Determining patient value profiles in psoriasis.

BACKGROUND: Healthcare professionals (HCPs) should strive to create the maximum value for their patients in which value is defined as the patient-relevant health outcomes achieved per costs made. However, currently it remains difficult to determine which outcomes matter to an individual psoriasis patient. OBJECTIVE: To define outcome profiles, or so called 'patient value profiles', within a cohort of psoriasis patients that can be translated to daily practice to increase value for the individual patient. METHODS: Hierarchical clustering on principal components (HCPC) was used to identify groups of patients sharing the same profile within an outcome ranking exercise. Once the clusters were defined, their characterization was provided based on a V-test. In a final step, a multi-class decision tree (MDT) based on relevant socio-demographic and clinical variables was built to allocate patients to a cluster. RESULTS: In the ranking exercise 120 patients participated. The median age was 50.0 (IQR 25.0) years and 36.7% were female. Median PASI score was 2.4 (IQR 5.2) and median duration of psoriasis was 17.0 (IQR 20.0) years. Primary treatment varied from topicals to biologicals. We found three distinct patient value profiles in this cohort (QoL, cost and treatment). A MDT was built which had an accuracy of 64%. CONCLUSION: We found three distinct patient value profiles in a cohort of psoriasis patients and patients can be easily assigned to one of these profiles based on a MDT. HCPs can use these profiles to steer psoriasis management accordingly allowing for a more goal-orientated approach.

Assessing the dynamic changes in vitiligo: reliability and validity of the Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS).

BACKGROUND: The assessment of the individual evolution of vitiligo is important for therapeutic decision making in daily practice. A fast, simple and validated physician-reported score to assess clinical changes in depigmentation over time in separate parts (activity and improvement) is currently missing. OBJECTIVE: The main objective of the study was to develop and validate the Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS). METHODS: The Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS) were evaluated based on a photo set of 66 patients with two different time points. In the first (short) version, only the number of changing body regions was counted based on 15 predefined areas (VDAS15 and VDIS15 ), while in the second (extensive) version the degree of worsening or improvement from +4 to -4 for each body area was added for a more detailed assessment (VDAS60 and VDIS60 ). Content and construct validity were tested. In addition inter-, intrarater reliability and feasibility were evaluated by 7 (test) and 5 (retest) physicians. RESULTS: Evidence for content and construct validity was provided. Overall, VDAS15 , VDIS15 , VDAS60 and VDIS60 demonstrated good to excellent inter-rater reliability [intraclass correlation (ICC): VDAS: range = 0.797-0.900; VDIS: range = 0.726-0.798]. The intrarater reliability ICCs were 0.865 and 0.781 for the VDAS15 and VDIS15 , respectively. Similar results were obtained for the VDAS60 and VDIS60 (ICC = 0.913 and 0.800, respectively). Completion time was short (median: 122 s/patient (first round); 95 s/patient (second round)]. LIMITATIONS: Single tertiary centre mainly of skin phototype 2 to 3. CONCLUSION: The VDAS and VDIS appear to be valid, reliable and feasible instruments to score the evolution of vitiligo lesions. This accommodates the current urgent need for a simple, standardized and practical assessment of vitiligo activity and improvement over time.

Lesion-directed screening to optimize skin cancer detection in dermatology practice: an observational study.

BACKGROUND: Early detection of skin cancer is still a major challenge in dermatology practice today. While surveillance programs are offered to high-risk patients, systematic total-body examination (TBE) in the general population is not cost-effective. In the past, we demonstrated that a lesion-directed screening (LDS) in the general population delivered similar detection rates to TBE and was less time-consuming. OBJECTIVES: To study whether a lesion-directed early-access consultation can optimize skin cancer detection in dermatology practice. METHODS: In this observational study, we offered an early-access consultation in patients contacting the dermatology department concerning 1 or 2 lesions of concern meeting predefined criteria. RESULTS: 342 persons were seen at the dermatology department after triage by phone. Skin cancer detection rate was 13.2% (4.1% for melanoma). If advised/referred by a doctor skin cancer detection rate was 23.6% (9% for melanoma). With a history of skin cancer, detection rate was 24.3% (4.3% for melanoma). In patients with no referral and a negative history of skin cancer, detection rate was 7.7% (1.7% for melanoma), which is at least triple the rates reported by population-based screening programs. In patients in whom the index lesion was benign, worry of having skin cancer had decreased significantly by the end of the consultation. Additional total-body examination in these patients had low additional detection rate (0.5%) and a high number of unnecessary excisions (number needed to excise 13). CONCLUSIONS: An early-access dermatology consultation for LDS after triage by phone resulted in high overall skin cancer and melanoma detection rates. Our data indicate that performing TBE is especially useful if the index lesion is suspicious. In addition to surveillance programs in high-risk patients, LDS may be a way to optimize skin cancer detection in the general population and use available time more efficiently in daily dermatology practice.

Comparison of methods to estimate the affected body surface area and the dosage of topical treatments in psoriasis and atopic dermatitis: the advantage of a picture-based tool.

