Exploring the burden of actinic keratoses through development of a patient decision aid: a mixed methods study.

BACKGROUND: Actinic keratoses (AKs) present on sun-exposed sites and are considered precursors of cutaneous squamous cell carcinoma (cSCC). A better understanding of the experiences of patients with this condition may improve patient-provider relationships and guide the introduction of shared-decision making (SDM) to treatment decisions. OBJECTIVES: To develop a patient decision aid (PDA) for field treatment of multiple actinic keratoses in line with the International Patient Decision Aid Standards (IPDAS), by (i) characterising the burden and lived experiences of patients with multiple AKs, (ii) understanding the decisional needs of patients requiring field treatment and (iii) exploring clinician preferences regarding field treatment for multiple AKs. MATERIALS AND METHODS: This mixed methods study followed the most up-to-date guidelines set out by the IPDAS Collaboration; a voluntary body which aims to enhance the quality of PDAs by developing an evidence-based systematic process for the development of unbiased and effective PDAs. RESULTS: Multiple actinic keratoses have a psychosocial impact on patients. Patients feel supported through the integration of evidence-based information to guide SDM. CONCLUSIONS: We propose that the use of a PDA for multiple AKs provides a key role in supporting informed shared patient-provider decision making and empowers patient involvement in their prospective treatment strategy.

Clinicopathological characteristics of individuals with coexisting melanoma and chronic lymphocytic leukaemia: a multicentre cohort study.

BACKGROUND: Individuals with a prior diagnosis of chronic lymphocytic leukaemia (CLL) have a higher risk of developing melanoma and exhibit poorer outcomes than patients without CLL. However, there are limited data reporting the clinicopathological features of melanoma diagnosed in patients with CLL. AIMS: To review clinicopathological characteristics of patients with coexisting diagnoses of melanoma and CLL. METHODS: A retrospective review was undertaken for patients with coexisting diagnoses of melanoma and CLL between 2005 and 2015 in 11 centres in the UK and Ireland. RESULTS: Overall, 46 cutaneous melanomas identified in 45 patients were included. In 28 (62.2%) patients, melanoma was diagnosed after an existing diagnosis of CLL. In this group, mean Breslow thickness was 2.7 mm (range 0.2-25 mm). Ten patients (35.7%) developed locoregional recurrence and 8 (28.6%) developed distant metastases. Melanoma-specific mortality was 5 of 28 (17.9%) and all-cause mortality was 13 of 28 (46.4%). In 17 patients, melanoma was diagnosed before CLL. In this group, mean BT was 2.9 mm (range 0.4-14 mm); five patients (29.4%) developed locoregional recurrence and three (17.6%) developed distant metastases. Melanoma-specific mortality was 1 of 17 (5.8%) and all-cause mortality was 5 of 17 (29.4%) in this group. CONCLUSIONS: To our knowledge, this is the first and largest cohort study to report clinicopathological data of coexisting melanoma and CLL in the UK and Ireland. Although the thickness of primary melanoma was not different before or after a CLL diagnosis, melanoma recurrence and melanoma-specific mortality appear to be more common in patients with a prior diagnosis of CLL.

The 'number needed to treat' metric: a further marker of the impact of COVID-19 on malignant melanomas.

We comment on a previous article, describing the number needed to treat metric as a further marker on the impact of COVID-19 on treatment of malignant melanomas.

Skin care advice to patients with multiple sclerosis on Fingolimod treatment at increased risk of skin malignancy-room for improvement?

Fingolimod is used to treat relapsing-remitting multiple sclerosis. It has an immunosuppressive effect that predisposes to skin malignancies. The Summary of Product Characteristics recommends that persons receiving Fingolimod be educated regarding photoprotection and vigilance of skin lesions and should undergo a dermatological evaluation at initiation of treatment and 6-12 monthly thereafter. The incidence of keratinocytic carcinomas in those on long-term immunosuppression following solid organ transplantation is declining. This trend coincided with temporal changes in immunosuppressive protocols and the introduction of skin cancer prevention programmes suggesting that the risk of developing these malignancies may be mitigated by the provision of education to patients amongst other measures. The aim of our study was to assess if health care professionals are explaining skin advice and documenting the discussion when prescribing Fingolimod in a University Hospital outpatient setting. Clinical records of consecutive patients on Fingolimod were reviewed. Data on demographics, documented provision of advice on skin protection and who provided the advice was collected. Fifty patients with multiple sclerosis were identified. Median age was 40.5 years (range 25-63). Forty-two were female (42/50, 84%). Provision of advice regarding skin protection was documented in 20% (10/50). This was provided by nurse specialists in 14% (7/50), doctors in 10% (5/50) and both in 4% (2/50). The risk of developing skin cancers can be reduced by the adoption of simple preventative measures; patients on Fingolimod are at an increased risk of developing these cancers. This study demonstrates a need for improvement in the documentation of advice around skin protection.

Understanding the role of cutaneous allergy testing in anogenital dermatoses: a retrospective evaluation of contact sensitization in anogenital dermatoses.

BACKGROUND: Patients with anogenital symptoms may delay before seeking medical attention. Attempted self-treatment with multiple topical preparations and excessive hygiene measures offer ideal conditions for sensitization. The aim of this study was to identify the common allergens detected on cutaneous allergy testing in patients presenting with anogenital symptoms. METHODS: A retrospective chart review of patients who underwent cutaneous allergy testing for perianal and/or genital symptoms over a 3-year period, January 2013 to December 2015, n = 99. Information was gathered from medical records, pretesting questionnaires, and cutaneous allergy testing records. RESULTS: At least one relevant allergen(s) was identified in 44/99 (45%) in our cohort, with allergic reactions to fragrances, Myroxylon pereirae, caine mix, sodium metabisulfite, and methylisothiazolinone most frequently observed. CONCLUSIONS: Cutaneous allergy testing is a useful investigation in patients presenting with anogenital symptoms, but advice regarding general skin care measures should not be omitted. The most commonly identified relevant allergens in our study were those present in over-the-counter cleansing and hemorrhoid preparations.

