Infliximab is associated with an increased risk of serious infection in patients with psoriasis in the U.K. and Republic of Ireland: results from the British Association of Dermatologists Biologic Interventions Register (BADBIR)

Background

Patients with psoriasis and clinicians are concerned that infliximab may be associated with a risk of serious infections.

Objectives

To compare the risk of serious infections associated with infliximab in patients with chronic plaque psoriasis against a cohort on nonbiologic systemic therapies.

Methods

A prospective cohort study was performed using data from the British Association of Dermatologists Biologic Interventions Register (BADBIR). Infliximab was compared with nonbiologic systemic therapies, inclusive of any exposure to methotrexate, ciclosporin, acitretin, fumaric acid esters, psoralen‐ultraviolet A or hydroxycarbamide. Serious infections were those associated with hospitalization, the use of intravenous antimicrobial therapy and/or those that led to death. Propensity score inverse probability treatment weights were used to adjust for potential confounding from a priori identified covariates. Cox proportional hazards models were calculated to obtain hazard ratios (HRs).

Results

In total, 3843 participants were included for analysis up to October 2016. The incidence rates were significantly higher in the infliximab cohort (47·8 per 1000 person‐years) [95% confidence interval (CI) 35·7–64·0], compared with 14·2 per 1000 person‐years (95% CI 11·5–17·4) in the nonbiologic systemic cohort. Infliximab was associated with an overall increase in the risk of serious infection compared with nonbiologics [adjusted HR (adjHR) 1·95, 95% CI 1·01–3·75] and methotrexate only (adjHR 2·96, 95% CI 1·58–5·57) and a higher risk of serious infection in the first 6 months of therapy (adjHR 3·49, 95% CI 1·14–10·70).

Conclusions

Infliximab is associated with an increased risk of serious infections compared with nonbiologic systemic therapies in patients with psoriasis in the U.K. and the Republic of Ireland.

What's already known about this topic?

Randomized clinical trials are not sufficiently powered to investigate the risk of serious infection in patients with psoriasis who are undergoing treatment with infliximab.

Published observational studies have used different methods to adjust for confounding and different comparators.

Previous studies also lacked the adequate sample size to obtain a precise estimate of the risk of serious infection for infliximab.

What does this study add?

Using methods that better address bias and confounding, our study suggests that infliximab is associated with a higher risk of serious infections compared with nonbiologic systemic therapies in patients with psoriasis.

Patients should be counselled on the risk of serious infection before infliximab is prescribed.

Linked Comment: Puig. Br J Dermatol 2019; 180: 257–258.

Plain language summary available online

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Cumulative exposure to biological therapy and risk of cancer in patients with psoriasis: a meta-analysis of Psonet studies from Israel, Italy, Spain, the U.K. and Republic of Ireland

BACKGROUND

Cancer risk following long-term exposure to systemic immunomodulatory therapies in patients with psoriasis is possible.

OBJECTIVES

To assess a dose-response relationship between cumulative length of exposure to biological therapy and risk of cancer.

METHODS

Four national studies (a healthcare database from Israel, and prospective cohorts form Italy, Spain and the U.K. and Republic of Ireland) collaborating through Psonet (European Registry of Psoriasis) participated in these nested case-control studies, including nearly 60 000 person-years of observation. 'Cases' were patients who developed an incident cancer. Patients with previous cancers and benign or in situ tumours were excluded. Four cancer-free controls were matched to each case on year of birth, sex, geographic area and registration year. Follow-up for controls was censored at the date of cancer diagnosis for the matched case. Conditional logistic regression was performed by each registry. Results were pooled using random-effects meta-analysis.

RESULTS

A total of 728 cases and 2671 controls were identified. After matching, differences between cases and controls were present for the Charlson Comorbidity Index in all three registries, and in the prevalence of previous exposure to psoralen-ultraviolet A and smoking (the British Association of Dermatologists Biologic Interventions Register only). The risk of first cancers was not significantly associated with cumulative exposure to biologics (adjusted odds ratio per year of exposure 1·02, 95% confidence interval 0·92-1·13). Results were similar if squamous and basal cell carcinomas were included in the outcome.

CONCLUSIONS

Cumulative length of exposure to biological therapies in patients with psoriasis in real-world clinical practice does not appear to be linked to a higher risk of cancer after several years of use.

