Daily Dermatological Practice Research Articles

Dermatologists on the medical need for therapeutic drug monitoring of biologics in psoriasis: results of a structured survey

Background Therapeutic drug monitoring (TDM) may lead to more rational use of biologics. Still, TDM is largely underexplored in psoriasis. Little is known about the dosing behavior of biologics by dermatologists, and their attitude toward TDM. Objective Exploration of the awareness and need for the concept of TDM in psoriasis amongst (inter)national dermatologists. Method A survey was distributed at the Belgian Dermatology Days 2019 and Skin Inflammation & Psoriasis International Network (SPIN) Congress 2019. Next, an online survey version was launched amongst the SPIN Scientific Committee members. We collected physician’s characteristics, prescription behavior of biologics, data regarding clinical response to biologics and attitude toward TDM. Results A total of 107 surveys were included for analysis. Most dermatologists were Belgium-based (54.2%), others from European (23.4%) or non-European countries (19.6%). Seventy percent performed either dose increase (64.8%), time interval shortening (74.6%), dose lowering (16.9%) or time interval extension (33.8%). The majority who performed dose adaptations acknowledged the need for TDM. Conclusion This study showed most dermatologists perform dose adaptations empirically. The need for TDM was indicated by the majority, implying the need for effective communication regarding availability, utility and implementation of TDM assays in daily dermatology practice.

Evaluation of treatment of acne scars with 25% trichloroacetic acid chemical peel followed by manual dermasanding.

Acne scars are common problems encountered in daily dermatologic practice. To evaluate the effectiveness and safety of 25% trichloroacetic acid (TCA) alone or followed by manual dermasanding in repeated sessions for the treatment of mild and moderate acne scars. Thirteen patients (nine females and four males) were enrolled. Twenty-five percent TCA superficial peel was performed in all patients, followed in 11 of them by manual dermasanding. Thirteen sessions of TCA peeling, one session for each patient, were done, and twenty-four sessions of dermasanding with different numbers for each patient. Acne scars were graded into a score ranging from 0 to 20, the score was recorded at each visit, and the results were compared. The score of scarring acne decreased after TCA peeling and each dermasanding session. The improvement was statistically significant. The improvement continued after the last dermasanding session. After both procedures, no significant complications were recorded except persistent erythema and post-inflammatory hyperpigmentation, which disappeared in all patients at 3-month follow-up visit. Trichloroacetic acid superficial peel followed by manual dermasanding in separate sessions was effective and the improvement became more significant after repeated dermasanding sessions for the treatment of mild and moderate acne scars.

Comparison between the Efficacies of Clotrimazole in the Treatment of Both Forms of Tinea Versicolor

Tinea versicolor is a common skin disorder seen in the daily dermatological practice. Tinea versicolor is an endogenous opportunistic infection caused by Malassezia yeasts which are part of the normal flora that normally live on the skin. Several systemic and topical treatments have been used in the treatment of tinea versicolor but their use has been limited by their side effects or variable therapeutic response. Therefore, there is ongoing search for safer and more effective drugs. In this study, it was aimed to evaluate the safety and the efficacy of topical clotrimazole in the treatment of tinea versicolor. The study included 20 patients of tinea versicolor (10 hypo- and 10 hyperpigmented TVC) who were treated with clotrimazole 0.1% cream. All patients were selected from the outpatient clinics of Dermatology and Andrology Department of Benha University Hospitals. From this study we can conclude that clotrimazole is equally effective in both forms of tinea versicolor.

Computerassistierte Hautkrebsdiagnose

Artificial intelligence (AI) is increasingly being used in medical practice. Especially in the image-based diagnosis of skin cancer, AI shows great potential. However, there is asignificant discrepancy between expectations and true relevance of AI in current dermatological practice. This article summarizes promising study results of skin cancer diagnosis by computer-based diagnostic systems and discusses their significance for daily practice. We hereby focus on the analysis of dermoscopic images of pigmented and unpigmented skin lesions. Aselective literature search for recent relevant trials was conducted. The included studies used machine learning, and in particular "convolutional neural networks", which have been shown to be particularly effective for the classification of image data. In numerous studies, computer algorithms were able to detect pigmented and nonpigmented neoplasms of the skin with high precision, comparable to that of dermatologists. The combination of the physician's assessment and AI showed the best results. Computer-based diagnostic systems are widely accepted among patients and physicians. However, they are still not applicable in daily practice, since computer-based diagnostic systems have only been tested in an experimental environment. In addition, many digital diagnostic criteria that help AI to classify skin lesions remain unclear. This lack of transparency still needs to be addressed. Moreover, clinical studies on the use of AI-based assistance systems are needed in order to prove its applicability in daily dermatologic practice.