The Implications of Recent Recommendations for Managing Patients with Psoriasis Treated with Fumaric Acid Esters.

BACKGROUND/AIMS: Fumaric acid esters (FAEs) are a well-established efficacious systemic treatment for psoriasis. Recent recommendations from the European Medicines Agency suggest monitoring of full blood count every 4 weeks for the duration of therapy for psoriasis. The aim of our study was to assess the incidence of lymphopenia in patients taking FAEs and the impact of recent recommendations for our practice. METHODS: We reviewed 151 patients treated with FAEs for psoriasis between December 2013 and 2015. RESULTS: Lymphopenia <700 × 109/L was detected within the last 12 months in 36/151 (24%) and lymphopenia <500 × 109/L in 10/151 (7%). Of 39 patients no longer on treatment, 7 (18%) stopped because of persistent lymphopenia. CONCLUSION: The implementation of these recommendations would have significant resource implications and also likely influence the acceptability of FAEs to patients. Cessation of FAEs necessitates the need for alternative therapy, commonly biologic therapy.

A randomised half body prospective study of low and medium dose regimens using the 308 nm excimer laser in the treatment of localised psoriasis.

This study compared two dose-escalation regimens using the 308 nm excimer laser treating localised plaque psoriasis, to determine the optimal regimen. A randomised, left-right body trial was designed including patients aged >18 years with localised plaque psoriasis (<10% body surface area). The standard/low dose regimen started at 70% of the minimal erythema dose (MED), with 20% dose increments. The medium dose regimen commenced at 200% MED, with 25% increments. Patients were treated until disease clearance or a maximum of 36 treatments. Fifteen patients aged 28-55 years completed the study. Psoriasis severity index scores analysed at weeks 0, 6 and 12 showed a significant reduction with each regimen (p < 0.0001). Six patients cleared, seven had significant improvement with uneven clearance of plaques and two failed. Average remission was four months (range 1-12 months). There was a significant reduction in DLQI (p = 0.014). Excimer laser improved psoriasis and reduced DLQI scores, but clearance was incomplete for many patients and remission was short-lived. Adverse effects of pain and blistering were commoner with the medium dose regimen, without any benefit in psoriasis clearance.

Artificial White Light vs Daylight Photodynamic Therapy for Actinic Keratoses: A Randomized Clinical Trial.

IMPORTANCE: Daylight photodynamic therapy using topical methyl 5-aminolevulinic acid (MAL) for actinic keratoses (AKs) is as effective as conventional photodynamic therapy but has the advantage of being almost pain free. Daylight photodynamic therapy, however, requires dry and warm weather conditions. OBJECTIVE: To establish if topical MAL photodynamic therapy using a white light light-emitting diode (LED) lamp is as effective and well-tolerated as daylight photodynamic therapy for the treatment of AKs. DESIGN, SETTING, AND PARTICIPANTS: Overall, 22 men with significant photodamage and a high number of AKs were enrolled in this prospective, randomized, single-blind study, employing a split-scalp design, comparing the effectiveness and adverse effects of daylight photodynamic therapy and artificial white light (AWL) LED photodynamic therapy for the treatment of AKs on the forehead and scalp. Organ transplant recipients were excluded. Patients were treated and evaluated at an academic tertiary referral dermatology center. Treatment lasted from April 2014 to July 2014 and follow-up visits occurred for 9 months posttreatment. INTERVENTIONS: Two symmetrical treatment fields were defined and AKs counted, mapped, and photographed at baseline, 1, 3, 6, and 9 months. Patients had half of their scalp treated with daylight photodynamic therapy and the other half treated with AWL photodynamic therapy 1 week apart and randomly allocated. MAL was applied, and treatment commenced 30 minutes later and lasted 2 hours. Irradiance, illuminance, and light spectra measurements were performed. The integrated dose in J/cm2 was measured. The effective light dose, weighted to the absorption spectrum for protoporphyrin IX, was calculated. MAIN OUTCOMES AND MEASURES: The primary end point was the reduction in total AK count per treatment field. Secondary end points included adverse effects and patient satisfaction. RESULTS: We enrolled 22 men with a median age of 72 years (range, 47-85 years) at baseline, the total (median of AKs per field) were 469 (20.5) for the DPDT group and 496 (20.5) for the AWLPDT group (P = .34). The median number and percentage of reduction in AKs per field were 12 and 62.3% for DPDT and 14 and 67.7% for AWLPDT at 1 month (P = .21 and P = .13, respectively). There was no significant difference in the reduction percentage of AKs for either treatment at 1, 3, and 6 months. At 9 months, the median number and percentage of reduction in AKs per field was 9.0 and 48.4% for DPDT and 12.0 and 64.4% for AWLPDT (P = .13 and P = .05, respectively). Pain was reported by 14 patients with DPDT and 16 patients with AWLPDT (median maximum score [out of 100], 4 vs 6; P = .51). Moderate erythema was reported by 9 patients after DPDT and 14 patients after AWLPDT. On a scale of 0 (intolerable) to 10 (very tolerable) patients rated DPDT as 9.5 and AWLPDT as 9 (P = .37). CONCLUSIONS AND RELEVANCE: Photodynamic therapy using an AWL source was as effective and well-tolerated as daylight photodynamic therapy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02520700.