Real-world data on the effectiveness of brodalumab in patients with moderate-to severe plaque psoriasis in the Greek clinical setting (the BrIDGE study).

BACKGROUND: Despite that brodalumab's efficacy and safety have been assessed in randomized clinical trials, real-life data remain scarce. BrIDGE was an observational, prospective, single-cohort, multicentre study that recruited patients with moderate-to severe plaque psoriasis in Greece. OBJECTIVES: The primary objective was to assess the proportion of patients who achieved Psoriasis Area and Severity Index (PASI)100 after 24 weeks. Other endpoints included: the maintenance of PASI90/100 through to 104 weeks, the short-term response [PASI75/90/100 and static Physician's Global Assessment (sPGA) 0/1] to brodalumab at 12-16 weeks and time to complete clearance. Moreover, we explored the change in quality of life [Dermatology Life Quality Index (DLQI) 0/1] and adherence to brodalumab. METHODS: Two hundred patients who were initiating treatment with or switching to brodalumab, were recruited. Analyses were conducted using the as observed data and three imputation approaches were also applied for the missing data (last observation carried forward, 'worst case' and 'best case' scenario). Continuous variables were reported using summary statistics, whereas categorical variables were reported in frequency tables. RESULTS: Based on the 'as observed data', 42.0% of patients achieved PASI100 at Week 24 after 25.9 ± 3.5 weeks and 65% of patients attained PASI100 at Week 104. In total, 70.2%, 47.5% and 32.0% achieved PASI75/90/100, respectively, whereas 72.6% of patients achieved sPGA 0/1, at Weeks 12-16. With respect to sPGA status 82.8%, 89.2% and 92.5% of patients achieved sPGA 0/1 at Weeks 24, 52 and 104, respectively. The time to achieve PASI100 at Weeks 12-16 was 13.7 ± 1.3, 52.1 ± 3.4 weeks at Week 52 and 105.5 ± 4.8 weeks at Week 104. Mean DLQI and Psoriasis Symptom Inventory (PSI) scores decreased by 11.4 ± 7.0 and 15.4 ± 6.5 points from baseline to Week 104, respectively. Adherence to treatment was equal to 98.9%. CONCLUSIONS: Brodalumab confers rapid and durable responses, as well as improvements in the quality of life of moderate-to-severe psoriasis patients.

Real-Life Data on the Management of Incompletely Excised Basal Cell Carcinoma.

BACKGROUND: The histopathologic presence of basal cell carcinoma (BCC) cells at one or more margins of the specimen after surgical excision is considered suggestive of incomplete tumor clearance. The management of incompletely excised BCC might vary in different clinical scenarios from re-excision to application of other treatments or even watchful waiting. OBJECTIVE: The aims of the study were to report the real-life management of incompletely excised BCC in a tertiary referral center and compare the recurrence rates according to the selected management modality. METHODS: A retrospective study was conducted at a tertiary Dermatology Center in Northern Greece. Our electronic database was scanned over a 5-year period to retrieve all BCCs with available histopathologic assay reporting at least one involved margin (lateral or deep). The included patients were divided into 3 groups according to the selected management after incomplete excision: group 1 included those who underwent immediate re-excision (n = 26), group 2 those who were followed up without any additional therapy (n = 40), and group 3 those who were treated with adjuvant/complementary non-surgical treatment (n = 18). Finally, we recorded the presence or absence of residual tumor in the new histopathologic report of those tumors that were selected to be re-excised (group 1). The primary outcome was the appearance of clinical tumor recurrence. RESULTS: Of 1,689 BCCs recorded in our database, 84 met the inclusion criteria and were included in the analysis. Re-excision had been selected in 26 of 84 patients (group 1), watchful waiting in 40 (group 2), and non-surgical treatments in 18 (group 3). The histopathologic reports of the 26 tumors of group 1 that were re-excised revealed residual tumor in 14 (53.8%) cases. Overall, a clinical recurrence occurred in 14 of 84 patients (16.7%) after a mean follow-up of 17 months. The median time to recurrence was 14 months. Of 40 patients without any treatment, recurrence developed in 10 (25%), while only 2 of 18 patients treated with non-surgical treatments recurred (11.1%). CONCLUSIONS: Our study suggests that positive histopathologic margins after BCC excision result in a clinical recurrence only in a proportion of patients. This percentage is higher when no further treatment is applied and lower when the area is re-excised or treated with imiquimod alone or combined with cryotherapy.

Dermatoscopic shiny white structures in benign cutaneous tumours.

