Chronic Inflammatory Dermatosis Research Articles

Teledermatology Versus In-Person Visits for the Follow-Up of Atopic Dermatitis Patients.

In recent years, teledermatology has rapidly emerged as a healthcare delivery method with potential implications for managing chronic inflammatory dermatoses like atopic dermatitis (AD). This study assesses the utility of telemedicine in the management of AD by comparing virtual care with traditional in-office visits with the aim of identifying differences in clinical outcomes between these 2 healthcare delivery modalities. Patients of all ages with AD were recruited from 2 dermatology practices. Consecutive patients presenting to the clinics who met the inclusion criteria were invited to enrol in the study. Those who consented to participate were randomly assigned to the virtual or in-person arm of the study, with the opportunity to decline care in either study arm. The inclusion criteria required participants to have a confirmed diagnosis of AD. Exclusion criteria included significant comorbidity that might affect the course of treatment, inaccessibility to teleconsults such as not having a camera for video conferences, and self-declared limitations in operating Zoom. Patients were assessed at baseline (week 0), 4 to 6 weeks, and 8 to 12 weeks using 6 efficacy parameters. In the virtual group, all 6 dermatological measures suggested improved outcomes. Average Body Surface Area scores decreased (β = -.07, 95% CI = -0.1, -0.3) over the course of follow-up. Virtual care patients had 80% lower odds of moderate-to-severe uncontrolled disease (OR = 0.2; 95% CI = 0.06, 0.5) and pruritus (OR = 0.2, 95% CI = 0.05, 0.7) over time. This study supports teledermatology as a feasible and effective option for providing follow-up care for atopic dermatitis patients of various demographic standings.

Hourglass shaped extragenital Csillag’s disease

Lichen sclerosus (LS) is a benign, chronic inflammatory dermatosis affecting both the epidermis and dermis. It commonly affects the anogenital area and is seen predominantly in women. In only 15–20% of cases, extragenital involvement is seen. In females, long-standing anogenital lesions progress to form hourglass or dumbbell or figure of eight morphology. Here, we are reporting a case of extragenital LS at an unusual site in an hourglass morphology, which is usually encountered in females. Our patient was started on ultrapotent topical corticosteroids, following which erythema was reduced. The patient is advised regular follow-up.

Biofilm of Cutibacterium acnes: a target of different active substances.

Acne vulgaris is a chronic inflammatory dermatosis. Cutibacterium acnes plays a crucial role in the acne pathophysiology. Recent works present evidence of C.acnes growing as a biofilm in cutaneous follicles. This development is currently considered one of the leading causes of C. acnes in vivo persistence and resistance to antimicrobials used to treat acne. Our objective was to evaluate the effects of various active compounds (clindamycin, erythromycin, doxycycline, and myrtle extract) on eight distinct, well-characterized strains of C. acnes following their growth in biofilm mode. Cutibacterium acnes isolates from phylotypes IA1 and IA2 produce more biofilm than other phylotypes. No antibiotic effect was observed either during the curative test or preventive test. Myrtle extract at 0.01% (w/v) showed significant efficacy on the biofilm for C. acnes strains (curative assays). Furthermore, it appear that myrtle extract and doxycycline together reduce the overall biomass of the biofilm. A significant dose-dependent effect was observed during the preventive test, greater than the one observed under curative conditions, with an important loss of activity of the myrtle extract observed from 0.001% (w/v) concentration onwards. Transmission electron microscopy showed that bacteria treated withmyrtle extract grew biofilms much less frequently than untreated bacteria. Additionally, when the quantity of myrtle extract grew, the overall number of bacteria dropped, indicating an additional antibacterial action. These findings support the hypothesis that the different C. acnes phylotypes have various aptitudes in forming biofilms. They also suggest that myrtle extract is a promising alternative as an anti-biofilm and antibacterial agent in fighting diseases caused by planktonic and biofilm C. acnes.

Downregulation of Ebp1Khib210 promotes keratinocyte proliferation through induction of TIF-IA-mediated rRNA synthesis.

