Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.

Comorbidities, mortality and survival in patients with pyoderma gangrenosum: a Danish nationwide registry-nested case-control study

BACKGROUND

Pyoderma gangrenosum (PG) is an ulcerative skin disease associated with comorbidities and increased mortality; however, the literature on this topic is scarce.

OBJECTIVES

To investigate the mortality, prevalence and risk of comorbidities in patients with PG.

METHODS

This nationwide registry nested case-control study included all inpatients and outpatients diagnosed with PG in tertiary dermatology centres in Denmark between 1 January 1994 and 31 December 2016. Each case was matched on date of birth and sex with 10 unique controls. The Danish National Patient Registry was used to identify all patients and to gather information on comorbidity. Information on age, sex, vital status and emigration was obtained from the Danish Civil Registration System. The outcomes were 19 different comorbidities and all-cause mortality. Prevalence was assessed from odds ratios (ORs) for specific comorbidities at the time of PG diagnosis. The risk of developing specific comorbidities and death was assessed using hazard ratios (HRs) obtained using the Cox proportional-hazards model.

RESULTS

A total of 1604 patients with PG were matched with 16 039 controls. Some associations were known, e.g. inflammatory bowel disease [OR 19·15 (15·27-24·02), HR 6·51 (4·24-10·01)], while others have not been described previously, e.g. osteoporosis [OR 1·57 (1·22-2·02), HR 2·59 (2·08-3·22)]. Mortality was significantly increased among patients with PG [HR 2·79 (2·57-3·03)].

CONCLUSIONS

Patients with PG have increased mortality and an increased prevalence and risk of both previously reported and novel comorbidities that may have severe consequences if left undiagnosed. Our findings are mainly related to moderate and severe PG.

Self-reported skin morbidities and health-related quality of life: a population-based nested case-control study

BACKGROUND

Impaired dermatological health-related quality of life (HRQoL) has been observed in hospital-based studies, but little is known on a population-based level.

OBJECTIVE

To investigate self-reported dermatological HRQoL in the general population.

METHODS

Hidradenitis suppurativa, psoriasis, pimples, hand rash or atopic eczema were identified using questionnaires in a 15,177 person population sample. A nested case-control study of 180 cases and 259 controls was made using the Dermatology Life Quality Index (DLQI), Skindex-29 and EQ-5D.

RESULTS

Cases had higher scores in DLQI and Skindex-29 and a lower score in EQ-5D, suggesting lower HRQoL. Adjusting for age and sex, the differences in Skindex-29 and DLQI were significant (p < 0.001).

CONCLUSIONS

Persons with self-reported skin morbidity had lower HRQoL than the general population. The impairment is not as significant as in studies of hospital-based cases, but considering the high prevalence of skin diseases it may still represent a significant burden of disease on society in aggregate.

Pretreatment of wheat straw using combined wet oxidation and alkaline hydrolysis resulting in convertible cellulose and hemicellulose

The wet oxidation process of wheat straw has been studied as a pretreatment method to attain our main goal: To break down cellulose to glucose enzymatic, and secondly, to dissolve hemicellulose (e.g., for fermentation) without producing microbial inhibitors. Wet oxidation combined with base addition readily oxidizes lignin from wheat straw facilitating the polysaccharides for enzymatic hydrolysis. By using a specially constructed autoclave system, the wet oxidation process was optimized with respect to both reaction time and temperature. The best conditions (20 g/L straw, 170 degrees C, 5 to 10 min) gave about 85% w/w yield of converting cellulose to glucose. The process water, containing dissolved hemicellulose and carboxylic acids, has proven to be a direct nutrient source for the fungus Aspergillus niger producing exo-beta-xylosidase. Furfural and hydroxymethyl-furfural, known inhibitors of microbial growth when other pretreatment systems have been applied, were not observed following the wet oxidation treatment.

A randomized controlled trial of R-salbutamol for topical treatment of discoid lupus erythematosus

BACKGROUND

In a recent open pilot trial, R-salbutamol sulphate, a well-known molecule with anti-inflammatory effects, was tested successfully on patients with therapy-resistant discoid lupus erythematosus (DLE).

OBJECTIVES

To compare the efficacy and safety of R-salbutamol cream 0.5% vs. placebo on DLE lesions in a multicentre, double-blinded, randomized, placebo-controlled phase II trial.

