CITY-PSO: Prescribing behaviour of French private-practice dermatologists in psoriasis management: An observational, multicentre, cross-sectional study.

BACKGROUND: Information regarding the prescribing behaviour of French private-practice dermatologists (PPDs) is scarce. OBJECTIVES: First, to describe the population of PPDs involved in psoriasis management. Second, to describe the population of adult patients treated for psoriasis and their management. METHODS: We published a call for participation targeting PPDs; we first asked respondents to complete a form regarding their prescribing behaviour, and then to include consecutive patients consulting for psoriasis during a one-month study period and to collect patient data. RESULTS: The 94 participating PPDs included 1022 patients of mean age 52.9±17.9 years. The average body mass index was 28, and 25% had vascular comorbidities. Two thirds of patients had chronic psoriasis, for which 45% had consulted at least 5 times. Psoriasis was mostly with plaques (70.8%) and 11.4% of patients had psoriatic arthritis. The average body surface area (BSA) affected was 10.1%. Among the 679 patients without initial systemic treatment, 159 were started on systemic treatment. The main agents initiated were phototherapy (n=63), methotrexate (n=40), acitretin (n=30) and apremilast (n=20). In multivariate analysis, a higher BSA [Odds Ratio (OR) 1.10, 95% Confidence Interval (CI): 1.07-1.13; P<10-4] and Dermatology Life Quality Index (DLQI) [OR 1.09, 95% CI: 1.03-1.15; P=0.04] were associated with prescription of systemic therapy at the end of the consultation. CONCLUSION: The main limitation of our study was that participating PPDs were strongly involved in psoriasis management, which accounts for the high proportion of moderate-to-severe psoriasis and prescription of systemic treatments. Such committed PPDs and the development of psoriasis networks are key factors for improving the quality of care provided to psoriasis patients.

Clinicopathologic analysis of trichoblastoma and comparison with nodular basal cell carcinoma.

BACKGROUND: Trichoblastoma (TB) is an uncommon benign follicular tumour for which clinical data is limited since most reports originate from pathology studies. OBJECTIVE: To describe the clinical aspects of TB. METHODS: This is an ancillary study of a prospective multicentre cohort of 2710 clinically suspected basal cell carcinoma (BCC), including 935 nodular BCCs. Sixty-two cases were TB: they were analysed and compared to 935 nodular BCCs. RESULTS: TB mostly occurred in females (61% vs. 43% for BCC, P<0.01) of mean age 63 years. They were located on the head and neck, mainly on the nose and forehead, in 87% of cases. The mean size was 8.1mm, 77% were<10mm (55% of BCCs, P<0.001), 8% were ulcerated (vs. 21% of BCCs, P<0.02), and 47% persisted for more than 1 year (34% of BCCs, P<0.05). Most cases had a clinical presentation similar to nodular BCC, except for 5 small, flat, white papules and 1 anfractuous plaque. LIMITATIONS: Cases originated from a series of tumours clinically suspected as BCCs. DISCUSSION: Some 2.6% of tumours clinically diagnosed as BCC are in fact TB. TB occurs on the head, are more frequent in women, and are smaller and of longer duration than BCC. In most cases, clinical diagnosis on clinical grounds is difficult.

Impact of the COVID-19 pandemic on children with psoriasis.

BACKGROUND: Children with psoriasis may have been directly impacted by the COVID-19 pandemic and their illness may also have affected their ability to follow preventive measures. OBJECTIVE: To investigate the impact of the COVID-19 pandemic on children with psoriasis. METHODS: A survey of children (<18 years) with psoriasis, conducted from June 10 to June 29, 2020. RESULTS: In total, 92 children were included: 71.7% had psoriasis lesions at the time of home lockdown while 45.2% were receiving systemic treatments, and two contracted COVID-19. During lockdown, psoriasis worsened in 47.3% of the children and 18.8% stopped their systemic treatments, mainly for reasons linked to the pandemic. A total of 41.3% had a consultation for psoriasis during lockdown (71.1% by teleconsultation): 39.5% due to worsening of their psoriasis and 21.1% for pandemic-related issues. Among patients not having a consultation during lockdown, 27.5% had a cancellation by the doctor and 9.3% had concerns over going to see the doctor. Finally, 22.8% of patients reported finding it difficult to respect hygiene measures because of their psoriasis, e.g., application of alcohol-based hand sanitizers (47.6%), handwashing routines (42.9%), and wearing a mask (28.6%). CONCLUSIONS: This study demonstrates the major clinical impact of the COVID-19 pandemic on children with psoriasis. Teleconsultations played a key role in patient management as regards patient monitoring, provision of information, and renewal of treatments. It is vital that we learn from these data to improve and adapt the monitoring of chronic dermatoses in both children and adults in the event of a future health crisis.