Psoriasis is a prevalent chronic inflammatory dermatosis characterized by excessive proliferation of keratinocytes. Protein lysine 2-hydroxyisobutyrylation (Khib) is a newly identified post-translational modification that regulates various biological processes. Abnormal Khib modification has been closely associated with the development of autoimmune diseases. To investigate the abnormal Khib profile and its pathogenic role in psoriasis. We utilized liquid chromatography-tandem mass spectrometry to analyze Khib-modified proteins in the epidermis of psoriasis and healthy controls. Mutated cells and mice with downregulated Ebp1Khib210 were generated to investigate its functional effects in psoriasis. The omic analysis revealed dysregulation of Khib modification in psoriatic lesions, exhibiting a distinct profile compared to controls. We observed the downregulation of Ebp1Khib210 in psoriatic lesions and IMQ-induced psoriatic mice. Notably, the expression of Ebp1Khib210 was upregulated in psoriatic patients following effective treatment. Decreased Ebp1Khib210 enhanced keratinocyte viability, proliferation, and survival while inhibiting apoptosis in vitro. Additionally, Pa2g4K210A mice with downregulated Ebp1Khib210 exhibited more severe psoriatic lesions and enhanced keratinocyte proliferation. Moreover, we found that Ebp1K210A mutation increased the interaction between Ebp1 and nuclear Akt, thereby inhibiting MDM2-mediated TIF-IA ubiquitination, and resulting to increased rRNA synthesis and keratinocyte proliferation. The downregulation of Ebp1Khib210 was attributed to inflammation-induced increases in HDAC2 expression. Our findings demonstrate that downregulation of Ebp1Khib210 promotes keratinocyte proliferation through modulation of Akt signaling and TIF-IA-mediated rRNA synthesis. These insights into Khib modification provide a better understanding of the pathogenesis of psoriasis and suggest potential therapeutic targets.

Interferon gamma as a trigger of chronic viral infections and inflammatory dermatoses

Interferon gamma as a trigger of chronic viral infections and inflammatory dermatoses

[Translated article] Epidemiological, Clinical, and Allergic Profile of Psoriatic Patients. Evaluation of the Spanish Registry of Contact Dermatitis and Cutaneous Allergy (REIDAC)

BackgroundPsoriasis is a chronic inflammatory dermatosis whose clinical and topographic distribution requires differential diagnosis, or the possible association with allergic contact dermatitis (ACD), requiring patch testing (PT) as part of the diagnostic procedure. ObjectivesTo describe the epidemiological, clinical, and allergic profile of patients with a primary or secondary diagnosis of psoriasis undergoing PT and compare them with patients with a diagnosis of ACD at the end of the diagnostic process. MethodsCross-sectional study with data from REIDAC from 2018 through 2023 of selected patients with a diagnosis of psoriasis and/or ACD. ResultsA total of 11 502 patients were included, 513 of whom had been diagnosed with primary or secondary psoriasis, 3640 with ACD, and 108 with both diseases. Men were more predominant in the groups of patients with psoriasis, psoriasis+ACD, and lesions were more predominantly seen in the hands with little association with atopic factors vs the ACD group. The rate of positivity in PT to the 2022 Spanish battery of allergens was lower in the group with psoriasis only in 27% of the patients. The most common allergens found in the psoriasis group were also the most common ones found in the overall ACD population. ConclusionsOverall, 36.2% of psoriatic patients tested positive in PT to the 2022 Spanish battery of allergens, which proved that this association is not uncommon. Overall, psoriatic patients had a higher mean age, were more predominantly men, and showed more hand involvement.

Clinical phenotypes and risk factors of hidradenitis suppurativa: A retrospective study of 57 Moroccan patients

Background: Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis. It is a challenging disease characterized by a clinical phenotypic heterogeneity. Clinical phenotypes of HS have different epidemiological and evolutive features, with a significant impact on the therapeutic management. To our days, literature data concerning clinical phenotypes of HS still scarce. Methods: We conducted a retrospective descriptive study in a Moroccan population, to identify the main clinical phenotype of HS and its risk factors, as a primordial step towards a personalized approach in the management of HS. Results: Fifty-seven patients were included. Gluteal phenotype (LC2) was the most represented (85.96%).The mean age of onset of symptoms in this group was 31years old.A male predominance (77.41%) was observed. Acne in adolescence was found in 18 patients (36.73%).Thirty-nine patients (79.59%) were active smokers. Fourteen patients (29.16%) had a prolonged sitting position. Their professional occupation was:drivers (n=10), shopkeepers(n=3) and secretaries (n=1).Five patients (10.20%) had a family history of hidradenitis suppurativa. Mean body mass index was 23.87. Follicular phenotype (LC3) was observed in 8 patients (14.03%).The average age of onset of symptomatology was 37 years old. A female predominance was noted(62.5%).Acne was found in 3 patients(37.5%),active smoking in 2 patients (25%).Mean body mass index was 22.83. Axillary-mammary phenotype (LC1) was observed only in a 15-year-old non-smoking girl in overweight presenting intermammary fold fistulas. Conclusions: The predominance of the gluteal phenotype in our population may be related to genetic factors, intestinal microbiota and prolonged gluteal friction.Large-scale analytical studies are needed to support these hypothesis.