METHODS

Thirty-seven patients with at least one newly developed DLE lesion were randomized - 19 to the R-salbutamol cream 0.5% and 18 to placebo - and treated twice daily for 8 weeks. Efficacy was evaluated through scores of erythema, scaling/hypertrophy and induration as well as pain and itching; general improvement scored by the investigator and global improvement scored by patients' assessment were also evaluated.

RESULTS

The mean area under the curve of improvement for scaling/hypertrophy, pain, itching and global patient assessment was significantly better for the actively treated patients as compared with placebo (scaling/hypertrophy, P = 0.0262; pain, P = 0.0238; itching, P = 0.0135; global patient assessment, P = 0.045). Moreover, the percentage of patients without induration was significantly higher in the active group compared with the placebo group (P = 0.013), and a statistically significantly greater decrease in the size of the lesional area was also seen in the overall analysis of the R-salbutamol-treated patients (P = 0.0197). No serious adverse events were reported.

CONCLUSIONS

Application of R-salbutamol cream 0.5% was safe and well tolerated. Statistically significant effects were seen on scaling/hypertrophy, induration, pain and itching as well as patient global assessment, suggesting that R-salbutamol could be a promising new topical therapy alternative for DLE.

Use of oral glucocorticoids and risk of skin cancer and non-Hodgkin's lymphoma: a population-based case-control study

In North Jutland County, Denmark, we investigated whether use of oral glucocorticoids was associated with an increased risk of developing basal cell carcinoma (BCC), squamous cell carcinoma (SCC), malignant melanoma (MM), and non-Hodgkin's lymphoma (NHL). From the Danish Cancer Registry we identified 5422 BCC, 935 SCC, 983 MM, and 481 NHL cases during 1989–2003. Using risk-set sampling we selected four age- and gender-matched population controls for each case from the Civil Registration System. Prescriptions for oral glucocorticoids before diagnosis were obtained from the Prescription Database of North Jutland County on the basis of National Health Service data. We used conditional logistic regression to estimate incidence rate ratios (IRRs), adjusting for chronic medical diseases (information about these were obtained from the National Patient Registry) and use of other immunosuppressants. We found slightly elevated risk estimates for BCC (IRR, 1.15 (95% CI: 1.07–1.25)), SCC (IRR, 1.14 (95% CI: 0.94–1.39)), MM (IRR, 1.15 (95% CI: 0.94–1.41), and NHL (IRR, 1.11 (95% CI: 0.85–1.46)) among users of oral glucocorticoids. Our study supports an overall association between glucocorticoid use and risk of BCC that cannot be explained by the presence of chronic diseases or concomitant use of other immunosuppressants.

Mortality in Danish patients with nonmelanoma skin cancer, 1978-2001

BACKGROUND

Nonmelanoma skin cancer (NMSC) is a growing public health problem among Caucasians, thus mortality data that may provide insight into the clinical course and foster our understanding of NMSC are important.

OBJECTIVES

We examined total and cause-specific mortality among patients with NMSC registered in the Danish Cancer Registry from 1978 to 2001.

METHODS

A total of 82 837 patients with basal cell carcinoma (BCC) and 13 453 patients with squamous cell carcinoma (SCC) were followed through the National Death Registry for specific causes of death. Standardized mortality ratios (SMRs) were computed based on mortality rates in the general population.

RESULTS

Among patients with BCC, we found a slightly reduced total mortality [SMR 0.97, 95% confidence interval (CI) 0.96-0.98] with decreased SMRs seen for chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD) and diabetes mellitus. The SMR for suicide was increased. Among patients with SCC, we found an increased total mortality (SMR 1.30, 95% CI 1.26-1.33) due primarily to excess deaths from cancers, COPD, CVD and infectious diseases.

CONCLUSIONS

We found markedly different mortality patterns among patients with BCC and those with SCC, suggesting important differences in the clinical course of these patients.