The dermatoscopic characteristics of shiny white structures (SWS) in malignant skin tumours are well described, but data on benign skin neoplasms are scarce. To evaluate dermatoscopic features of SWS in common benign tumours, we reviewed our database for histopathologically confirmed cases. The dermatoscopic images were evaluated for the presence of any type of SWS. Those images with SWS were further analyzed for their quantity, distribution and shape. Of 2420 evaluated benign tumours, 357 (14.8%) displayed SWS. The highest frequencies were observed in pyogenic granuloma (62/100, 62.0%), angioma (63/113, 55.8%) and adnexal tumours (42/84, 50.0%). The lowest frequency was found in common nevi (16/1032, 1.6%) and solar lentigo (0%). The presence of SWS was not associated with sex or anatomic location. SWS were usually diffuse and multiple. SWS may be present in a broad spectrum of benign tumours. Therefore, they should not be considered as de-facto indicators of malignancy.

Dermatoscopy of nodular/plaque-type primary cutaneous T- and B-cell lymphomas: A retrospective comparative study with pseudolymphomas and tumoral/inflammatory mimickers by the International Dermoscopy Society.

BACKGROUND: Limited data on dermatoscopy of nodular/plaque-type T-/B-cell primary cutaneous lymphomas (PCLs) is available. OBJECTIVE: To describe dermatoscopic features of nodular/plaque-type PCLs, comparing them with those of clinical mimickers (pseudolymphomas, tumors, and inflammatory lesions) and investigating possible differences according to histologic subtypes. METHODS: Participants were invited to join this retrospective, multicenter case-control study by submitting histologically/immunohistochemically confirmed instances of nodular/plaque-type PCLs and controls. Standardized assessments of the dermatoscopic images and comparative analyses were performed. RESULTS: A total of 261 lesions were included (121 PCLs and 140 controls). Orange structureless areas were the strongest PCL dermatoscopic predictor on multivariate analysis compared with tumors and noninfiltrative inflammatory dermatoses. On the other hand, a positive association was found between PCLs and either unfocused linear vessels with branches or focal white structureless areas compared with infiltrative inflammatory dermatoses, whereas white lines were predictive of PCLs over pseudolymphomas. Differences in the vascular pattern were also seen between B- and T-cell PCLs and among B-cell PCL subtypes. LIMITATIONS: Retrospective design and the lack of a dermatoscopic-pathologic correlation analysis. CONCLUSION: Nodular/plaque-type PCLs display dermatoscopic clues, which may partially vary according to histologic subtype and whose diagnostic relevance depends on the considered clinical differential diagnoses.

Real world experience of brodalumab treatment in patients with moderate-to-severe plaque psoriasis in the Greek population: Results from an interim analysis of the BrIDGE study.

Brodalumab's clinical efficacy and favorable safety profile have been demonstrated during controlled clinical trials, but real-world data remain scarce. BrIDGE, an ongoing 104 week, observational, prospective, multicenter study conducted in Greece, enrolled moderate-to-severe plaque psoriasis patients, with body surface area (BSA) > 10 or psoriasis area severity index score (PASI) > 10 and dermatology life quality index (DLQI) > 10, based on European consensus, initiating brodalumab treatment as per routine clinical practice. This interim analysis includes evaluations 12-16 weeks following treatment initiation. Key efficacy endpoints included proportion of patients achieving static Physician's Global Assessment (sPGA) score of "clear/almost clear" (0/1) and a reduction ≥75%, 90%, 100% from baseline in PASI (PASI75, PASI90, and PASI100) at weeks 12-16. Other endpoints included time to achieve PASI100, changes in self-reported DLQI and psoriasis symptom inventory (PSI) at weeks 12-16. From 200 patients (mean age 51.4 years, 70% male, mean disease duration 13.8 years) enrolled, 72.8% achieved sPGA of 0/1, whereas 70.2%, 47.5%, and 32.0% achieved corresponding PASI75, PASI90, and PASI100 responses following 12-16 weeks of brodalumab treatment, according to the "as-observed" analysis. The mean time to achieve PASI100 was 13.7 ± 1.2 weeks for the 32% who achieved PASI100. Concurrent decreases in mean DLQI and PSI were observed. Furthermore, 90% adherence to brodalumab was noted and nine adverse events were reported. Brodalumab confers substantial clinical improvements short-term as reflected by high levels of skin clearance in moderate-to-severe plaque psoriasis patients within 12-16 weeks of treatment under everyday clinical conditions, followed by improvements in symptoms and quality of life and a favorable safety profile.

