dermatology Department between 2001 and 2006 was reviewed. RESULTS: There were 703 referrals identified. Patients were referred from all wards in the hospital. There were a total of 113 different dermatological diagnoses in the group. One-fifth (22%) consultations were for skin infections, 12% had atopic dermatitis, 8% had psoriasis and 8% had clear or suspected drug cause for their rash. In 391 cases, the Consultant Dermatologist's diagnosis was different to the inpatient referral diagnosis on the consultation referral form. CONCLUSIONS: Our results emphasise the need for junior dermatology trainees to undertake extra training in both the dermatologic conditions. This data supports the need for expansion of service provision of dermatology in the region.