Insulin resistance and chronic inflammatory dermatoses

Recently, the impact of insulin resistance (IR) on the possibility of increasing the risk of skin diseases has attracted increasing attention of scientists. The causes of comorbid conditions have not been finally clarified. Determining the role of IR in the mechanism of development of dermatoses can affect the diagnosis and effectiveness of treatment. Objective — to analyze literary sources that highlight research on the relationship between IR and some diseases of the skin and its appendages, as well as to find out possible mechanisms of interaction. Materials and methods. The literature search was carried out using key words (IR, psoriasis, acne, adult acne, androgenetic alopecia, pathogenesis), sources from the databases of V.I. Vernadskyi National Library of Ukraine, PubMed, Web of Science and Scopus. Preference was given to sources published in the last 5 years. Results and discussion. The literature review presents a specific and possible relationship between the development of psoriasis, acne vulgaris, acne tarda, androgenetic alopecia and IR based on updated data. IR is considered as a disturbed biological response of the body’s peripheral tissues (muscle, fat, and liver) to the influence of endogenous or exogenous insulin. Analysis of the literature proved that patients with chronic dermatoses have a high risk of developing IR. There are multiple molecular factors responsible for the close association of IR with the metabolic syndrome. Adipokines play a key role in both conditions. Conclusions. IR is an important independent factor in the development of many inflammatory skin diseases, acting both independently and through associated metabolic disorders. It has been established that excess body weight and obesity are significantly associated with IR and the adverse course of dermatoses, so it is advisable for patients to determine HOMA­IR. The severity of chronic inflammatory dermatoses (psoriasis, adult acne, and AGA) is considered an independent predictor of IR.

Efficacy of Low-Dose Isotretinoin in the Treatment of Rosacea: A Systematic Review and Meta-Analysis.

Rosacea is a common cutaneous condition caused by persistent, recurring lesions in facial skin vessels. It is a chronic skin condition with a variety of clinical symptoms and an unknown cause. Rosacea begins with the widening of capillaries and a flushed appearance. Following that, telangiectasia appears, and reddened patches persist, particularly on the cheeks and nose. Erythema persists due to repeated vasodilationand telangiectasia. In addition, skin inflammation manifests as papules, pustules, lymphedema, and fibrosis. Despite recent advances in treatment, rosacea, a chronic inflammatory relapsing central facial dermatosis, can be extremely difficult to manage. The purpose of this meta-analysis and systematic review was to evaluate the effectiveness of low-dose isotretinoin in the treatment of rosacea. Following the guidelines set forth by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA), the researcher employed the following search terms in the EMBASE, Web of Science, PubMed, Cochrane Library, and Google Scholar databases to provide a therapeutic update relevant to clinical practice: "low dose isotretinoin," "isotretinoin and rosacea," "isotretinoin treatment of rosacea," and "effectiveness of isotretinoin in treating rosacea". The search was carried out by the researcher for articles published from February 2019 to February 2024. The articles included were all published in the English language. The overall frequency of patients with adverse events differed significantly between the groups treated with low-dose isotretinoin and the comparators(minocycline, pulsed dye laser, evening primrose oil, Lactobacillus plantarum, doxycycline, combined dose or placebo) (0.80, 95% CI 0.73 to 0.88, p = 0.0001). Sub-group analysis indicated that there was a difference between the interventions used in the treatments all in favor of low-dose isotretinoin treatment. The results showed that the moderate group had RR: 0.76, 95% CI: 0.44-1.30, I2 = 0%;the mild group had RR: 0.94, 95% CI: 0.56-1.57, I2 = 0%;and the group with severe rosacea had RR: 0.73, 95% CI: 0.47-1.13, I2 = 0%. According to this study, rosacea can be treated effectively with low-dose isotretinoin even in patients at severe stages of the disease by using the recommended dose once a week. Further, the intervention has also been shown to have fewer side effects on the patients. Therefore, this study recommends randomized controlled trials to be done to fully investigate the best combination options for isotretinoin on mild to severe rosacea based on the fact that some of the treatments combined have shown to be effective on treatment.

