Exploring treatment and antifungal resistance in an outbreak of tinea caused by Microsporum audouinii.

BACKGROUND: Microsporum audouinii has resurged recently. Infections with the dermatophyte are difficult to treat, which raises the question if we treat M. audouinii infections with the most effective antifungal (AF) agent. OBJECTIVES: The aims of this study was to investigate an outbreak of tinea capitis (TC) in Denmark, address the challenges in outbreak management and to conduct two reviews regarding previous outbreaks and minimal inhibitory concentration (MIC). METHODS: We used Wood's light, culture, direct microscopy, and PCR for screening and antifungal susceptibility testing (AFST) for treatment optimization. We performed two reviews to explore M. audouinii outbreaks and MIC values using broth microdilution method. RESULTS: Of 73 screened individuals, 10 had confirmed M. audouinii infections. Clinical resistance to griseofulvin was observed in 4 (66%) cases. While previous outbreaks showed high griseofulvin efficacy, our study favoured terbinafine, fluconazole and itraconazole in our hard-to-treat cases. AFST guided the choice of AF. Through the literature search, we identified five M. audouinii outbreaks, where differences in management included the use of Wood's light and prophylactic topical AF therapy. Terbinafine MIC values from the literature ranged from 0.002 to 0.125 mg/L. CONCLUSION: Use of Wood's light and preventive measurements were important for limiting infection. The literature lacked MIC data for griseofulvin against M. audouinii, but indicated sensitivity for terbinafine. The clinical efficacy for M. audouinii treatment was contradictory favouring both terbinafine and griseofulvin. AFST could have a key role in the treatment of difficult cases, but lack of standardisation of AFST and MIC breakpoints limits its usefulness.

The correlation between self-reported hand eczema and clinically based diagnosis in professional cleaners.

BACKGROUND: Most studies investigating the prevalence of hand eczema (HE) in professional cleaners use self-reported questionnaire-based data. However, no validation studies of self-reporting of HE among professional cleaners have previously been conducted. OBJECTIVES: To investigate (1) the point prevalence of self-reported HE, (2) the point prevalence of HE estimated by physical examination of the hands and (3) the sensitivity and specificity of self-reporting of HE compared with the diagnosis based on physical examination among professional cleaners. METHODS: Professional cleaners at three different hospitals in Region Zealand were invited to fill out a questionnaire. The point prevalence of self-reported HE was estimated based on questions from the Nordic Occupational Skin Questionnaire. After completing the questionnaire, each cleaner underwent a physical examination of the hands by a dermatologist on the same day. RESULTS: In total, 234 cleaners were invited to participate in the study, and 224 (response rate = 96.0%) agreed to take part. Based on the self-reported questionnaires, 5.3% (n = 12) of the cleaners had current HE. Based on an examination by a physician, 19.2% (n = 43) of the cleaners had current HE. The sensitivity of self-reported HE was found to be 28.0%, while the specificity was found to be 100.0%. The positive predictive value was found to be 100.0%, while the negative predictive value was 85.0%. CONCLUSION: The true point prevalence of HE among professional cleaners is underestimated when based on self-reporting.

Increased cancer incidence among patients with hidradenitis suppurativa - a Danish nationwide register study 1977-2017.

BACKGROUND: The chronic, inflammatory skin disease hidradenitis suppurativa (HS) (prevalence: 0.5%-1%, diagnostic delay: 7-10 years) primarily arises in younger adults and frequently coincides with autoimmune comorbidities and unhealthy life-styles (smoking and obesity). These factors are known to increase cancer risk, but despite this, information on cancer occurrence among HS patients is scarce. MATERIALS AND METHODS: A nationwide retrospective register-based study assessing relative risk of cancer - overall and by anatomical site - following HS diagnosis expressed as standardized incidence ratios (SIRs), which is ratios between observed cases among all Danes diagnosed with HS since 1977 and expected cases based on cancer incidence rates of the entire Danish population during the same period. RESULTS: Participants consisted of a cohort of 13,919 Danes with HS, who during an average of 14.2 years of follow-up developed a total of 1,193 incident cancers, corresponding to a 40% increased risk (SIR = 1.4, 95% CI: 1.3 to 1.4, p < 0.001). Increased risks were observed for cancers of the respiratory system, oral cavity and pharynx, digestive organs and peritoneum, urinary tract, and the lymphatic tissues. INTERPRETATION: These findings underline an unmet need for health monitoring, lifestyle interventions and cancer screening if and when relevant.