Extensive acquired macular hyperpigmentation in a teenager.

A teenage girl with phototype IV skin presented with extensive gradually progressing asymptomatic macular hyperpigmentation not responding to topical steroids for several months. Histopathology showed foci of increased numbers of melanophages and melanin in the dermis. Click here for the corresponding questions to this CME article.

Hidradenitis suppurativa-related expenditure, a call for awareness: systematic review of literature.

Data regarding hidradenitis suppurativa (HS)-related expenditure is limited and non-homogeneous, but HS does incur significant expenses. We performed a systematic review of literature reports documenting financial data regarding any healthcare domain or other expenditure incurred by HS and/or HS impact on work, income and personal economic growth (indirect costs). Three electronic databases were searched (MEDLINE, ScienceDirect, and the Cochrane Library - last search date: September 14th , 2021). All costs were adjusted for inflation (2022) and converted into US dollars. Twenty-three papers were included (18 cost-of-illness studies, 4 observational studies and 1 case series), drawing economic data from 77,287 HS patients. The total mean cost incurred by HS per patient per year ranged from $ 258 to $ 8,078. This number increased in case of surgical intervention, disease progression, antibiotic failure and certain comorbid diseases. The costliest healthcare sector was inpatient care, followed by outpatient and emergency care. Significant differences were observed between the USA and the rest of studied countries. Hospitalization was likelier, lengthier, and costlier for HS compared to psoriasis patients, whereas the less costly outpatient care appeared to be reduced among HS patients. Preventing disease progression by optimizing early diagnosis and dermatology outpatient care could decrease HS-related expenditure.

Hidradenitis-suppurativa-bedingte Kosten, ein Plädoyer für Aufmerksamkeit: eine systematische Literaturübersicht.

Die Daten zu Hidradenitis suppurativa (HS)-bedingten Kosten sind begrenzt und inhomogen. Sie sind jedoch erheblich. Wir führten eine systematische Sichtung der Literaturberichte durch, in denen finanzielle Daten über jeden Gesundheitsbereich oder andere Ausgaben dokumentiert wurden, die durch HS und/oder HS-bedingte Auswirkungen auf Beschäftigung, Einkommen und persönliches wirtschaftliche Entwicklung entstanden sind (indirekte Kosten). Dafür wurden drei elektronische Datenbanken durchsucht (MEDLINE, ScienceDirect und die Cochrane Library -letzte Suche: 14. September 2021). Alle Kosten wurden inflationsbereinigt (2022) und in US-Dollar umgerechnet. Es wurden 23 Artikel eingeschlossen (18 Krankheitskostenstudien, 4 Beobachtungsstudien und 1 Fallserie), in denen ökonomische Daten von 77.287 HS-Patienten erfasst wurden. Die durch HS entstandenen durchschnittlichen jährlichen Kosten pro Patient reichten von 258 $ bis 8.078 $. Diese Zahl erhöhte sich bei chirurgischen Eingriffen, Krankheitsprogression, Antibiotika-Versagen und bestimmten Begleitkrankheiten. Der kostspieligste Faktor war die stationäre Versorgung, gefolgt von ambulanter und Notfallversorgung. Signifikante Unterschiede wurden zwischen den USA und den übrigen untersuchten Ländern beobachtet. Im Vergleich zu Psoriasis-Patienten waren Krankenhausaufenthalte bei HS wahrscheinlicher, länger und kostspieliger, während die weniger kostspielige ambulante Versorgung bei HS-Patienten verringert war. Das Vermeiden der Krankheitsprogression durch frühzeitige Diagnose und Optimierung der ambulanten dermatologischen Versorgung könnte HS-bedinge Ausgaben reduzieren.

Human Papillomavirus Vaccine to End Oropharyngeal Cancer. A Systematic Review and Meta-Analysis.