Ocular Lichen Planus: A clinicopathologic review.

Lichen planus is a chronic inflammatory dermatosis that can affect the skin, mucous membranes and nails. Cutaneous lichen planus lesions are best described by the "six Ps" - purple pruritic polygonal planar papules and plaques. Mucous membrane lesions are commonly associated with cutaneous lichen planus. Ocular involvement with lichen planus is rare and conjunctival involvement usually predominates, it can however be visually devastating. Ocular lichen planus often progresses to extensive conjunctival scarring which can be impossible to distinguish clinically from other cicatrising conjunctivitis, requiring histopathological confirmation. Here we review the ocular pathology of this condition.

Evaluation of Delayed Contact Hypersensitivity in Patients with Rosacea

Introduction: Rosacea is a common chronic inflammatory dermatosis characterized by erythema, telangiectasia, papules, and pustules on the central face. The frequency of contact sensitization complicating rosacea and its therapy is unknown, with only few studies published in the literature. In the present study, we aimed to evaluate contact sensitivity in patients with rosacea. Methods: A total of 50 rosacea patients and 50 age- and sex-matched healthy controls were enrolled. Both groups were patch tested with the European Baseline Series. Results: A positive reaction to at least one allergen of the European Baseline Series was observed in 15 (30%) of rosacea patients and 10 (20%) of the healthy controls. Although the rate of positive reaction in the rosacea group was higher than in the controls, no statistically significant difference was documented. In addition, the total number of positive reactions to allergens in the rosacea group was higher than the control group, namely, 26 versus 17. Conclusion: Contact hypersensitivity may coexist with rosacea. Its identification holds significant clinical relevance, influencing the long-term management and justifying the application of patch testing in rosacea patients.

Perfil epidemiológico, clínico y alérgico en pacientes con psoriasis. Evaluación del Registro Español de Dermatitis de Contacto (REIDAC)

BackgroundPsoriasis is a chronic inflammatory dermatosis whose clinical and topographic distribution requires differential diagnosis, or the possible association with allergic contact dermatitis (ACD), requiring patch testing (PT) as part of the diagnostic procedure. ObjectivesTo describe the epidemiological, clinical, and allergic profile of patients with a primary or secondary diagnosis of psoriasis undergoing PT and compare them with patients with a diagnosis of ACD at the end of the diagnostic process. MethodsCross-sectional study with data from REIDAC from 2018 through 2023 of selected patients with a diagnosis of psoriasis and/or ACD. ResultsA total of 11 502 patients were included, 513 of whom had been diagnosed with primary or secondary psoriasis, 3640 with ACD, and 108 with both diseases. Men were more predominant in the groups of patients with psoriasis, psoriasis+ACD, and lesions were more predominantly seen in the hands with little association with atopic factors vs the ACD group. The rate of positivity in PT to the 2022 Spanish battery of allergens was lower in the group with psoriasis only in 27% of the patients. The most common allergens found in the psoriasis group were also the most common ones found in the overall ACD population. ConclusionsOverall, 36.2% of psoriatic patients tested positive in PT to the 2022 Spanish battery of allergens, which proved that this association is not uncommon. Overall, psoriatic patients had a higher mean age, were more predominantly men, and showed more hand involvement.

OPN promotes pro-inflammatory cytokine expression via ERK/JNK pathway and M1 macrophage polarization in Rosacea.