Protocol of a scoping review of outcome domains in dermatology.

INTRODUCTION: Core outcome sets (COSs) are agreed outcomes (domains (subdomains) and instruments) that should be measured as a minimum in clinical trials or practice in certain diseases or clinical fields. Worldwide, the number of COSs is increasing and there might be conceptual overlaps of domains (subdomains) and instruments within disciplines. The aim of this scoping review is to map and to classify all outcomes identified with COS projects relating to skin diseases. METHODS AND ANALYSIS: We will conduct a scoping review of outcomes of skin disease-related COS initiatives to identify all concepts and their definitions. We will search PubMed, Embase and Cochrane library. The search dates will be 1 January 2010 (the point at which Core Outcome Measures in Effectiveness Trials (COMET) was established) to 1 January 2024. We will also review the COMET database and C3 website to identify parts of COSs (domains and/or instruments) that are being developed and published. This review will be supplemented by querying relevant stakeholders from COS organisations, dermatology organisations and patient organisations for additional COSs that were developed. The resulting long lists of outcomes will then be mapped into conceptually similar concepts. ETHICS AND DISSEMINATION: This study was supported by departmental research funds from the Department of Dermatology at Northwestern University. An ethics committee review was waived since this protocol was done by staff researchers with no involvement of patient care. Conflicts of interests, if any, will be addressed by replacing participants with relevant conflicts or reassigning them. The results will be disseminated through publication in peer-reviewed journals, social media posts and promotion by COS organisations.

Tumor necrosis factor-α inhibitor treatment of acne fulminans - a clinical and literature review.

Acne fulminans (AF) is a rare, serious, sudden-onset and long-lasting skin disease that causes scarring of face and body. Standard treatment with combined long-term isotretinoin and prednisolone is not always sufficient and has a well-known propensity for adverse effects leaving an unmet need for improved therapy. Case reports suggest that tumor necrosis factor (TNF)-α inhibitors may play a role in the management of AF. In a 3-year retrospective data collection from two dermatology centers and literature review of clinical cases of acne fulminans treated with anti-TNF-α therapy, three clinical cases and twelve literature cases were identified. A total of five different TNF-α inhibitors have been tested, with adalimumab being the most commonly used. Clinical response was seen after 1 month in 2/3 (67%) clinical cases and 5/12 (42%) literature cases, respectively, and treatment was successful in 2/3 (67%) and 11/12 (92%) after a median 3-7 months. All reported adverse effects were mild and reversible. Anti-TNF-α treatment may provide rapid improvement in patients with AF when initial treatment with isotretinoin and prednisolone fails. However, randomized controlled trials are lacking, and exact dosage and timing need to be explored before clinical implementation.

Credibility of clinical research depends on consensus on outcomes.

In clinical studies, beneficial and harmful effects of interventions are investigated by measuring predefined outcomes. The uncontrolled choice of these outcomes carries a risk of outcome reporting bias, large heterogeneity of outcomes with reduced options for evidence synthesis. Furthermore, such outcomes may not be important for stakeholders including patients. A potential solution to these problems is to develop a core outcome set (COS) - a list of outcomes which have been estimated to be important to include in all future studies in a given setting by all relevant stakeholders. This review summarises the benefits of defining a COS.

Prevalence and risk factors for hand eczema among professional hospital cleaners in Denmark: A cross-sectional questionnaire-based study.