Enhanced visualization of blood and pigment in multispectral skin dermoscopy.

Dermoscopy has proven its value in the diagnosis of skin cancer and, therefore, is well established in daily dermatology practice. Up until now, analogue white light dermoscopy is the standard. Multispectral dermoscopy is based on illumination of the skin with narrowband light sources with different wavelengths. Each of these wavelengths is differently absorbed by skin chromophores, such as pigment or (de)oxygenated blood. Multispectral dermoscopy could be a way to enhance the visualization of vasculature and pigment. We illustrate possible additional information by such "skin parameter maps" in some cases of basal cell carcinoma and Bowen's disease. Using a new digital multispectral dermatoscope, skin images at multiple wavelengths are collected from different types of skin lesions. These particular images together with the knowledge on skin absorption properties, result in so called "skin parameter maps". A "pigment contrast map," which shows the relative concentration of primarily pigment, and a "blood contrast map" which shows the relative concentration of primarily blood were created. Especially, the latter is of importance in diagnosing keratinocyte skin cancer hence vascular structures are a characteristic feature, as further illustrated in the study. Skin parameter maps based on multispectral images can give better insight in the inner structures of lesions, especially in lesions with characteristic blood vessels such as Bowen's disease and basal cell carcinoma. Skin parameter maps can be used complementary to regular dermoscopy and could potentially facilitate diagnosing skin lesions.

Clinical management of very small pigmented lesions: Improved clinical outcome through dermoscopy and reflectance confocal microscopy combination.

Small-sized pigmented lesions (SSPL) <3mm in diameter are common pitfall in the daily dermatology practice. Dermoscopy alone is hampered by the lack of specific features inversely proportional to the diameter of the lesions and its performance is highly operator-dependent. Reflectance confocal microscopy (RCM) has been demonstrated to be effective in the diagnosis of several difficult lesions where dermoscopy lacks to provide conclusive information. A total of 179 lesions with uncertain or equivocal clinical and dermoscopy appearance were selected. Dermoscopist has been requested to express a diagnostic suspect when possible. Equivocal lesions underwent RCM performed by expert for second-level evaluation before surgical excision for histological diagnosis. Results have been later statistically analysed. Dermoscopy was not diagnostic in large number of lesions with low concordance histology (39.1%) instead of a much high concordance when combined with RCM (93.9%). Small-sized pigmented lesions were more likely to be located on the face area. Diagnosis of pigmented BCC was relatively easy on dermoscopy and also in the case of small lesions showing typical signs of BCC. LM and MM have been seen to be particularly difficult to be diagnosed using only dermoscopy. The combination of digital dermoscopy and RCM represents the correct approach of SSPL.

Aesthetic Filler Injections and the Management of Side Effects

Over the past years aesthetic procedures have been evolving as an important part of daily dermatological practice. Herein, fillers represent an integral component of a modern, multimodal aesthetic treatment approach. Advances in the understanding of the aging face and modern fillers offer a broad variety of indications ranging from augmentation to hydration or collagen-induction. At the same time the range of available injection materials, products and techniques has grown to mere unmanageable dimensions. Finally, dermatologists are frequently confronted with the consequences of improper filler treatments or late side effects of early filler materials which have already disappeared from the market and even the experienced injector may encounter treatment-associated side effects. Here, we review the most important current and historic filler materials, including indications, injection techniques, adverse effects and the respective management recommendations.

Noninvasive Imaging Tools in the Diagnosis and Treatment of Skin Cancers.