Clinical factors predictive for histological aggressiveness of basal cell carcinoma: A prospective study of 2274 cases.

INTRODUCTION: Since surgery is the first-line treatment for basal cell carcinomas (BCC), the histological aggressiveness of the disease must be clinically predicted in order to apply optimal safety margins that ensure a high rate of complete resection while minimising the risk of recurrence. OBJECTIVES: To evaluate clinical predictive factors of histological aggressiveness of BCC, we conducted a national prospective multi-centre study. METHODS: All consecutive patients presenting for BCC surgery were included, and standardised clinical data collected, and slides were submitted for review. Trabecular, micronodular and morpheaform BCCs were classified as aggressive. RESULTS: Of the 2710 cases included, 2274 were histologically confirmed. Clinical subtyping was correct in 49.9% of superficial BCCs, 86.2% of nodular BCCs and only 22% of aggressive BCCs. By multivariate analysis, aggressive BCCs were more frequently ulcerated (45%), indurated (70%), showed adherence (8.6%), and were associated with high-risk anatomical zones (50.3%, P<0.0001). These predictive clinical features may be helpful for decision making.

[Introduction to tissue movements - Principles of flaps]. / Introduction aux mouvements tissulaires ­ Principes des lambeaux.

The practice of surgical dermatology allows the dermatologist to take overall management of patients, particularly in the domain of skin cancer. It is the dermatologist who makes a diagnosis based on his expertise and his understanding, determines the tumour edges and the surgical margins to be applied, carries out the excision and repair procedures, and performs monitoring. Such comprehensive management requires knowledge of fundamental principles that allow for repair procedures suited to specific sites. Normally, simple repair involving direct suture can be performed using the intrinsic elasticity and plasticity of skin. However, depending on the site and the extent of substance loss, it may be necessary to perform a more complex repair by recruiting adjoining skin to create a flap. Skin flaps follow certain shared general rules. Their primary purpose is to fill in for surgically removed tissue that cannot be corrected by suturing by simply moving them from their current anatomical placement, creating a second and different shaped tissue loss at a point where simple wound closure may be effected thanks to looseness of the skin. In this article, we lay the groundwork for reflection on the practice of autoplasty, we set out the rules required to ensure optimal results, and we explain the various types of flaps using a classification based on tissue mobilization including advancement, rotation and transposition flaps.

Prise en charge chirurgicale du carcinome basocellulaire: Surgical management of basal cell carcinoma.

The incidence of basal cell carcinoma (BCC) is increasing as the population is aging and doubles every ten years. Surgery is the first-line treatment of BCC. Dermatological surgery is an oncological skin surgery whose first objective is to obtain a complete resection of the tumor. Its aim is also to reconstruct the defect using the optimal repair technique for the best cosmetic and scarring outcome and without functional impairment. The dermatological approach with the "oncological reading" of cutaneous tumors constitutes the essential preliminary time to the diagnosis of BCC and the identification of its limits. The perfect knowledge of the security margins in accordance with the guidelines allows a complete excision and a reconstruction in one stage under local anesthesia in the majority of cases. The surgical treatment must use 3D histology techniques or micrographic surgery to manage difficult cases of aggressive BCC in high risk zone or recurrence. Management of very aggressive BCC or locally advanced BCC is discussed in a multidisciplinary consultation by assessing the benefit/risk ratio of the surgical treatment and by identifying the appropriate surgeon after documenting the tumor, its operability and patient's adherence to the surgical treatment. © 2018. Published by Elsevier Masson SAS. All rights reserved. Cet article fait partie du numéro supplément Prise en charge des carcinomes basocellulaires difficiles à traiter réalisé avec le soutien institutionnel de Sun Pharma.