BACKGROUND: Professional cleaners are commonly affected by hand eczema (HE) due to wet work and exposure to cleaning products in the work environment. OBJECTIVE: To investigate (1) the prevalence of HE in a group of professional hospital cleaners, (2) the association of HE with various comorbidities and self-reported signs/symptoms of skin lesions and (3) the association of HE with various occupational and personal risk factors in the same population. METHODS: A cross-sectional questionnaire-based study including all cleaners working in three hospitals in Denmark. The questionnaire was composed of 35 questions. Prevalence is reported using proportions with 95% confidence intervals and compared using difference of proportions and Fisher's exact test. RESULTS: A total of 122 out of 180 cleaners (response rate = 68%) participated in this study. The self-reported lifetime prevalence of HE among the cleaners was 30.3%, while the 1-year prevalence was 18.9%. HE was significantly associated with a history of atopic diseases. There was a significant correlation between having HE, and self-reported redness and itch of the hands in the last 12 months, as well as the use of hydrochloric acid ≥4 days/week during the last 12 months. Logistic regression analysis found HE significantly associated with washing hands ≥20 times during a working day and a history of atopic dermatitis. CONCLUSION: Cleaners are at an elevated risk of developing HE. More focus on education/information regarding the prevention and treatment of HE is necessary for the cleaning profession. Self-reported redness and itching of the hands may be a useful prediction of HE in cleaners.

Two Novel Human Leukocyte Antigen Alleles Are Associated with Decreased Risk of Onychomycosis in a Large Cohort of Danish Blood Donors.

Introduction: Antigen presentation and antimicrobial immune responses involve the human leukocyte antigen (HLA) system. Onychomycosis is primarily caused by dermatophytes and affects around 5.5% of the population worldwide. Yet, only limited data exist on the associations between the HLA system and onychomycosis. Thus, the objective of the study was to investigate if there is an association between HLA alleles and onychomycosis. Methods: Participants in the Danish Blood Donor Study were defined as cases of onychomycosis and controls based on antifungal prescriptions in the national prescription registry. Associations were investigated using logistic regressions adjusted for confounders and were Bonferroni corrected for multiple tests. Results: A total of 3,665 participants were considered onychomycosis cases, and 24,144 participants were considered controls. We found two protective HLA alleles of onychomycosis: DQB1*06:04, odds ratios (OR) 0.80 (95% confidence interval (CI) 0.71-0.90), and DRB1*13:02, OR 0.79 (95% CI: 0.71-0.89). Conclusion: The finding of two novel protective alleles of onychomycosis indicates that certain HLA alleles have certain antigen presentation properties affecting the risk of fungal infection. These findings may provide the basis for future research identifying immunologically relevant antigens of fungi causing onychomycosis, which could ultimately lead to targets of new drugs with antifungal effects.

Prevalence of Hidradenitis Suppurativa in an African Population: Validation of a Screening Questionnaire in Lagos, Nigeria.

BACKGROUND: Epidemiologic hidradenitis suppurativa (HS) studies from Africa are lacking. This study aimed at uncovering the prevalence of HS in Lagos, Nigeria, to validate an HS screening questionnaire, and to contribute to the Global Hidradenitis Suppurativa Atlas (GHiSA). METHODS: This was a cross-sectional study of 802 healthy adults accompanying their relations to the outpatient clinic of Family Medicine and Ophthalmology at the Lagos State University Teaching Hospital in Lagos, Nigeria, following ethical approval. Verbal and written consents were obtained prior to inclusion of study participants. The study was conducted using a validated screening questionnaire. Screen-positive and randomly selected screen-negative participants were clinically examined. Severity was categorized using the Hurley score. RESULTS: The prevalence of HS in the sample was 2.2% (18/802; 95% CI: 1.4-3.5%) with no gender predominance. The mean age in the HS group was 34 years (IQR 28-42) and the median body mass index (BMI) of the HS patients was 27.0 (IQR 21.4-28.6). There was no significant difference in BMI between the HS and control group. The screening questionnaire had a sensitivity of 1 (18/18), specificity of 0.8 (20/25), positive predictive value of 0.8 (18/23), and a negative predictive value of 1 (20/20). The axilla was the predominant site of affection (66.7%), and all HS patients were classified as mild disease (Hurley score 1). CONCLUSION: The prevalence of HS in Lagos, Nigeria, was 2.2% and, in this population, BMI did not appear to be a risk factor. The axilla was the most affected site, and all patients had a mild disease severity (Hurley score 1). Finally, the HS screening questionnaire is a suitable tool in population surveys.

Primary skin abscess microbiota a systematic review.