In the 1980s, the increasing incidence of skin cancers prompted the development of noninvasive medical devices to improve skin cancer diagnosis in daily dermatology practice. As a result of the development of these noninvasive techniques, diagnosis is now established earlier and with better accuracy. These advances are of great benefit to high-risk patients, who previously would have had to undergo several excisions. In this review, we focus on the classic technique of dermoscopy and the more recent digital version, as well as on advanced noninvasive imaging techniques, such as reflectance confocal microscopy and optical coherence tomography. On the basis of their specific features, these noninvasive medical devices can be used not only to diagnose and monitor melanoma and nonmelanoma skin cancers but also to choose the best therapy and follow the patient’s response to treatment in vivo.

Clinicopathological correlation of noninfectious erythematous papulosquamous cutaneous lesions in a tertiary care hospital

Aims and Objectives: Papulosquamous lesions, the largest conglomerate of skin diseases, are characterized by scaling papules and plaques which amount to lots of confusion, and hence, a definitive histopathological diagnosis has a significant role. Our study was thus aimed at evaluation of correlation between clinical diagnosis with histopathological diagnosis of different noninfectious erythematous papulosquamous skin lesions encountered in a tertiary care center. Materials and Methods: A total of 50 cases of noninfectious erythematous, papulosquamous lesions prediagnosed by dermatologists of the same institute were included over a period of 1 year. Diagnosis was confirmed by histopathological examination using hematoxylin and eosin stain. Cases were tabulated according to the distribution of age, gender, localization of lesions, clinical, and histopathological diagnosis. Results: Majority of the patients were in the 20–40 years age group (66%) with slight female preponderance (52%). The limbs (42%) were most frequently involved site. Histopathologically, lichen planus was the most common (52%) followed by psoriatic lesions (20%), pityriasis rosea (4%), pityriasis rubra pilaris (4%), subacute cutaneous lupus erythmatosus (4%), prurigo simplex (4%), pityriasis lichenoides chronica (4%), urticaria (2%) and ashy dermatosis (2%). Correlation of clinical with histopathological diagnosis was positive in 92% cases and negative in 8% cases. Conclusion: The contribution of histopathology to the final diagnosis was significant. Skin biopsy is thus valuable in daily dermatology practice and appropriate clinicopathological correlation is very important for the effective diagnosis and treatment of patients.

Factors driving the use of dermoscopy in Europe: a pan-European survey

When used correctly, dermoscopy is an essential tool for helping clinicians in the diagnosis of skin diseases and the early detection of skin cancers. Despite its proven benefits, there is a lack of data about how European dermatologists use dermoscopy in everyday practice. To identify the motivations, obstacles and modifiable factors influencing the use of dermoscopy in daily dermatology practice across Europe. All registered dermatologists in 32 European countries were invited to complete an online survey of 20 questions regarding demographic and practice characteristics, dermoscopy training and self-confidence in dermoscopic skills, patterns of dermoscopy use, reasons for not using dermoscopy and attitudes relating to dermoscopy utility. We collected 7480 valid answers, of which 89% reported use of dermoscopy. The main reasons for not using dermoscopy were lack of equipment (58% of nonusers) and lack of training (42%). Dermoscopy training during residency was reported by 41% of dermoscopy users and by 12% of nonusers (P < 0·001). Dermatologists working in public hospitals were the least likely to use dermoscopy. High use of dermoscopy across the spectrum of skin diseases was reported by 62% of dermoscopy users and was associated with dermoscopy training during residency, the use of polarized light and digital dermoscopy devices, longer dermoscopy practice, younger age and female gender. Expanding access to dermoscopy equipment, especially in public healthcare facilities and establishing dermoscopy training during dermatology residency would further enhance the substantially high dermoscopy use across European countries.

Melapred: first susceptibility test to sporadic melanoma in daily dermatological practice.

e21056Background: Melanoma (MM) has a dramatically poor prognosis in case of late diagnosis, emphasizing the critical role of early detection and prevention. We have developed a predictive algorith...