ABSTRACT: Oropharyngeal cancer (OPC) is currently the most frequent human papillomavirus (HPV)-related malignancy in high-income countries. Oral HPV16 infection is the cause of HPV-related OPC in more than 90% of cases and is primarily (90%) linked to oral sex. This systematic review and meta-analysis aimed at comparing the prevalence of oral vaccine-type HPV infection in individuals vaccinated with HPV vaccines and unvaccinated controls. Three databases (MEDLINE, ScienceDirect, and the Cochrane Library), as well as other sources, were searched by 2 independent reviewers. Controlled studies testing the efficacy or effectiveness of licensed HPV vaccines were included. The primary end point was multiple oral HPV infections in one individual with low-risk and high-risk types. Secondary end point was the number of oral HPV16 infections. Six studies-2 randomized controlled trials and 4 cross-sectional studies-with a total of 15,240 participants were included in a meta-analysis, which showed that vaccinated individuals were 46% (risk ratio, 0.54; 95% confidence interval, 0.32-0.91) less likely to develop oral vaccine-type HPV infection (P = 0.02). A second meta-analysis of 4 studies (1 randomized controlled trial and 3 cross-sectional studies) and 13.285 participants showed 80% (risk ratio, 0.20; 95% confidence interval, 0.09-0.43) less likelihood of oral HPV16 infection (P < 0.0001). This study suggests that HPV vaccines can protect against oral vaccine-type HPV infection including high-risk HPV16 infection, thus reducing the incidence of HPV-related OPC. Vaccination against HPV, especially in males, who are predominantly affected by HPV-related OPC, could result in the prevention of this disease.

Second primary melanomas in a cohort of 977 melanoma patients within the first 5 years of monitoring.

BACKGROUND: In retrospective studies, a second primary melanoma (SPM) develops in 2%-20% of melanoma patients. Scarce evidence exists on the usefulness of total-body photography (TBP) and digital dermatoscopic documentation (DDD) for detecting SPMs. OBJECTIVE: The primary aim was to quantify the risk and investigate the time of occurrence of SPMs. Secondary aims were to identify risk factors for SPM and to assess the usefulness of TBP and DDD for SPM detection. METHODS: This prospective cohort included patients with recently diagnosed melanoma that underwent sequential clinical and dermatoscopic examinations for up to 5 years. Life table analysis and Kaplan-Meier survival analysis were performed. Multivariate Cox models were constructed to identify factors affecting the outcome. RESULTS: An SPM developed in 46 of 977 (4.7%) patients. Life table analysis revealed a 5-year cumulative risk of 8.0% for SPM. High nevus count, fair phototype, and occupational sun exposure were potent predictors of SPM. Of all new melanomas, 17.3% were diagnosed by clinical and dermatoscopic examination, 48.1% by TBP, and 34.6% by DDD. LIMITATIONS: All patients followed the same protocol and diagnostic bias associated with sequential dermatoscopic imaging. CONCLUSION: In this cohort, melanoma patients were at 8% risk of an SPM developing within 5 years. TBP and DDD significantly contributed to the early detection of SPM.

Total IgE, eosinophils, and interleukins 16, 17A, and 23 correlations in severe bullous pemphigoid and treatment implications.

Bullous pemphigoid (BP) patients are predominantly above 70 years of age, with limited tolerance to the side effects of the immunosuppressive drugs. Advancements in our understanding of the pathophysiology of BP have led to the development of molecules which target specific pathways involved in induction and perpetuation of disease. Patients with BP Disease Area Index above 60 and less than 100 were split into two groups-one with high and the other with normal levels of IgE. The tested parameters included eosinophils' count, total IgE serum level, and interleukins (IL) 16, 17A, and 23 counts in the peripheral blood and skin bulla serum, before any therapeutic intervention. Thirty individuals fulfilled the criteria for enrollment. Patients with high IgE blood serum levels had significantly higher levels of IL17A and normal IL23 levels in blood and bulla serum. Patients with normal serum IgE levels had slightly higher IL23 levels in blood and bulla serum. The eosinophil count was positively related to IL17 blood serum level and negatively related to IL23. IL16 did not differ in the two groups. BP patients may represent a group of patients benefiting most substantially from the introduction of nonimmunosuppressive therapeutics into the treatment regimens for their disease. Clinical criteria and immune biomarkers are needed for making the best therapeutic choice.

The dermatoscopic spectrum of cutaneous lupus erythematosus: A retrospective analysis by clinical subtype with clinicopathological correlation.