Differential effects of phototherapy, adalimumab and betamethasone-calcipotriol on effector and regulatory T cells in psoriasis

BACKGROUND

Psoriasis is a chronic T-cell-mediated skin disease with marked social and economic burdens. Current treatments are unsatisfactory, with unpredictable remission times and incompletely understood modes of action. Recent advances in our understanding of the pathogenesis of psoriasis have identified the imbalance between CD4⁺ T effector cells, particularly the T helper (Th)17 subset, and regulatory T cells (Tregs) as key to the development of psoriatic lesions, and therefore a novel therapeutic target.

OBJECTIVES

To quantify in patients the effects of three commonly used psoriasis treatment modalities on the Th1, Th2, Th17 and Treg subsets, and to test whether any change correlates with clinical response.

METHODS

Flow cytometry was used to enumerate Th1, Th2, Th17 and Treg subsets in blood and skin of patients with psoriasis before and after receiving any of the following treatments: narrowband ultraviolet B (NB-UVB), adalimumab and topical betamethasone-calcipotriol combination (Dovobet^® ) RESULTS: All patients responded clinically to the treatments. NB-UVB significantly increased the numbers of circulating and skin Tregs, while, by contrast, adalimumab reduced Th17 cells in these compartments, and Dovobet had dual effects by both increasing Tregs and reducing Th17 cells.

CONCLUSIONS

The differential effects reported here for the above-mentioned treatment modalities could be exploited to optimize or design therapeutic strategies to overcome the inflammatory drivers more effectively and restore the Th17-Treg balance in psoriasis.

Generating new evidence, improving clinical practice and developing research capacity: the benefits of recruiting to the U.K. Dermatology Clinical Trials Network's STOP GAP and BLISTER trials

Clinical trials may benefit clinical practice in three ways: firstly, clinicians may change their practice according to the new trial evidence; secondly, clinical processes can improve when working on a trial; and thirdly, research capacity is increased. We held a meeting to present and discuss the results of two large multicentre randomized controlled trials delivered through the U.K. Dermatology Clinical Trials Network. Investigators gave reflections on how the trials had changed their clinical practice. The STOP GAP trial showed that prednisolone and ciclosporin are equally effective as first-line systemic treatment for pyoderma gangrenosum. The final decision of which treatment to use should be based on the different adverse event profiles of the two drugs in relation to comorbidities, along with age, disease severity and patient preference. The BLISTER trial showed that starting people with pemphigoid on doxycycline produces acceptable short-term effectiveness and a superior safety profile to oral corticosteroids. Recruiting to these trials has led to the development of new specialist clinics with improved documentation. It has increased the profile of participating departments and embedded research in the department's activities. Helping to design and run these trials has also allowed trial staff to develop new skills in research design, which has been beneficial for career development. These and other benefits of recruiting to the trials are summarized here. We hope that these reflections will inspire wider involvement in clinical research.

Ciclosporin compared with prednisolone therapy for patients with pyoderma gangrenosum: cost-effectiveness analysis of the STOP GAP trial

Background

Pyoderma gangrenosum (PG) is a painful, ulcerating skin disease with poor evidence for management. Prednisolone and ciclosporin are the most commonly used treatments, although not previously compared within a randomized controlled trial (RCT).

Objectives

To compare the cost‐effectiveness of ciclosporin and prednisolone‐initiated treatment for patients with PG.

Methods

Quality of life (QoL, EuroQoL five dimensions three level questionnaire, EQ‐5D‐3L) and resource data were collected as part of the STOP GAP trial: a multicentre, parallel‐group, observer‐blind RCT. Within‐trial analysis used bivariate regression of costs and quality‐adjusted life years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost‐effectiveness from a health service perspective.

Results

In the base case analysis, when compared with prednisolone, ciclosporin was cost‐effective due to a reduction in costs [net cost: −£1160; 95% confidence interval (CI) −2991 to 672] and improvement in QoL (net QALYs: 0·055; 95% CI 0·018–0·093). However, this finding appears driven by a minority of patients with large lesions (≥ 20 cm²) (net cost: −£5310; 95% CI −9729 to −891; net QALYs: 0·077; 95% CI 0·004–0·151). The incremental cost‐effectiveness of ciclosporin for the majority of patients with smaller lesions was £23 374/QALY, although the estimate is imprecise: the probability of being cost‐effective at a willingness‐to‐pay of £20 000/QALY was 43%.

Conclusions

Consistent with the clinical findings of the STOP GAP trial, patients with small lesions should receive treatment guided by the side‐effect profiles of the drugs and patient preference – neither strategy is clearly a preferred use of National Health Service resources. However, ciclosporin‐initiated treatment may be more cost‐effective for patients with large lesions.

What's already known about this topic?

Pyoderma gangrenosum is characterized by severe, painful skin ulcers.