Acne - a potential skin marker of internal disease

Polycystic ovary syndrome (PCOS) is the most prevalent endocrine disorder in adult women. Hyperandrogenism is the crux of the pathogenesis of both acne and hirsutism, the most frequent clinical presentations of the syndrome. The chronic anovulation that may occur, often but not always associated with enlarged cystic ovaries, has long been recognized as an important feature of PCOS.In recent years major changes have occurred with regard to PCOS:(1)Sophisticated radiologic technology, together with increased awareness and clinical suspicion, have led to a massive increase in patients diagnosed with PCOS, and guidelines for diagnosis have been agreed upon, with any two of the following essential for a diagnosis: clinical or biochemical evidence of hyperandrogenism, chronic anovulation, or cystic changes in the ovaries.(2)Insulin resistance has been found to be a major component of PCOS; interaction can occur whereby hyperinsulinemia can promote hyperandrogenism and possibly also vice-versa. Insulin resistance is also thought to have a major role in the pathogenesis of metabolic syndrome, an ever-increasing worldwide cause of morbidity and mortality from ischemic heart disease and type 2 diabetes mellitus.(3)Patients with PCOS appear to have a fourfold increased risk of developing metabolic syndrome, although this is not equal in all PCOS patients.Although management of the common cutaneous manifestations, mainly acne, hirsutism, alopecia, and acanthosis nigricans, remains strictly within the realm of daily dermatologic practice, the pendulum is shifting toward greater awareness of the longer-term systemic implications of PCOS, with emphasis on the unique opportunity and privileged position of the dermatologist to diagnose this potentially serious problem at an early stage, when effective long-term treatment can be instituted. Patients need to be advised that PCOS cannot be cured but can be controlled. Management should involve a multidisciplinary team with emphasis on lifestyle change, insulin sensitizing agents, androgen blockers, and attention to specific cutaneous manifestations.

Cutaneous leishmaniasis: diagnostic pitfall. Case report

Introduction: Cutaneous Leishmaniasis is a parasitic infection encountered in our daily dermatologic practice. Case report: We present a case of 57 year-old man of Moroccan origin, with erythematous squamous and indurated plaque on the abdomen, treated as sarcoidosis with corticosteroids with no improvement. Discussion: Cutaneous Leishmaniasis is endemic in 88 countries. Aside from its classical presentation it can manifest in multiple different ways. In our case, the diagnostic of Erysipeloide Leishmaniasis was corrected on the basis of the skin smear and the histopathological examination. Our observation is particular in its clinical presentation and location. To our knowledge it is the first Moroccan case. Conclusion: Even in endemic countries it is worth reporting unusual forms and locations of Cutaneous Leishmaniasis in order to avoid inappropriate diagnosis and management.

Community‐acquired skin infections caused by Staphylococcus aureus: What is the role of the Panton‐Valentine leukocidin toxin?

The data concerning frequency and relevance of the toxin Panton-Valentine leukocidin (PVL) in skin infections caused by Staphylococcus aureus is controversial. The objective of the study was the identification of the role of the toxin in community-acquired skin infections caused by S. aureus. We performed a retrospective analysis of 112 patients with the diagnosis of skin infections caused by S. aureus. Frequency of PVL was investigated by PCR for the lukSF gene. Risk factors and severity of the disease were analyzed. Furthermore, spa typing was done in 55 of the isolated S. aureus. PVL occurred in 45 % of patients with skin infections caused by methicillin-susceptible S. aureus; methicillin-resistant strains were positive in 63 %. Mean age was 30.9 years in PVL-positive infections and thus statistically highly significantly lower than in PVL-negative infections. There was no correlation between presence of PVL and severity and course of skin infections or presence of special risk factors. The spa types showed a high variability in PVL-positive as well as in PVL-negative strains. In our study the PVL status of S. aureus isolated from skin infections was neither correlated with methicillin-resistance nor with the severity of disease. Remarkably, PVL-positive S. aureus strains appeared to be more frequent in younger than in older patients. Our results demonstrate that routine determination of PVL status is not required since the outcome has no diagnostic or therapeutic consequences in daily dermatological practice.

Burden of Disease: Psoriasis and Psoriatic Arthritis

Psoriatic arthritis (PsA) increases the disease burden associated with psoriasis by further diminishing quality of life, increasing health care costs and cardiovascular risk, and potentially causing progressive joint damage. The presence of PsA influences psoriasis treatment by increasing overall disease complexity and, within the framework of current guidelines and recommendations, requiring the use of conventional disease-modifying anti-rheumatic drugs or tumor necrosis factor-α inhibitors in order to prevent progressive joint damage. Despite its important impact, PsA is still under-diagnosed in dermatology practice. Dermatologists are well positioned to recognize and treat PsA, given that it characteristically presents, on average, 10years subsequent to the appearance of skin symptoms. Regular screening of psoriasis patients for early evident joint symptoms should be incorporated into daily dermatologic practice. Although drugs effective in PsA are available, not all patients may respond to treatment, and others may lose their initial response over time. New investigational therapies, such as inhibitors of interleukin-17A, interleukin-12/23, Janus kinase 3, or phosphodiesterase-4, may address unmet needs in psoriatic disease, with further research needed to determine the role of these agents in reducing joint damage and other comorbidities.