The skin is the most common organ of involvement during the course of lupus erythematosus (LE). The literature data concerning the dermatoscopic patterns of the different clinical variants of cutaneous LE (CLE), namely chronic (CCLE), subacute (SCLE), and acute (ACLE), are scarce. To determine the dermatoscopic spectrum of CLE and to correlate the dermatoscopic features with the histological findings. This was a retrospective, observational, multicenter, cohort study. We evaluated the dermatoscopic features in a cohort of patients diagnosed with CLE. Furthermore, we investigated their frequency per clinical subtype and correlated them with the anatomic alterations. We included 79 patients. The most prevalent dermatoscopic features of CCLE included follicular plugs (86.4%, P < .01), patchy distribution (75%, P = .1) of mostly linear curved vessels (56.8%, P = .8), white scales (68.2%, P < .01), and structureless white color (68.2%, P < .01). The most common criteria of SCLE were patchy distribution (90%, P = .1) of mostly linear curved vessels (53.3%, P = .8) and fine white scales (60%, P < .01), while ACLE was characterized by erythema (100%, P < .05) and patchy distribution (100%, P = .1) of mostly dotted vessels (60%, P = .4). Follicular plugs/rosettes in dermatoscopy strongly correlated with follicular plugs in histology (rho = 0.919). Hyperkeratosis significantly correlated with white (rho = 0.644) and yellow/brown scales (rho = 0.225), telangiectasia with linear curved vessels (rho = 0.321) and white color with dermal fibrosis (rho = 0.623). Depending on CLE subtype, distinct dermatoscopic patterns are recognized. In CLE there is a high correlation between certain dermatoscopic criteria and the underneath anatomic alteration.

Real-life data on basal cell carcinoma treatment: Insights on clinicians' therapeutic choices from an institutional hospital registry.

Basal cell carcinoma (BCC) is the most common skin cancer in white skin individuals. The treatment of choice is surgical excision, but several other therapeutic choices are available and might also be efficient and cost-effective in selected cases of low-risk BCC or when surgery is complicate or contraindicated. The aim of the current study was to analyze the applied treatments for BCC in the real-life practice of a tertiary hospital, and investigate factors associated to the tumor and the patients that might influence the treatment selection of clinicians. Data on all BCCs treated from 1st January 2018 to 31st December 2019 were extracted. A total of 751 BCCs from 585 patients were included. The baseline characteristics of patients and tumors, the type of applied treatment and the histopathologic report when available were analyzed. Most tumors were located on the head/neck (64.2%). The most frequently applied treatment was surgical excision (580/751, 77.2%). In 22.8% of tumors a nonsurgical treatment was selected. The most frequently selected alternative treatments were, imiquimod, cryosurgery, their combination (immunocryosurgery), and vismodegib. A pretreatment diagnosis of superficial BCC was associated with a 12-fold increased probability of selecting a nonsurgical treatment except of vismodegib. Every added year of age increased the probability of selecting a nonsurgical treatment by 3-fold. Every added mm of diameter increased the possibility of vismodegib use by 4%. Surgery is the most frequently applied BCC treatment, but nonsurgical modalities do also have an essential role in real settings.

Terra firma-forme dermatosis: Differential diagnosis and response to salicylic acid therapy.

Terra firma-forme dermatosis (TFFD), first described by Duncan in 1987, is a relatively common but probably underdiagnosed condition, characterized by a reticular hyperpigmented dirtlike eruption resistant to washing with common soap but typically removed with rubbing with 70% isopropyl alcohol. We present a case of TFFD in an 8-year-old boy with rapid response to 5% salicylic acid in petrolatum ointment.

Structured Expert Consensus on Actinic Keratosis: Treatment Algorithm Focusing on Daylight PDT.

BACKGROUND: A practical and up-to-date consensus among experts is paramount to further improve patient care in actinic keratosis (AK). OBJECTIVES: To develop a structured consensus statement on the diagnosis, classification, and practical management of AK based on up-to-date information. METHODS: A systematic review of AK clinical guidelines was conducted. This informed the preparation of a 3-round Delphi procedure followed by a consensus meeting, which combined the opinions of 16 clinical experts from 13 countries, to construct a structured consensus statement and a treatment algorithm positioning daylight photodynamic therapy (dl-PDT) among other AK treatment options. RESULTS: The systematic review found deficiencies in current guidelines with respect to new AK treatments such as ingenol mebutate and dl-PDT. The Delphi panel established consensus statements across definition, diagnosis, classification, and management of AK. While the diagnosis of AK essentially rests on the nature of lesions, treatment decisions are based on several clinical and nonclinical patient factors and diverse environmental attributes. Participants agreed on ranked treatment preferences for the management of AK and on classifying AK in 3 clinical situations: isolated AK lesions requiring lesion-directed treatment, multiple lesions within a small field, and multiple lesions within a large field, both requiring specific treatment approaches. Different AK treatment options were discussed for each clinical situation. CONCLUSIONS: The results provide practical recommendations for the treatment of AK, which are readily transferable to clinical practice, and incorporate the physician's clinical judgement. The structured consensus statement positioned dl-PDT as a valuable option for patients with multiple AKs in small or large fields.