X-linked spondylo-epiphyseal dysplasia tarda in the Danish-Swedish farm hound

In two litters from the same parents, three out of four males had an abnormally short leg and body length. Affected dogs showed signs of pain when moving, which could be eliminated by analgesia. On radiography, these animals had widened, radiolucent, irregularly bordered intervertebral disc spaces. When examined at seven months of age, the epiphyses appeared widened and irregular in shape and outline. General bone opacity in the vertebral column was lower in the affected male dogs than in the normal littermate. The affected dogs developed spondylosis and arthrosis of the larger limb joints. All affected dogs were euthanased on humane grounds, the eldest at the age of two years nine months. Based on the clinical and radiographic evidence, the condition seen in the male dogs described here resembles X-linked spondylo-epiphyseal dysplasia tarda caused by a collagenopathy due to malformation of COL2A1 as seen in human beings.

Wheezing, asthma, hayfever, and atopic eczema in childhood following exposure to tobacco smoke in fetal life

BACKGROUND

Prenatal maternal smoking has been associated with adverse respiratory effects in childhood such as lung deficits and wheezing, but results concerning asthma, hayfever, and atopic eczema are inconsistent.

OBJECTIVE

In the present study, we investigate the effects of maternal smoking in pregnancy on asthma, hayfever, atopic eczema, and wheezing in the offspring up to the age of 14-18.

METHODS

The study was based on a cohort of mothers enrolled during midwife visits around the 36th week of gestation in Odense and Aalborg, Denmark, 1984-1987. Singleton, live born children (n = 11,144) were followed-up in 2002 to obtain a childhood history of atopic diseases, by means of questionnaires to the parents. Multivariate logistic regression analyses for medical diagnoses of asthma, hayfever, atopic eczema, and symptoms of wheezing before the age of 3, were carried out on 7844 children.

RESULTS

After adjustment for confounders, late prenatal smoke exposure was associated with wheezing, with an odds ratio (OR) of 1.2, and a 95% confidence interval (CI) of 1.1-1.5. Furthermore, slightly reduced estimates for hayfever (OR 0.8, CI 0.7-1.0) and atopic eczema (OR 0.8, CI 0.7-0.9) were obtained for children exposed in late pregnancy compared with non-exposed.

CONCLUSION

Late gestational smoke exposure was associated with wheezing but not with asthma, while null or even protective estimates were indicated for hayfever and atopic eczema. However, lack of control options for hereditary factors may have affected the results.

Thymus size and head circumference at birth and the development of allergic diseases

BACKGROUND

The positive association between a large head circumference at birth and total serum IgE levels has been suggested to be due to negative associations between head circumference at birth and thymus development and between thymus development and total serum IgE levels.

OBJECTIVES

To examine the associations between head circumference and thymus size at birth and the development of allergic disease.

METHODS

The size of the thymus was assessed by sonography during the first week of life in 149 healthy term infants. Information on birth characteristics and mode of delivery was collected at delivery. The presence of allergic disease was assessed 5 years later by mailed questionnaires, which were returned by 85% of the eligible families.

RESULTS

At birth, head circumference was positively associated with thymus size (P < 0.001). In all, 27 (23%) of the children had developed at least one allergic disease. Multivariate analysis revealed that both parental allergy (Prevalence Ratio and 95% CI) = 3.18 (1.49-6.78)) and caesarean delivery (2.62 (1.48-4.64)) were independently correlated with allergic disease, whereas thymus size was not.

CONCLUSIONS

Our study does not support that a large head circumference is associated with a small thymus size, nor that a small thymus size is associated with allergic disease. Whether thymus size at birth is related to total serum IgE levels still remains to be elucidated.

Association between atopic dermatitis and insulin-dependent diabetes mellitus: a case-control study

BACKGROUND

Up to two-thirds of children with atopic dermatitis have IgE-mediated allergic reactions and a Th2 immune reactivity pattern with low production of interferon gamma and high production of interleukin 4 after allergen stimulation of T lymphocytes. Insulin-dependent diabetes mellitus (IDDM) seems to be associated with a Th1 immune reactivity pattern. We therefore postulated that these diseases may be inversely associated.

METHODS

We designed a case-control study including 920 children with IDDM, registered in the Danish Registry for Childhood Diabetes, and a sample of 9732 non-diabetic children registered in the Danish Medical Birth Registry. The children were aged 3-15 years. Information on atopic dermatitis was obtained by questionnaires.