An abscess is a collection of pus forming a cavity in the tissue, for example, the skin. They are generally perceived as the result of infection but infection is not mandatory for the diagnosis. Skin abscesses may occur independently (primary) or be part of other diseases such as the recurrent inflammatory skin disease hidradenitis suppurativa (HS). HS is noninfectious but nevertheless abscesses are a common differential diagnosis. The purpose of this study is to review the microbiome of bacteria positive primary skin abscesses in order to explore the reported microbiota. EMBASE, MEDLINER, and COCHRANE LIBRABRY were searched on 9th of October 2021 for microbiome, skin, and abscesses. Studies with more than 10 patients reporting the microbiome in human skin-abscesses were included and studies with abscess microbiota sampled from HS patients, microbiota not sampled from skin-abscesses, missing information on microbiome data, sampling bias, studies in other language than English or Danish, reviews and meta-analyses were excluded. In total 11 studies were included for further analysis. S. aureus is likely to dominate the microbiome of bacteria positive primary skin abscesses in contrast to the polymicrobial microbiome of HS.

What do professional cleaners know about the skin care? A questionnaire-based study.

BACKGROUND: Correct daily skin care is important regarding hand eczema (HE). However, only a few studies have evaluated the level of knowledge among hospital cleaners. OBJECTIVE: To examine the level of knowledge regarding skin protective behaviour and risk factors with respect to HE in hospital cleaners. METHODS: All cleaners working in four hospitals in Denmark were invited to participate in the study, which was based on a questionnaire consisting of 22 questions. RESULTS: 142 of 236 cleaners (response rate = 60.1%) were included. The mean of total correct answers were approximately five out of nine questions. 85.6% of participants evaluated themselves to have a low degree of knowledge of skin care and protection. Based on the number of correct answers, 90% were defined as having low knowledge. Being born or raised outside of Denmark was statistically significantly associated with lower level of knowledge. Risk factors for HE such as, work with wet hands, and use of household cleaning products were only recognized as risk factors by less than 50%. CONCLUSION: Our study indicates that Danish hospital cleaners have a low degree of knowledge regarding skin care and protection. Cleaning workers born or raised outside of Denmark are in need of special attention.

Comparative Efficacy and Safety of Janus Kinase Inhibitors Used in Alopecia Areata: A Systematic Review and Meta-analysis.

The aim of this study was to compare the efficacy and safety of treatment with Janus kinase inhibitors for alopecia areata, measured by change in Severity of Alopecia Tool (SALT) score. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was performed using Medline, EMBASE and Cochrane library. All studies investigating the efficacy of treatments for alopecia areata were included. Primary outcomes were the proportion of patients with alopecia areata achieving 30%, 50%, 75%, 90% and 100% improvement in SALT score after treatment with a Janus kinase inhibitor. A meta-analysis was performed including all randomized controlled trials investigating Janus kinase inhibitors. A total of 37 studies matched the inclusion criteria and were included. Meta-analysis was performed based on 5 randomized studies. Regarding patients with alopecia areata defined as ≥ 50% scalp hair loss, baricitinib 4 mg once daily demonstrated the highest efficacy. However, among patients with alopecia areata defined as a SALT score ≥ 50, oral deuruxolitinib 12 mg twice daily demonstrated the highest efficacy. Deuruxolitinib and baricitinib appear to be promising drugs for the treatment of alopecia areata. However, the response depends on the dosage of the drug. More randomized trials, with identical inclusion criteria and dose and duration of treatment, are required to confirm these findings.

Prevalence, risk factors, and prevention of occupational contact dermatitis among professional cleaners: a systematic review.

OBJECTIVE: The aim of this study was to investigate the prevalence, risk factors, and prevention of occupational contact dermatitis (OCD), as well as risk factors and consequences of OCD among professional cleaners. METHODS: A systematic review following PRISMA guidelines was performed using Medline, EMBASE, and Cochrane Library. RESULTS: Thirty-nine studies containing over 109.000 participants were included in the review. The prevalence of OCD varied between 2.2% and 30.1%. Main occupational risk factors for developing OCD among cleaners included wet work and irritants in cleaning products (bleach, chlorine, ammonia, multi-use-cleaning) and skin contact to metal. The most common contact allergies included rubber, biocides, nickel/cobalt, and perfumes. Other risk factors were inconsistent use of protective gloves and low educational level. Consequences associated with OCD included significant impairment in quality of life, tendency to have unscheduled absence from work, sick leave, increased rate of disability, and recognized degree of injury. Only one prevention study has been published investigating the effect of an educative course in skin-protective behavior in cleaners. The study reported a higher degree of knowledge of skin protection, a decrease in the severity of hand eczema, and a shift toward fewer daily hand washings at follow-up after 3 months. CONCLUSION: Our study proves that OCD is common in cleaners, and the main risk factors included wet work, irritants, and contact allergies, as well as inconsistent use of protective gloves and low educational level. More focus and a greater number of studies are needed on skin protection in this population.