Rosacea is a chronic inflammatory dermatosis that involves dysregulation of innate and adaptive immune systems. Osteopontin (OPN) is a phosphorylated glycoprotein produced by a broad range of immune cells such as macrophages, keratinocytes, and T cells. However, the role of OPN in rosacea remains to be elucidated. In this study, it was found that OPN expression was significantly upregulated in rosacea patients and LL37-induced rosacea-like skin inflammation. Transcriptome sequencing results indicated that OPN regulated pro-inflammatory cytokines and promoted macrophage polarization towards M1 phenotype in rosacea-like skin inflammation. In vitro, it was demonstrated that intracellular OPN (iOPN) promoted LL37-induced IL1B production through ERK1/2 and JNK pathways in keratinocytes. Moreover, secreted OPN (sOPN) played an important role in keratinocyte-macrophage crosstalk. In conclusion, sOPN and iOPN were identified as key regulators of the innate immune system and played different roles in the pathogenesis of rosacea.

Squamous Cell Carcinoma Arising in Chronic Inflammatory Dermatoses.

Squamous cell carcinoma (SCC) is a known sequela of chronic inflammatory conditions of the skin. Labial discoid lupus erythema-tosus (DLE), oral lichen planus (OLP), and lichen sclerosus have a relatively short lag time from dermatosis onset to manifestation of malignancy; cutaneous DLE, hypertrophic lichen planus, chronic wounds, hidradenitis suppurativa (HS), and necrobiosis lipoidica can be present for decades before an associated malignancy is observed. Vigilant monitoring is essential for orolabial DLE, chronic HS, and chronic wounds because malignancies in these settings are particularly aggressive and often fatal. We summarize what is known about the nature and demographics of SCC arising within chronic inflammatory dermatoses, emphasizing lag time from dermatosis diagnosis to malignancy onset of common inflammatory conditions.

Clinical Presentation of Atopic Dermatitis.

Atopic dermatitis, commonly known as eczema, is a chronic inflammatory dermatosis that can affect individuals from infancy to adulthood. Also referred to as "the itch that rashes," atopic dermatitis is classically associated with significant pruritus that is accompanied by characteristic cutaneous and other clinical findings. The diagnosis of atopic dermatitis can be challenging due to the wide range of clinical presentations based on patient factors such as age, skin type, ethnicity, and other comorbid conditions. This chapter reviews the classical findings as well as the less common manifestations of atopic dermatitis.

Acne-induced pathological scars: pathophysiology and current treatments.

Acne is a common chronic inflammatory dermatosis that can lead to pathological scars (PSs, divided into hypertrophic scars and keloids). These kinds of abnormal scars seriously reduce the quality of life of patients. However, their mechanism is still unclear, resulting in difficult clinical prevention, unstable treatment effects and a high risk of recurrence. Available evidence supports inflammatory changes caused by infection as one of the keys to abnormal proliferation of skin fibroblasts. In acne-induced PSs, increasing knowledge of the immunopathology indicates that inflammatory cells directly secrete growth factors to activate fibroblasts and release pro-inflammatory factors to promote the formation of PSs. T helper cells contribute to PSs via the secretion of interleukin (IL)-4 and IL-13, the pro-inflammatory factors; while regulatory T cells have anti-inflammatory effects, secrete IL-10 and prostaglandin E2, and suppress fibrosis production. Several treatments are available, but there is a lack of combination regimens to target different aspects of acne-induced PSs. Overall, this review indicates that the joint involvement of inflammatory response and fibrosis plays a crucial role in acne-induced PSs, and also analyzes the interaction of current treatments for acne and PS.

Prevalence of prescribing topical corticosteroids to patients with lichen sclerosus following surgery for vulvar cancer: a survey among gynaecologic oncologists in The Netherlands

Background Vulvar lichen sclerosus (LS) is a chronic inflammatory dermatosis which can progress to precursor lesion differentiated vulvar intraepithelial neoplasia (dVIN) and vulvar squamous cell carcinoma (VSCC). The risk of developing recurrent vulvar cancer following LS-associated VSCC is high. Evidence suggests that treatment of LS with topical corticosteroids (TCS) can prevent progression to dVIN, VSCC and recurrences. However, current guidelines do not give any recommendation on the management of LS following surgery for VSCC. The aim of this study was to conduct a survey among all registered gynaecologic oncologists (GOs) in the Netherlands to evaluate the current management of LS patients without a history of VSCC (LSnoVSCC) and patients with LS following surgery for VSCC (LSVSCC). Methods An online survey was distributed to all registered GOs in the Netherlands. Primary outcome measures were the frequency, type and duration of TCS treatment prescribed for LSnoVSCC and LSVSCC patients, separately. As a secondary outcome measure, reasons for treating or not treating patients with LSnoVSCC and LSVSCC with TCS were analysed. Results Forty-four GOs completed the survey, resulting in a response rate of 75%. TCS were prescribed more often to patients with LSnoVSCC as compared to patients with LSVSCC (86% versus 52%, respectively, p < 0.001). If treatment was initiated, ultra-potent (class IV) TCS were most commonly prescribed for an indefinite period of time for both patient groups. The most reported reason for treating patients in both groups with TCS was symptoms, followed by clinical aspects of the lesion and prevention of progression to dVIN and VSCC. Conclusion The majority of GOs who participated in our study endorse the utilisation of long-term ultra-potent TCS therapy in both patients with LSnoVSCC and LSVSCC. Nevertheless, Dutch GOs are currently prescribing TCS more frequently to patients with LSnoVSCC than to patients with LSVSCC.