FINDINGS

The cumulative incidence of atopic dermatitis up to age 15 years was 13.1% among children with IDDM and 19.8% in non-diabetic children (p<0.0001). Among children who developed IDDM, the incidence of atopic dermatitis was significantly lower than in the controls before onset of IDDM (73 cases in 5314 person-months vs 1375 in 57432 person-months; odds ratio 0.49 [0.39-0.63]). After onset of IDDM, diabetic and non-diabetic groups did not differ in incidence of atopic dermatitis (1.36 [0.89-2.07]).

INTERPRETATION

Our findings may be explained by different acquired or inherited reactivity patterns associated with atopic dermatitis (Th2) and IDDM (Th1). The results do not allow us to find out whether early development of atopic dermatitis reduces the risk of IDDM, or a propensity for IDDM reduces the risk of early-onset atopic dermatitis.

Atopic dermatitis and birth factors: historical follow up by record linkage

OBJECTIVE

To study if factors at birth are associated with later development of atopic dermatitis.

DESIGN

Historical follow up by record linkage from Danish medical birth register. Children were followed up for 5.5 to 8.5 years. Second historical follow up study comprising questionnaire to mothers of singleborn children 6.5 to 9.5 years after birth.

SETTING

Private dermatology clinics and dermatology and paediatric departments in the municipality of Aarhus, Denmark.

SUBJECTS

7862 singletons born in hospital between 1 January 1984 and 31 December 1986 to mothers living in the municipality of Aarhus. Questionnaires sent to 985 mothers.

MAIN OUTCOME MEASURES

Gestational age, birth weight, parity, and age of mother at the time of birth. Atopy in children diagnosed by specialists in dermatology and physicians. Family size; diagnosis of atopic dermatitis, allergic rhinitis, and asthma; family predisposition; and mothers' smoking habits during pregnancy determined from questionnaires.

RESULTS

Of 7862 children, 403 were diagnosed as having atopic dermatitis by a specialist; the cumulative incidence at age 7 was 5.6%. High gestational age and low parity were associated with an increased risk of atopic dermatitis. Among 985 children atopic dermatitis had been diagnosed by any physician in 184; the cumulative incidence at age 7 was 18.7%. High birth weight, high gestational age, and family history of atopy were associated with increased risk of atopic dermatitis.

CONCLUSION

In both studies the incidence of atopic dermatitis was associated with high gestational age and in one with high birth weight also. The causes for these associations are at present unknown but may indicate that even during gestation factors associated with atopic dermatitis influence maturation.

Mast cells and atopic dermatitis. Stereological quantification of mast cells in atopic dermatitis and normal human skin

Stereological quantification of mast cell numbers was applied to sections of punch biopsies from lesional and nonlesional skin of atopic dermatitis patients and skin of healthy volunteers. We also investigated whether the method of staining and/or the fixative influenced the results of the determination of the mast cell profile numbers. The punch biopsies were taken from the same four locations in both atopic dermatitis patients and normal individuals. The locations were the scalp, neck and flexure of the elbow (lesional skin), and nates (nonlesional skin). Clinical scoring was carried out at the site of each biopsy. After fixation and plastic embedding, the biopsies were cut into 2 microns serial sections. Ten sections, 30 microns apart, from each biopsy were examined and stained alternately with either toluidine blue or Giemsa stain and mast cell profile numbers were determined. The study yielded the following results: (1) in atopic dermatitis lesional skin an increased number of mast cell profiles was found as compared with nonlesional skin, (2) comparing atopic dermatitis skin with normal skin, a significantly increased number of mast cell profiles per millimetre squared was found in specimens from the neck, (3) staining with toluidine blue yielded a lower number of mast cell profiles than Giemsa staining, (4) the use of Carnoy's fixative resulted in a lower mast cell profile count than the use of formaldehyde, and (5) there was no statistically significant correlation between the clinical score and the number of mast cell profiles per millimetre squared. Using stereological techniques, this study indicated that mast cells might participate in the inflammatory process in skin leading to atopic dermatitis.