Management of actinic keratosis at specific body sites in patients at high risk of carcinoma lesions: expert consensus from the AKTeam™ of expert clinicians.

Actinic keratoses (AK) arise on sun-exposed regions of the skin. If left untreated, AK may progress to invasive squamous cell carcinoma (SCC), although the rate of progression is low. A practical treatment algorithm for the treatment of AK in standard situations has been published by the AKTeam™ expert panel. However, management of particular situations of AK with increasing/higher carcinoma risk or AK progressing into carcinomas with increased aggressiveness due to their anatomical location (risky areas), or in patients with an increased risk of SCC requires further discussion. These include AK on the dorsal hands, forearms, legs, periorbital region, eyelids, ears, or lips, and organ transplant recipients, patients undergoing treatment with carcinogenic agents and patients with chronic lymphocytic leukaemia. The main objective was to propose therapeutic strategies for the treatment of AK located in risky areas and in patients with more invasive/aggressive lesions and a higher risk of progression to SCC. A systematic review of the literature was initially performed, and results were discussed by the experts to propose best management practices in specific situations. Finally, adapted management strategies for AK occurring in risky areas and in high-risk patients are presented, taking into account the experts' own clinical experience and current guidelines. In most of these 'at-risk' situations, patients can be treated according to the AKTeam™ treatment algorithm. Difficult-to-treat lesions should be treated more aggressively due to their higher risk of transformation. For patients with skin that is highly susceptible to actinic damage, monitoring and sun protection strategies are mandatory, and patients should undergo more regular follow-up. Further assessment of newer therapies in clinical trials is necessary to determine optimal treatment conditions. This expert consensus provides guidance for the management of AK in risky body sites and in patients with an increasing/higher risk for SCCs.

[How to optimize scarring in dermatologic surgery?] / Optimisation de la cicatrisation en chirurgie dermatologique et gestions des aléas.

Scarring is the response elicited by the skin surface to injury and loss of tissue material. Wound healing takes place through a complex natural repair system consisting of vascular, inflammatory and proliferative phenomena, followed by a remodelling and cell apoptosis phase. This incredible repair system is inevitable, but sometimes unpredictable due to individual differences based on multiple factors. The scar is the objective criterion of a skin surgery, both for the patient and the dermsurgeon. It is therefore crucial to establish with the patient during the preoperative consultation, the size and positioning of the expected scar, taking into account the oncologic, anatomic and surgical constraints. Scars can ideally blend into normal skin, but may also give rise to various abnormalities. We can manage and prevent these abnormalities by mastering initial inflammation, that may induce hyperpigmentation and hypertrophy. Early massage using cortocosteroid topic or anti-inflammatory moisturizers may be effective. Random individual scarring may be minimized by a dynamic personalized accompanying scarring.

[Locally advanced basal-cell carcinoma: Combined alternative treatments beyond surgery]. / Carcinomes basocellulaires localement avancés: intérêt de traitements combinés, alternatifs à la chirurgie.

The vismodegib, inhibitor of the hedgehog signaling pathway, is a new therapeutic option in locally advanced BCC when surgery or radiotherapy are inappropriate. If the response rate is high with rapid and sustained efficacy, complete responses are rare. Furthermore, the common side effects may limit continuous and prolonged treatment and lead to discuss sequential treatments. We report two cases that illustrate the severity of LaCBC, tumors neglected by patients and their families limiting therapeutic choice especially surgery that become impossible and for which vismodegib is indicated. These observations illustrate the possible interest of radiotherapy in combination or after tumor debulking by vismodegib. Vismodegib must be known by surgeons for LaCBC, mainly as an alternative beyond surgery but also as a possible neoadjuvant treatment to surgery that have to be evaluated.