Genital lichen sclerosus and lichen planus

Lichen sclerosus (LS) and lichen planus (LP) are chronic inflammatory dermatoses of unknown aetiology. They pose the most important differential diagnoses of inflammatory dermatoses in the genital area. There is often adelay in diagnosing LS and LP and subsequently treatment is initiated late in the course of the disease, which will lead to scarring and adecreased quality of life. There is an increased risk of the development of malignancies in the genital area in both diseases; however, early and continuous treatment with potent topical steroids will decrease this risk.

Patients' Expectations and Satisfaction with the Patient-Doctor Relationship in Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis with a vast psychosocial burden. We analyzed the actual and ideal patient-doctor relationship and patients' satisfaction with the patient-doctor relationship in relation to their satisfaction with life (SWL), HS-related quality of life, and psychopathological symptoms. 105 HS patients (53% females; mean age 37.64 ± 14.01 years) were enrolled. Severity of the disease was measured using Hurley staging and the International HS Score System (IHS4). Instruments utilized: Patient Expectation Test; Satisfaction with Life Scale; HS Quality of Life; Patient Health Questionnaire-9; Generalized Anxiety Disorder-7; General Health Questionnaire. Patients with Hurley I and mild IHS4 had the lowest satisfaction with the patient-doctor relationship. There were significant correlations between the actual patient-doctor relationship and the patients' SWL (r = 0.30; p = 0.002), depressive (r = -0.36; p < 0.01), anxiety (r = 0.37; p < 0.01) and psychopathological symptoms (r = -0.47; p < 0.0001) and between the satisfaction with the patient-doctor relationship and their SWL (r = -0.32; p = 0.00098). Multiple regression analysis revealed a significant influence of the following factors: Hurley II + III, psychopathological symptoms, and severe anxiety about the actual patient-doctor relationship and the satisfaction with the patient-doctor relationship. Assessment of relations between patients and doctors is related to the patients' mental health and SWL. The usage of the Patient Expectation Test in clinical practice can improve the patient-doctor relationship and the general quality of care for and compliance by HS patients.

Long-term maintenance treatment of rosacea: experts' opinion.

Rosacea is a chronic inflammatory dermatosis characterized by remissions and flares. Although the rosacea active treatment phase is well established, the long-term maintenance phase is still challenging. To discuss and make recommendations on how to treat patients during the long-term maintenance phase for the main rosacea phenotypes. A panel of six board-certified Brazilian dermatologists and one American dermatologist gathered to compose a consensus based upon an initial statement on how to treat rosacea during the long-term maintenance phase based on the methodology Nominal Group Technique. The experts discussed each factor based upon an initial statement on how to treat rosacea patients in the long-term maintenance phase. A sequence of comprehensive narrative reviews was performed; a questionnaire preparation about the definition of the maintenance phase and its management was presented; an interpersonal discussion and ranking of the ideas were conducted. Recommendations were made if the specialists had 75% agreement. The maintenance treatment phase, which starts by achieving IGA 0 or 1 grades at the active phase, should be considered at least during the 9-month period after remission. The recommendations of all treatments target this period. Daily skincare regimen and sunscreen are crucial. Active treatment phase should be recommended if signs or symptoms reappear or worsen. Maintenance phase success depends on patient's adherence to daily skin care, appropriate treatments, continued follow-up with dermatologist, and self-assessment to identify new signs and symptoms indicating disease relapse.