Although prednisolone has been the main systemic treatment, ciclosporin has been used increasingly because of its perceived greater effectiveness and fewer side‐effects.

STOP GAP was a pragmatic randomized controlled trial comparing ciclosporin and prednisolone: clinical effectiveness was similar, but only 50% of ulcers had healed by 6 months on either drug and adverse events were common with both drugs.

What does this study add?

For patients with small lesions (< 20 cm²), neither treatment is clearly more cost‐effective than the other.

However, ciclosporin‐initiated treatment may be the more cost‐effective option in patients with large (≥ 20 cm²) lesions.

Decisions about treatment will continue to be informed primarily by patient preference, underlying comorbidities, and drug side‐effect profiles (e.g. serious infections with prednisolone, hypertension and renal dysfunction with ciclosporin).

Linked Comment: Bray. Br J Dermatol 2017; 177:1475–1476.

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Interventions for hidradenitis suppurativa: a Cochrane systematic review incorporating GRADE assessment of evidence quality

More than 50 interventions have been used to treat hidradenitis suppurativa (HS), and so therapy decisions can be challenging. Our objective was to summarize and appraise randomized controlled trial (RCT) evidence for HS interventions in adults. Searches were conducted in Medline, Embase, CENTRAL, LILACS, five trials registers and abstracts from eight dermatology conferences until 13 August 2015. Two review authors independently assessed study eligibility, extracted data and assessed methodological quality. Primary outcomes were quality of life and adverse effects of the interventions. Twelve trials, from 1983 to 2015, investigating 15 different interventions met our inclusion criteria. The median trial duration was 16 weeks and the median number of participants was 27. Adalimumab 40 mg weekly improved the Dermatology Life Quality Index (DLQI) by 4·0 points, which equates to the minimal clinically important difference for the scale, compared with placebo (95% confidence interval -6·5 to -1·5 points). Evidence quality was reduced to 'moderate' because the results are based on only a single study. Adalimumab 40 mg every other week was ineffective in a meta-analysis of two studies comprising 124 participants. Infliximab 5 mg kg(-1) improved the DLQI score by 8·4 points after 8 weeks in a moderate-quality study completed by 33 of 38 participants. Etanercept 50 mg twice weekly was ineffective. Inclusion of a gentamicin sponge prior to primary closure did not improve outcomes. Other interventions, including topical and oral antibiotics, were investigated by relatively small studies, preventing treatment recommendations due to imprecision. More, larger RCTs are required to investigate most HS interventions, particularly oral treatments and surgical therapy. Moderate-quality evidence suggests that adalimumab given weekly and infliximab are effective, whereas adalimumab every other week is ineffective.

T cell participation in autoreactivity to NC16a epitopes in bullous pemphigoid

Bullous pemphigoid is a blistering skin disease characterized by autoantibodies against the NC16a domain of bullous pemphigoid 180. This study was performed to characterize and map the fine specificity of T cell responses to NC16a. Peripheral blood mononuclear cells (PBMC) from a total of 28 bullous pemphigoid patients and 14 matched controls were tested for proliferative and cytokine responses to recombinant NC16a and a complete panel of 21 overlapping peptides spanning this region of BP180. Proliferative responses to NC16A and the peptide panel in the patients with active disease were similar in frequency and magnitude to those in healthy donors, and included late responses typical of naive cells in approximately 60% of each group. Interleukin (IL)-4 responses were slightly stronger for six peptides, and significantly stronger for Nc16a, in patients than in controls. Factor analysis identified factors that separate responses to the peptide panel discretely into IL-4, T helper type 2 (Th2) pattern, interferon (IFN)-γ, Th1 pattern and IL-10 or transforming growth factor [TGF-β, regulatory T cell (Treg )] pattern. Factors segregating IL-10 versus IFN-γ were predicted by active blistering or remission, and TGF-β or IL-10 versus IFN-γ by age. Finally, we confirmed a significant up-regulation of IgE responses to BP180 in the patients with pemphigoid. This shows the complexity of T cell phenotype and fine autoreactive specificity in responses to NC16A, in patients and in normal controls. Important disease-associated factors determine the balance of cytokine responses. Of these, specific IL-4 and IgE responses show the strongest associations with pemphigoid, pointing to an important contribution by Th2 cytokines to pathogenesis.