[What's new in instrumental dermatology?]. / Quoi de neuf en dermatologie instrumentale?

This "What's new in instrumental dermatology" focuses on cutaneous oncologic surgery, base on a review of the 2012-2014 literature. First, the ability of dermatologists to make a good "oncologic reading of tumors" is the key of radical surgical treatment. Advantages and disadvantages of the biopsy are discussed. Then, the second message is the management of anticoagulants, that should not be interrupted for skin surgery. Despite recommendations, this practice is not followed in 40% of cases; this point is critical because bleeding complications are minor compared to potential morbidity of thrombotic events when stopping these medications. Regarding infection, nasal carriage of Staphylococcus aureus is identified as a risk factor for wound infection. A preoperative shower with chlorhexidine and mupirocin topical decolonization of nostril reduces this risk. Surgical techniques are trying to reach minimalism, by reducing undermining and scarring. On the trunk, using deep slow resorbable sutures improve scarring. In addition using adhesive sutures (strip) reduce the wideness of scar. On the face, the lower third of the nose is the most challenging because of the free edges, which are deformable. In this location bilobed or trilobed transposition flap offer the advantage of remaining in the nasal aesthetic unit and not disturbing the free edges of the nasal orifices. Regarding scarring, early hypertrophic scar is now well defined and linked with transposition flaps of the nasal region. An early treatment with intralesional corticosteroid injection appears to be effective. Finally, the biological mechanism of the effectiveness of compression in the prevention and treatment of dystrophic scar is now clear. The mechanotransduction explain how a mechanical stress of the skin activates biological cell pathways, which regulate the quality of collagen synthesis and the arrangement of skin fibrosis.

Management of actinic keratosis: a practical report and treatment algorithm from AKTeam™ expert clinicians.

BACKGROUND: Actinic keratoses (AK) are common photo-induced cutaneous lesions that may progress to invasive squamous-cell carcinoma and serve as a risk marker for skin cancer. Although numerous studies present the various therapeutic options for AK, publications that can be used to pragmatically guide dermatologists in their daily practice are limited. National and international guidelines have been published, however, they are based on clinical trials with highly selected patient populations and do not always capture the range of patients seen in everyday practice. OBJECTIVE: The objective of this expert panel of French dermatologists was to present an analysis of AK geared towards everyday practice, to express an informed opinion about most recent treatments, and to propose a treatment algorithm for AK for daily practice in France. METHODS: Over a 12 month period, six expert dermatologists in the field of AK (AKTeam(TM) expert panel) met regularly to formulate an opinion about treatment in everyday practice compared with the analysis of the literature and guidelines published since 1990. RESULTS: Definitions, terminology, diagnosis and risk factors were summarized. Data from the literature and current practices related to the initial evaluation, indications for biopsy, therapeutic indications, therapeutic options and effectiveness, monitoring and prevention were discussed. A pragmatic treatment algorithm was formalized according to current data available. This practical algorithm distinguishes between different clinical situations depending on the number of AK, their hyperkeratotic or suspicious nature, and includes cryotherapy, curettage-electrocoagulation, 5% 5-fluorouracil, 3% diclofenac sodium, 5% imiquimod, 150 and 500 µg/g ingenol mebutate, lasers, photodynamic therapy and surgery. CONCLUSION: This up-to-date expert opinions about AK and its treatment provide a management strategy and practical treatment algorithm for AK for French dermatologists to use.

[Early hypertrophic scar after surgery on the nasal region: value of long-acting corticosteroid injections]. / Hypertrophie cicatricielle précoce post-chirurgicale de la région nasale : intérêt des injections de corticoïde retard.