SAT0300 Nail psoriasis per se does not predict psoriatic arthritis: Analysis of risk factors in a cohort of italian psoriatic patients

BackgroundNail psoriasis is acknowledged to be associated with Psoriatic Arthritis (PsA). Onycho-Psoriasis (ONPS), however, is extremely common in psoriatic population and correlate poorly with skin involvement. Further, not all clinical...

Psychoonkologie in der Dermatologie

Psycho-oncology is a young discipline-in dermatology as well as in the medicine. The topic is heterogeneous and not clearly defined. The proportion of indications for emotional care in oncology is up to 50%, depending on the method of diagnosis. In daily dermatological practice, careful distribution of information and helping with coping are essential in order to not overwhelm the patient. The doctor should ask questions about the patient's expectations, fears, and any unclear items.

Optical coherence tomography: its role in daily dermatological practice

Optical coherence tomography (OCT) is a non-invasive, tomographic imaging technique which generates high-resolution in-vivo images up to mid-dermal layers. Due to continuous technological improvements, OCT is moving from research projects into daily dermatological practice. It can complement other imaging methods like high-frequency ultrasound or confocal microscopy. There is a wide variety of indications for OCT. In addition to aiding in the diagnosis and clinical monitoring of inflammatory dermatoses, OCT is a very useful and feasible technique in dermato-oncology.

Origins of the KOH technique

The potassium hydroxide (KOH) procedure is an integral diagnostic procedure, commonly used in daily dermatology practice but with vague origins. Given the many eponyms that exist in dermatology—both for the discovery of a disease and for the pioneering of a technique—it is surprising that no historical consensus exists on the inception of this procedure, nor much scholarly commentary on notable evolutions in technique or utilized materials. Modern dermatology textbooks are notably vague on the matter. Is it because theKOH examination has been considered a largely apprenticed practice—evading widespread description in print and rather kept alive through anecdotal teachings from mentor to trainee? Alternatively, have we technically evolved such that this procedure, with individual adaptations, is largely accepted and practiced in a uniform and systematic manner? The answers seem yes, for contemporary textbook editors provide little detail about the KOH preparation. After its introduction, the KOH examination was received with great aplomb as a novel technique and acquired subsequent modifications to mature into an efficient, diagnostic method of choice. A retrospective exploration of the literature appears to confirm the former, although the

Frequency of non‐histologically diagnosed basal cell carcinomas in daily Dutch practice

Population-based basal cell carcinoma (BCC) incidences are based on cancer registry data; however, these only include histologically diagnosed tumours. First, to investigate the number of subsequent non-histologically diagnosed BCC(s) in patients with a first histologically diagnosed BCC in 2004. Secondly, to observe differences in tumour characteristics between subsequent histologically and subsequent non-histologically diagnosed BCC(s). All patients, from four hospitals located in the serving area of the Eindhoven Cancer Registry, with a first histologically diagnosed BCC in 2004 (n = 1290) were selected. A linkage was made with PALGA, the nationwide network and registry of histo- and cytopathology, to obtain pathology reports of subsequent histologically diagnosed BCC(s) up to 1 November 2010. Patient records were extracted from the participating dermatology departments and reviewed up to 1 November 2010 to identify non-histologically diagnosed BCC(s). Overall, 33.2% of the 1089 followed up patients developed subsequent histologically and/or non-histologically diagnosed BCCs. In total, 1974 BCCs were observed of which 1833 were histologically and 141 were non-histologically diagnosed BCCs. The distribution of tumour site and subtype differed significantly between subsequent histologically and subsequent non-histologically diagnosed BCCs. The total burden of BCC is underestimated by the absence of data on the occurrence of non-histologically diagnosed BCCs in daily dermatological practice. It is pivotal for Dutch healthcare policy makers to acknowledge this to make accurate BCC-related cost estimates.