Achenbach syndrome: no need for skin biopsy.

As dermatologists with Achenbach syndrome, we argue against the need for skin biopsy to confirm the diagnosis in this benign condition.

Evaluating dermatology education and training.

The purpose of education and training in dermatology ranges from increasing knowledge and skills to improving confidence or enhancing patient outcomes. Specification of the purpose of the education and training is vital so that evaluation can be aligned to purpose, and thus provide evidence on effectiveness. Further, the quality and quality improvement of education and training can be enhanced by a careful specification of how they are expected to achieve their purpose. Multiple theories and methods can be used to evaluate both the process and the outcome of education and training. In this paper, we summarize some of these and focus particularly on the use of behavioural science to evaluate education and training. We illustrate these theories and methods with an example in dermatology.

Lymphomatoid papulosis: A cutaneous lymphoproliferative disorder in a patient on fingolimod for multiple sclerosis.

BACKGROUND: Fingolimod was the first oral disease-modifying treatment for relapsing-remitting multiple sclerosis. It has previously been associated with the development of lymphoma. OBJECTIVE: To describe a case of lymphomatoid papulosis, a CD30+ cutaneous lymphoproliferative disorder, in a patient taking fingolimod. METHODS: Case study. RESULTS: Our patient developed lymphomatoid papulosis 2 months after starting fingolimod. Histology confirmed the diagnosis. The drug was withdrawn. Resolution began only 2 days later. CONCLUSIONS: Lymphomatoid papulosis is a benign subtype of cutaneous T-cell lymphoma, but up to 20% of cases can transform to a malignant course. Patients on fingolimod and physicians caring for them should be mindful of the need to monitor the skin.

H1-antihistamines for chronic spontaneous urticaria: an abridged Cochrane Systematic Review.

BACKGROUND: Chronic spontaneous urticaria is characterized by recurrent itchy wheals. First-line management is with H1-antihistamines. OBJECTIVE: We sought to conduct a Cochrane Review of H1-antihistamines in the treatment of chronic spontaneous urticaria. METHODS: A systematic search of major databases for randomized controlled trials was conducted. RESULTS: We included 73 studies with 9759 participants; 34 studies provided outcome data for 23 comparisons. Compared with placebo, cetirizine 10 mg daily in the short and intermediate term (RR 2.72; 95% confidence interval [CI] 1.51-4.91) led to complete suppression of urticaria. Levocetirizine 20 mg daily was effective for short-term use (RR 20.87; 95% CI 1.37-317.60) as was 5 mg for intermediate-term use (RR 52.88; 95% CI 3.31-843.81). Desloratadine 20 mg was effective for the short term (RR 15.97; 95% CI 1.04-245.04) as was 5 mg in the intermediate term (RR 37.00; 95% CI 2.31-593.70). There was no evidence to suggest difference in adverse event rates between treatments. LIMITATIONS: Some methodological limitations were observed. Few studies for each comparison reported outcome data that could be incorporated in meta-analyses. CONCLUSIONS: At standard doses, several antihistamines are effective and safe in complete suppression of chronic spontaneous urticaria. Research on long-term treatment using standardized outcome measures and quality of life scores is needed.

H1-antihistamines for chronic spontaneous urticaria.