Predominance of activated, clonally expanded T helper type 17 cells within the CD4+ T cell population in psoriatic lesions

Recent evidence points to the T helper type 17 (Th17) subset as key in the pathogenesis of psoriasis, but cells of this type in lesions remain to be fully characterized. Here we isolated, enumerated, functionally tested and clonotyped the CD4(+) Th cell population ex vivo from lesional biopsies and paired peripheral blood samples from psoriasis patients. Th17 cells were over-represented dramatically in lesions from all patients, representing 49-93% of CD4(+) Th cells compared with 3-18% in blood. Most lesional Th17 cells produced interleukin (IL)-17A ex vivo without further stimulation and expressed the CD45RO(+) phenotype characteristic of activated or memory cells. There was no increase in 'natural' [CD25(hi) forkhead box protein 3 (FoxP3(+))] regulatory T cells in lesions versus peripheral blood, but there was enrichment of 'induced' IL-10(+) regulatory T cell numbers in biopsies from some patients. The lesional Th17 cells exhibited a bias in T cell receptor Vβ chain usage, suggestive of specific expansion by antigen. The therapeutic challenge is to overcome the dominance of overwhelming numbers of such antigen-specific Th17 cells in psoriatic lesions.

Challenges for synthesising data in a network of registries for systemic psoriasis therapies

BACKGROUND

Large disease registries are the preferred method to assess long-term treatment safety. If psoriasis registries collaborate in a network, their power to assess safety is increased.

OBJECTIVE

To identify heterogeneity in psoriasis registries and methodological challenges for synthesising the data they provide.

METHODS

We surveyed the registries in PSONET and identified and addressed the challenges to collaborative analysis for the network in several round table meetings.

RESULTS

Eight out of 10 registries had a prospective comparator cohort with similar disease characteristics but not on biologics. Registries differed in the coding and validation or follow-up of adverse events and in the way they sampled their population. Fifteen challenges to registries collaborating were identified in the areas of operational governance, structural conduct, bias and analysis.

CONCLUSIONS

Participation in PSONET, a network of psoriasis registries, helps identify and solve common issues, enhancing the individual registries, and provides larger sets of more powerful safety data in a diverse population. Challenges to interpreting data collectively include heterogeneity in sampling, variable penetration of biologics and compatibility of different datasets.

Awareness and uptake of recommended vaccines among immunosuppressed patients

The Green Book recommended in 2009 that immunosuppressed patients should be receiving the yearly seasonal flu vaccine, the pandemic swine influenza A H1N1/09 vaccine and should have had the single pneumococcal vaccination. A retrospective audit in 2010 involving 60 immunosuppressed patients revealed that 83.3% of participants were aware of their entitlement to the vaccines. The majority were informed by their GP practice rather than the prescribing specialist. In 2009, 70% of participants received the seasonal flu vaccine, 40% received the H1N1 vaccine and 21.6% had received the pneumococcal vaccine. Reasons given for not receiving the recommended vaccines were lack of awareness, reported by 37.5%, followed by worries regarding side-effects reported by 25%. The data suggest that uptake rates, particularly for pneumococcal vaccination, could be improved with targeted information and promotion at the point of commencing immunosuppressants and approaching the influenza season. Prescribing physicians should take a more active role in routinely promoting and planning vaccination for at-risk groups and should provide information on how to receive the recommended vaccines and their side-effect profiles.

Teledermatology: a tool for remote supervision of a general practitioner with special interest in dermatology

BACKGROUND

Teledermatology (TD) has been developed as an alternative to face-to-face (FTF) dermatology care in remote areas.

AIM

To assess the feasibility of TD in remote supervision and education of a general practitioner with special interest (GPwSI), to reduce FTF consultations with the consultant dermatologist, and to provide appropriate diagnosis and care. Our secondary aim was to evaluate patient satisfaction with this mode of consultation.

METHODS

A TD service in Aberdeen was set up to augment supervision of a remote rural GP training in dermatology. This service was audited over a 2-year period to assess its usefulness in the education of the remote GP.

RESULTS

Prospective data on 230 selected referrals was analysed. Store-and-forward TD provided a high level of patient satisfaction, and was effective in remote supervision and education of a GPwSI in dermatology. FTF consultations with the consultant were avoided in 69% of consultations, and diagnostic agreement was considered high (61%). Educational feedback was given to the GP in 66% of consultations.

CONCLUSIONS

TD can supplement infrequent specialist dermatology service in remote areas, as in this case. We conclude that for selected patients, TD was a useful training tool for supervising the GPwSI, and ensuring clinical governance and quality assurance in clinics in a remote rural area. However, this model of care was limited by cost and the inherent limitations of TD.