Atopic dermatitis may be a genetically determined dysmaturation of ectodermal tissue, resulting in disturbed T-lymphocyte maturation. A hypothesis

Although atopic dermatitis is a skin disorder, it includes immune deviations such as T-cell accumulation and activation in the skin, resulting in chronic, relapsing eczema. The T-lymphocyte activation in the skin is not accompanied by specific allergies in up to two thirds of the patients. It has been shown that T-cell lines and clones can be established from skin biopsies of patients with atopic dermatitis showing cytokine-dependent, but antigen-independent, continuous growth in vitro. This indicates the existence of skin-homing T-lymphocytes with growth requirements different from those of mature T-lymphocytes in the blood. We suggest that atopic dermatitis is a genetically determined change of ectodermal tissue. The thymic epithelium is derived from the ectoderm, and because of that we hypothesize that the maturation of the T-cell immune system of persons who develop atopic dermatitis is disturbed due to a faulty selection of T-lymphocytes in the thymus. "Dys"-matured T-cells leave the thymus as a consequence of faulty selection and continue their growth in the skin. The cells are eventually eradicated by the immune surveillance conducted by the normal part of the patients' immune system and as a consequence of diminished output of faulty selected T-lymphocytes during maturation. Because of the increased proliferation capacity of the aberrant T-cells, a cytokine imbalance occurs and in some patients this leads to the development of type I allergies due to a skewing of the humoral immune system towards IgE production.

Atopic dermatitis may be linked to whether a child is first- or second-born and/or the age of the mother

Five hundred and thirty families with at least 1 child who had been referred to a dermatologist with atopic dermatitis were interviewed in an effort to determine whether factors such as the age of the mother when a child is born and/or birth rank can contribute to the development of atopic dermatitis. The families interviewed had a total of 1,084 children, or an average of 2 children per family. Sixty per cent of the children with atopic dermatitis were under 5 years of age. Ninety-one per cent of them had developed the disease before the age of 3; those most severely affected had developed the disease during the first year of life. In families with 2 children, but only 1 child with atopic dermatitis, the odds ratio for the second child to develop atopic dermatitis was 1.379 (0.025 < p < 0.05). The average maternal age was 24.8 to 25.2 years when giving birth to the first child and 28 years when giving birth to the second child, irrespective of the status of the child. Thus, atopic dermatitis can be related to birth rank or to the age of the mother.

Pretreatment of wheat straw using combined wet oxidation and alkaline hydrolysis resulting in convertible cellulose and hemicellulose

The wet oxidation process of wheat straw has been studied as a pretreatment method to attain our main goal: To break down cellulose to glucose enzymatic, and secondly, to dissolve hemicellulose (e.g., for fermentation) without producing microbial inhibitors. Wet oxidation combined with base addition readily oxidizes lignin from wheat straw facilitating the polysaccharides for enzymatic hydrolysis. By using a specially constructed autoclave system, the wet oxidation process was optimized with respect to both reaction time and temperature. The best conditions (20 g/L straw, 170 degrees C, 5 to 10 min) gave about 85% w/w yield of converting cellulose to glucose. The process water, containing dissolved hemicellulose and carboxylic acids, has proven to be a direct nutrient source for the fungus Aspergillus niger producing exo-beta-xylosidase. Furfural and hydroxymethyl-furfural, known inhibitors of microbial growth when other pretreatment systems have been applied, were not observed following the wet oxidation treatment.

Distribution of feline blood types detected in the Copenhagen area of Denmark

The purpose of the present study was to make the first survey of the distribution of feline AB blood types in the Copenhagen area of Denmark. A total of 244 cats (139 purebred cats and 105 Domestic Shorthair cats) were tested. 93% of all tested cats had blood type A. Neither an AB nor an O type cat was detected and thus, the frequency of blood type B among all tested cats was 7%. Most type B cats were purebred cats (Birman, British Shorthair and Persian cats). No association between sex and blood type could be demonstrated among British Shorthair and Persian cats. Thus, the present study indicates that cats in Denmark predominantly have blood type A, and that blood type B cats are rare, except for certain breeds such as Birman and British Shorthair cats.

Distribution of feline blood types detected in the Copenhagen area of Denmark

The purpose of the present study was to make the first survey of the distribution of feline AB blood types in the Copenhagen area of Denmark. A total of 244 cats (139 purebred cats and 105 Domestic Shorthair cats) were tested. 93% of all tested cats had blood type A. Neither an AB nor an O type cat was detected and thus, the frequency of blood type B among all tested cats was 7%. Most type B cats were purebred cats (Birman, British Shorthair and Persian cats). No association between sex and blood type could be demonstrated among British Shorthair and Persian cats. Thus, the present study indicates that cats in Denmark predominantly have blood type A, and that blood type B cats are rare, except for certain breeds such as Birman and British Shorthair cats.