BACKGROUND: "Pincushioning" is a complication of post-surgical scarring following use of transposition flaps particularly when surgery is performed on the nasal region. The transposition flap technique is very useful for the repair of certain defects of the tip of the nose, the medial canthus or of the ala nasi. The aim of this study is to define the clinical characteristics of this scarring dystrophy, which we propose to call "early hypertrophy scarring", to clarify the nature thereof and to assess the efficacy of intralesional injection of corticosteroids at the first signs of hypertrophy. PATIENTS AND METHOD: A prospective, open, non-comparative, single-centre study examined the clinical and histological characteristics of early hypertrophy scarring and the effectiveness of therapy with one or two injections of corticosteroids performed on the 15th day post-operatively and optionally repeated at D45 depending on the outcome. From January 2011 to January 2013, 12 consecutive patients with early hypertrophy scarring were included (ten men and two women - mean age: 64 years). All had undergone surgery for basal cell carcinoma under local anaesthesia with one-stage repair by means of a rhombic flap or a bilobed flap located in the nasal area. Scars were injected strictly intra-lesionally with triamcinolone acetate (40 mg/1 mL) until whitening occurred. A single injection was performed in three cases of rhombic flap while a second injection was given at D45 in the remaining nine cases. RESULTS: Complete regression of the early hypertrophy scarring was obtained in ten of the 12 patients by D90. Incomplete regression was observed but with a marked improvement in the other two patients. DISCUSSION: Early hypertrophy scarring is distinguished by its clinical characteristics of hypertrophic or keloid scars. Biopsy performed in two cases showed the fibrous but non-fatty nature of early hypertrophy scarring. Biomechanical factors particular to the nasal region and the transposition flap technique could account for the early and excessive collagen production causing early hypertrophy scarring. Early injection of corticosteroids, which was consistently effective in our study, could represent a simple treatment for early hypertrophy scarring, thus avoiding surgical correction. These preliminary results in a small number of patients require confirmation by a comparative, multicentre, prospective controlled study.

Dermatosurgery: total quality management in a dermatology department.

BACKGROUND: Dermatosurgery (DS) is a growing sector in dermatology. Performance measurement is organized worldwide to improve the quality of health care. Clinical audit relies on self-assessment, comparison with guidelines, frames of references and implementation of improvement actions. OBJECTIVE: To assess the efficiency of our DS department. METHODS: A clinical audit focusing on the organization of the DS unit, patient routing, continuing medical education and training for students was conducted by two external auditors. After an initial evaluation, improvements were implemented and reassessed 1 year later by the same auditors. RESULTS: The audit resulted in the implementation of preoperative consultation, improved pre- and postoperative information leaflets for patients, standardizing of surgery reports, earmarking of funds for materials, and patient satisfaction survey. The training of residents was organized. CONCLUSION: This audit was a driving force for communication among the medical and paramedical teams and helped improve patient care and training of residents in DS. It also highlighted areas needing further improvement.

[Evaluation of the activity of skin tumor's excision in dermatology (France, 2009)]. / Bilan de l'activité de chirurgie d'exérèse des tumeurs cutanées en dermatologie en France en 2009.

BACKGROUND: Dermatosurgery has been gaining in importance in recent years. STUDY AIMS: The aim of our study was to describe this activity to increase its value and to inform the other specialists and the general public. PATIENTS AND METHODS: We performed a national prospective study during one month in the hospital centers and university teaching hospitals in France and among the members of the Surgical Group of the Société française de dermatologie. Data were collected with a pre-established questionnaire. They were captured on EpiData 3.1 and Excel software package and were analysed using the SPSS 15.0 software package. RESULTS: The participation of dermatology departments in hospital was 66.7 %. For the members of the surgical group, it was 43.1 %. A total of 2308 dermatological surgical procedures was performed. The mean age was 55.5 years ± 20.7. Three hundred and thirty-six (14.6 %) procedures were performed with antiplatelet agents or anticoagulants. The excisions of skin cancers were carry out with no previous biopsy in 71.3 % of cases. We described repairs in one time in the majority of cases (92.2 %), and the most frequent type of procedure was direct closure (83.4 %). Complete excision was obtained directly in 95.2 % of cases and the clinicopathological correlation was also excellent (89.5 %). Three percent of patients suffered complications during or following surgery and these complications were more frequent with the patients treated by antithrombotic medications. CONCLUSION: This is, in our knowledge, the first prospective study on dermatosurgery activity practised by dermatologists in France. The important rate of participation exemplified the implications of dermatologists in the treatment of skin cancers with an optimal follow-up.