Disinfection trials with terbinafine-susceptible and terbinafine-resistant dermatophytes.

BACKGROUND: Treatment of tinea pedis and onychomycosis is complicated by high rates of reinfection and the emergence of terbinafine-resistant strains of Trichophyton spp. Effective disinfection of contaminated socks is an important measure. Appropriate washing reduces the risk of reinfection and is paramount in treating tinea pedis and onychomycosis. OBJECTIVES: The aim of this study was to describe the effect of commonplace disinfection methods using socks pieces inoculated with terbinafine-resistant or terbinafine-susceptible isolates of Trichophyton spp. METHODS: Sock pieces were inoculated with seven terbinafine-resistant isolates of Trichophyton spp. with known mutations in the SQLE-gene (T. rubrum (n = 3), T. interdigitale (n = 1) and T. indotineae (n = 3)) and six terbinafine-susceptible isolates of Trichophyton spp. (T. rubrum (n = 3) and T. interdigitale (n = 3)). Methods of disinfection included soaking in a quaternary ammonium (QAC) detergent (0.5, 2 and 24 h), freezing at -20°C (0.5, 12 and 24 h), domestic and steam washing (both at 40°C with detergent). Sock pieces were cultured for 4 weeks following disinfection. The primary end point was no growth at the end of week 4. RESULTS: Soaking in a QAC-detergent for 24 h procured at disinfectant rate of 100% (13/13), whilst soaking in 0.5 and 2 h had a disinfectant rate of 46.2% (6/13) and 84.6% (11/13), respectively. Domestic washing (40°C with detergent) produced a disinfectant rate of 7.7% (1/13). Freezing at -20°C (0.5, 12 and 24 h) and steam washing (40°C with detergent) had no disinfectant properties. CONCLUSIONS: Soaking in a QAC-detergent for 24 h effectively disinfected sock pieces contaminated with dermatophytes.

Communicating with patients through pictograms and pictures - a scoping review.

BACKGROUND: Communication between patients and healthcare workers (HCWs) may on occasion be challenged by disparities in cultural background, age and educational level. Written educational material is commonly used to reduce the risk of miscommunication. However, literacy among patients may also differ and it is, therefore, speculated that the use of pictograms may improve patients' understanding and adherence. OBJECTIVE: To evaluate the scientific literature and investigate the effect and practical utility of pictograms in medical settings with focus on dermatological patients. MATERIALS AND METHODS: Pubmed, EMBASE, and Cochrane Library were searched July 2021 for studies regarding use of pictograms in medical settings and dermatology. RESULTS: The use of pictograms in dermatology is not well characterized, but studies in other fields of medicine report a positive effect of using pictograms in communication. Pictograms have a significant positive effect when presented alongside verbal or written explanations. CONCLUSIONS: The quality of the development process is important to ensure the utility of any pictogram. Involving the target population in the design and validation of the pictograms may be critical. In the validation process, testing of transparency and translucency may benefit from international recommendations.

International Dermatology Outcome Measures (IDEOM): Report from the 2020 Annual Meeting.