BACKGROUND: The accurate determination of the dosage of topical treatments is important given its repercussions on patient adherence and therapeutic efficacy. Up till now, the fingertip unit calculated by the rule of hands is considered the gold standard, although its use is associated with several drawbacks. OBJECTIVE: To compare different methods to estimate the affected body surface area (BSA) and dosage of topical treatments in atopic dermatitis and psoriasis and investigate its reliability, user-friendliness and timing. METHODS: In this study, we compared the reliability of three different methods: (i) the fingertip unit calculated by the 1% hand rule; (ii) a picture-based tool [termed Cutaneous Inflammatory Disease Extent Score (CIDES)]; and (iii) a digital drawing tool. Eleven observers scored 40 patients with psoriasis and eczema to assess the inter-rater and intrarater reliability. Timing was automatically recorded, and user-friendliness was investigated by a questionnaire. RESULTS: An excellent intraclass correlation (ICC) was found for both inter-rater agreement and intrarater agreement for the picture-based tool (ICC = 0.92 and ICC = 0.96, respectively). The ICCs for drawing the area of involvement on a silhouette were 0.89 and 0.93, respectively. Finally, the rule of hands was associated with an increased inter-rater variability although an excellent intrarater agreement was found (ICC = 0.79 and 0.95, respectively). Automated calculation of the amount of topical treatment improved reliability, and CIDES was associated with the least variation. CIDES was considered the preferred method by all observers and was fast to perform (median: 30 s). CONCLUSION: A picture-based method offered the most advantages (in terms of reliability, speed and user-friendliness) to estimate the affected BSA and calculate the dosage of topical treatments.

Chemoprevention of basal cell carcinoma: reply from authors.

The review started from the question whether early detection of BCC in the general (asymptomatic) population could lead to any benefit in terms of outcome and cost. In other words, should early detection efforts for skin cancer (secondary prevention) also include BCC? Review of available literature suggests that early detection and adequate treatment of BCC of the face could increase cost-effectiveness. Although these results could also pertain to patients who have had already a history of BCC, their setting is different since they may already be in a follow-up programme (tertiary prevention). This article is protected by copyright. All rights reserved.

Is early detection of basal cell carcinoma worthwhile? Systematic review based on the WHO criteria for screening.

The incidence of basal cell carcinoma (BCC) has risen three- to fourfold over the last 30 years and is expected to continue to increase with ageing of the population. Although BCC has a good prognosis, it causes significant morbidity and has an important impact on the public health budget due to direct treatment costs. Based on the existing evidence, a systematic evaluation of the World Health Organization criteria was performed to determine whether earlier detection of BCC could reduce morbidity and cost. BCC slowly increases in size, with a median increase in diameter of 0·5 mm over 10 weeks. There is an important delay in diagnosis ranging from 19 to 25 months. In several studies BCC size was the main determinant of treatment cost, surgical complexity, reconstruction technique and the specific surgical procedure performed, such as Mohs micrographic surgery or surgical excision. One study showed that size also seems to affect the cost per treatment for other nonsurgical options. The use of vismodegib, an inhibitor of the hedgehog pathway, is confined to locally advanced or metastatic BCC. Delays in diagnosis and appropriate treatment are the most important underlying causes in the occurrence of giant BCC and/or BCC with metastasis. Although the latter represent only a very small fraction of all BCCs, the majority of them are located in the facial region. The available data point to a slow increase in the size of BCCs over time. Size is one of the major determinants in choice of treatment and the associated cost, especially for facial BCC. Therefore we conclude that current data support early detection and adequate management of BCCs on the face.

Mohs micrographic surgery for basal cell carcinoma: evaluation of the indication criteria and predictive factors for extensive subclinical spread.

BACKGROUND: The incidence of basal cell carcinoma (BCC) is rising and BCC treatment has an important impact on healthcare budget. Mohs micrographic surgery (MMS) has the highest 5-year cure rate but is an expensive technique. OBJECTIVES: To study the indication criteria for MMS, using a series of 1062 patients treated for facial BCCs between 1998 and 2011. METHODS: The accuracy of the indication criteria was evaluated by comparing the characteristics of BCC requiring one vs. more than one round of MMS. Predictors for extensive subclinical spread (three or more rounds) were examined using the preoperative patient and all tumour characteristics. RESULTS: BCCs with a surface > 1 cm(2) and aggressive histology (morphoeaform and micronodular), and a patient age > 80 years are strong predictors for two or more rounds of MMS being required. Extensive subclinical spread was present in recurrent tumours, morphoeaform BCC or BCC with mixed histology. CONCLUSIONS: We found that tumour size and aggressive histology are the strongest indication criteria for MMS. Recurrence and aggressive histology are predictors for extensive subclinical spread but not for two or more rounds of MMS. Evidence-based indications for MMS are necessary to ensure cost-effective management of BCC.

Primary focal hyperhidrosis: current treatment options and a step-by-step approach.

Primary focal hyperhidrosis is a common disorder for which treatment is often a therapeutic challenge. A systematic review of current literature on the various treatment modalities for primary focal hyperhidrosis was performed and a step-by-step approach for the different types of primary focal hyperhidrosis (axillary, palmar, plantar and craniofacial) was established. Non-surgical treatments (aluminium salts, local and systemic anticholinergics, botulinum toxin A (BTX-A) injections and iontophoresis) are adequately supported by the current literature. More invasive surgical procedures (suction curettage and sympathetic denervation) have also been extensively investigated, and can offer a more definitive solution for cases of hyperhidrosis that are unresponsive to non-surgical treatments. There is no consensus on specific techniques for sympathetic denervation, and this issue should be further examined by meta-analysis. There are numerous treatment options available to improve the quality of life (QOL) of the hyperhidrosis patient. In practice, however, the challenge for the dermatologist remains to evaluate the severity of hyperhidrosis to achieve the best therapeutic outcome, this can be done most effectively using the Hyperhidrosis Disease Severity Scale (HDSS).