Background Chronic spontaneous urticaria (CSU) is characterised by the development of crops of red, itchy, raised weals or hives with no identifiable external cause.Objectives To assess the effects of H1-antihistamines for CSU.Search methods We searched the following databases up to June 2014: Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 5), MEDLINE(from 1946), EMBASE (from 1974) and PsycINFO (from 1806). We searched five trials registers and checked articles for references to relevant randomised controlled trials.Selection criteria We included randomised controlled trials of H1-antihistamines for CSU. Interventions included single therapy or a combination of H1-antihistamines compared with no treatment (placebo) or another active pharmacological compound at any dose.Data collection and analysis We used standard methodological procedures as expected by The Cochrane Collaboration.Our primary outcome measures were proportion of participants with complete suppression of urticaria: 'good or excellent' response,50% or greater improvement in quality of life measures, and adverse events.We present risk ratios (RR) with 95% confidence intervals(CIs). Main results We identified 73 studies (9759 participants); 34 studies provided data for 23 comparisons. The duration of the intervention was up to two weeks (short-term) or longer than two weeks and up to three months (intermediate-term).Cetirizine 10mg once daily in the short term and in the intermediate term led to complete suppression of urticaria by more participants than was seen with placebo (RR 2.72, 95% CI 1.51 to 4.91). For this same outcome, comparison of desloratadine versus placebo in the intermediate term (5 mg) (RR 37.00, 95% CI 2.31 to 593.70) and in the short term (20 mg) (RR 15.97, 95% CI 1.04 to 245.04)favoured desloratadine, but no differences were seen between 5 mg and 10 mg for short-term treatment.Levocetirizine 20 mg per day (short-term) was more effective for complete suppression of urticaria compared with placebo (RR 20.87,95% CI 1.37 to 317.60), and at 5 mg was effective in the intermediate term (RR 52.88, 95% CI 3.31 to 843.81) but not in the shortterm, nor was 10 mg effective in the short term.Rupatadine at 10 mg and 20 mg in the intermediate term achieved a 'good or excellent response' compared with placebo (RR 1.35,95% CI 1.03 to 1.77).Loratadine (10 mg) versus placebo (RR 1.86, 95% CI 0.91 to 3.79) and loratadine (10 mg) versus cetirizine (10 mg) (RR 1.05, 95%CI 0.76 to 1.43) over short-term and intermediate-term treatment showed no significant difference for 'good or excellent response' or for complete suppression of urticaria, respectively.Loratadine (10 mg) versus desloratadine (5 mg) (intermediate-term) showed no statistically significant difference for complete suppression of urticaria (RR 0.91, 95% CI 0.78 to 1.06) or for 'good or excellent response' (RR 1.04, 95% CI 0.64 to 1.71). For loratadine(10 mg) versus mizolastine (10 mg) (intermediate-term), no statistically significant difference was seen for complete suppression of urticaria (RR 0.86, 95% CI 0.64 to 1.16) or for 'good or excellent response' (RR 0.88, 95% CI 0.55 to 1.42).Loratadine (10mg) versus emedastine (2mg) (intermediate-term) showed no statistically significant difference for complete suppression(RR 1.04, 95% CI 0.78 to 1.39) or for 'good or excellent response' (RR 1.09, 95% CI 0.96 to 1.24); the quality of the evidence was moderate for this comparison.No difference in short-term treatment was noted between loratadine (10mg) and hydroxyzine (25mg) in terms of complete suppression(RR 1.00, 95% CI 0.32 to 3.10).When desloratadine (5 to 20 mg) was compared with levocetirizine (5 to 20 mg), levocetirizine appeared to be the more effective (P value < 0.02).In a comparison of fexofenadine versus cetirizine, more participants in the cetirizine group showed complete suppression of urticaria(P value < 0.001).Adverse events leading to withdrawals were not significantly different in the following comparisons: cetirizine versus placebo at 10 mg and 20 mg (RR 3.00, 95% CI 0.68 to 13.22); desloratadine 5 mg versus placebo (RR 1.46, 95% CI 0.42 to 5.10); loratadine 10 mg versus mizolastine 10 mg (RR 0.38, 95% CI 0.04 to 3.60); loratadine 10mg versus emedastine 2mg (RR 1.09, 95%CI 0.07 to 17.14);cetirizine 10 mg versus hydroxyzine 25 mg (RR 0.78, 95% CI 0.25 to 2.45); and hydroxyzine 25 mg versus placebo (RR 3.64, 95%CI 0.77 to 17.23), all intermediate term.No difference was seen between loratadine 10 mg versus mizolastine 10 mg in the proportion of participants with at least 50%improvement in quality of life (RR 3.21, 95% CI 0.32 to 32.33).Authors' conclusions Although the results of our review indicate that at standard doses of treatment, several antihistamines are effective when compared with placebo, all results were gathered from a few studies or, in some cases, from single-study estimates. The quality of the evidence was affected by the small number of studies in each comparison and the small sample size for many of the outcomes, prompting us to downgrade the quality of evidence for imprecision (unless stated for each comparison, the quality of the evidence was low).No single H1-antihistamine stands out as most effective. Cetirizine at 10 mg once daily in the short term and in the intermediate term was found to be effective in completely suppressing urticaria. Evidence is limited for desloratadine given at 5 mg once daily in the intermediate term and at 20 mg in the short term. Levocetirizine at 5 mg in the intermediate but not short term was effective for complete suppression. Levocetirizine 20 mg was effective in the short term, but 10 mg was not. No difference in rates of withdrawal due to adverse events was noted between active and placebo groups. Evidence for improvement in quality of life was insufficient.