BACKGROUND: The International Dermatology Outcome Measures (IDEOM) initiative is a non-profit organization that aims to develop evidence-based outcome measurements to evaluate the impact of treatments for patients with dermatological disease. IDEOM includes all key stakeholders in dermatology (patient, physician, industry, insurer, and government) during the process of developing such outcome measurements. SUMMARY: Here, we provide an update of IDEOM activities that were presented at the 2020 IDEOM Virtual Annual Meeting (October 23-24, 2020). During the meeting, multiple IDEOM workgroups (psoriasis, psoriatic arthritis, hidradenitis suppurativa, acne, pyoderma gangrenosum, and actinic keratosis) shared their progress to date, as well as future directions in developing and validating Patient-Reported Outcome Measures. Updates on demonstrating efficacy in clinicals trials by the US Food and Drug Administration are also summarized. KEY MESSAGES: In this report, we summarize the work presented by each IDEOM workgroup (psoriasis, psoriatic arthritis, hidradenitis suppurativa, acne, pyoderma gangrenosum, and actinic keratosis) at the 2020 IDEOM Virtual Annual Meeting.

Optical coherence tomography quantifying photo aging: skin microvasculature depth, epidermal thickness and UV exposure.

INTRODUCTION: Photo aging predominantly occurs in the face, neck and hands due to UVA and UVB irradiation. It is associated with skin cancer and histological studies indicate thinning of the epidermis and elastosis occurs. Dynamic Optical coherence tomography (D-OCT) is a non-invasive imaging tool able to visualize the epidermis and upper dermis and its blood vessels as well as to evaluate epidermal thickness (ET) and blood flow. OBJECTIVE: To investigate ET and blood vessel depth using D-OCT in human subjects correlated to UV exposure. METHODS: We evaluated data from 249 healthy adults, that had D-OCT-scans conducted at four different regions (forehead, neck, arm and hand) and correlated ET and blood vessel depth with occupational UV exposure (total standard erythema dose, Total SED), season and demographic data. RESULTS: Regional differences in ET and blood vessel depth were found (p values < 0.001). Multiple linear regressions showed a seasonal effect on both ET (- 0.113 to - 0.288 µm/day, p values < 0.001) and blood vessel depth (0.168-0.347 µm/day, p values < 0.001-0.007) during August-December. Significant age-related decrease of ET was seen in forehead, arm and hand (0.207-0.328 µm/year, p values = 0.002-0.18) and blood vessel depth in forehead (0.064-0.553 µm/year, p values = 0.01-0.61). Males had thicker epidermis (3.92-10.93 µm, p values = 0.002-0.15). CONCLUSION: Changing seasons are a major predictor of both ET and blood vessel depth, showing strongest effect in non-exposed areas, suggesting a systemic effect, possibly due to seasonal vitamin D fluctuation. Sex, age and occupational UV exposure affect ET. This study demonstrated the feasibility of D-OCT to evaluate epidermal thickness and blood vessel depth.

Inflammation of Actinic Keratoses Induced by Combination of Carboplatin and Paclitaxel: Two Case Reports.

The observations of a beneficial effect of 5-fluorouracil-induced actinic keratoses (AK) inflammation led to the development of topical fluorouracil, a product registered for the management of AK. A conscientious surveillance of AK inflammation during chemotherapy may conceivably lead to the development of further drugs for treatment of AK. A number of other chemotherapeutics have thus been linked to similar reactions without ensuing development. Here, we describe two further cases linking chemotherapy with carboplatin and paclitaxel to possible anti-AK effects, identifying them as potential treatments. Whether multidrug chemotherapy leads to stronger AK inflammation or cure AK more successfully is currently unknown.

Darier's Disease Flare following COVID-19 Vaccine.

Darier's disease is a rare genodermatosis characterized clinically by dyskeratotic papules in the seborrheic and intertriginous areas and nail abnormalities. Dyskeratosis and acantholysis are typical histological findings. Darier's disease is not known to be inflammatory by nature as inflammation occurs primarily due to local infections, and it may therefore differ from inflammatory dermatoses such as psoriasis and cutaneous lupus in response to antigen stimulation. Known triggers of Darier's disease primarily include exogenous factors such as sun exposure, friction, or infection. We present a case of a 47-year-old white female with a flare of Darier's disease 2 days following her first vaccination with COVID-19 vaccine (ChAdOx1-s [recombinant]) (Vaxzevria® [previously known as COVID-19 vaccine AstraZeneca]). In this case report, we discuss possible mechanisms linking the vaccination and the flare of Darier's disease. We consider inflammatory mechanisms as well as a random co-occurrence. Due to the close time-related association between the disease flare and the COVID-19 vaccination, we find an urge to make other clinicians aware of a possible association.