European S3-guidelines on the systemic treatment of psoriasis vulgaris

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

Patients with moderate-to-severe psoriasis recapture clinical response during re-treatment with etanercept

BACKGROUND

Patients with psoriasis experience remission and gradual reappearance of erythematous and scaly plaques and require individualized treatment over time. A goal of psoriasis treatment is to provide optimal efficacy with a flexible therapeutic regimen that may include treatment pauses.

OBJECTIVES

To determine whether patients receiving initial treatment with etanercept who then pause therapy would subsequently recapture response during re-treatment.

PATIENTS AND METHODS

A post-hoc analysis of 226 patients with moderate-to-severe psoriasis from a large multicentre trial was performed. Patients had received etanercept 50 mg twice weekly subcutaneously until a target clinical response had been achieved, then had paused treatment and eventually relapsed. They were then re-treated with etanercept 25 mg twice weekly. The number of patients recapturing a Physician Global Assessment (PGA) of psoriasis rating of < or = 2 (clear, almost clear or mild) on first re-treatment was assessed. Patient satisfaction during the initial treatment and first re-treatment period was also determined.

RESULTS

A total of 187 (83%) patients recaptured the target clinical response of a PGA of < or = 2 after re-treatment. The majority of patients [219 of 226 (97%)] reported satisfaction with etanercept re-treatment. No new safety concerns emerged during re-treatment.

CONCLUSIONS

In this post-hoc analysis, patients with psoriasis who were re-treated with etanercept 25 mg twice weekly effectively recaptured clinical responses that patients found satisfactory. A flexible treatment option is available to dermatologists and patients for individualized care.

Systematic review of dermoscopy and digital dermoscopy/ artificial intelligence for the diagnosis of melanoma

BACKGROUND

Dermoscopy improves diagnostic accuracy of the unaided eye for melanoma, and digital dermoscopy with artificial intelligence or computer diagnosis has also been shown useful for the diagnosis of melanoma. At present there is no clear evidence regarding the diagnostic accuracy of dermoscopy compared with artificial intelligence.

OBJECTIVES

To evaluate the diagnostic accuracy of dermoscopy and digital dermoscopy/artificial intelligence for melanoma diagnosis and to compare the diagnostic accuracy of the different dermoscopic algorithms with each other and with digital dermoscopy/artificial intelligence for the detection of melanoma.

METHODS

A literature search on dermoscopy and digital dermoscopy/artificial intelligence for melanoma diagnosis was performed using several databases. Titles and abstracts of the retrieved articles were screened using a literature evaluation form. A quality assessment form was developed to assess the quality of the included studies. Heterogeneity among the studies was assessed. Pooled data were analysed using meta-analytical methods and comparisons between different algorithms were performed.

RESULTS

Of 765 articles retrieved, 30 studies were eligible for meta-analysis. Pooled sensitivity for artificial intelligence was slightly higher than for dermoscopy (91% vs. 88%; P = 0.076). Pooled specificity for dermoscopy was significantly better than artificial intelligence (86% vs. 79%; P < 0.001). Pooled diagnostic odds ratio was 51.5 for dermoscopy and 57.8 for artificial intelligence, which were not significantly different (P = 0.783). There were no significance differences in diagnostic odds ratio among the different dermoscopic diagnostic algorithms.

CONCLUSIONS

Dermoscopy and artificial intelligence performed equally well for diagnosis of melanocytic skin lesions. There was no significant difference in the diagnostic performance of various dermoscopy algorithms. The three-point checklist, the seven-point checklist and Menzies score had better diagnostic odds ratios than the others; however, these results need to be confirmed by a large-scale high-quality population-based study.

Recent advances in inflammatory skin diseases

Inflammatory skin diseases are frequently chronic skin conditions affecting many people at all stages of life. This article is a review intended to bring clinicians up to date with recent advances in the knowledge and management of inflammatory skin diseases, conditions that are commonly seen in general medicine and will be encountered in MRCP(UK) PACES and OSCE examinations.

Management of basal cell carcinoma by surveyed dermatologists in Scotland

BACKGROUND

The British Association of Dermatologists (BAD) has produced guidelines for management of basal cell carcinoma (BCC) in the UK.

OBJECTIVES

Our primary objectives were to assess the management of BCCs in Scotland and to compare it with BAD guidelines. Our secondary objectives were to audit waiting times and referral patterns.

METHODS

In phase I of the audit, dermatologists in 14 centres across Scotland prospectively registered demographic and clinical data of all lesions suspected to be BCCs over a 6-week period between October and December 2000. In phase II, details of management of these lesions were evaluated by case note review.

RESULTS

Of the 48 consultant dermatologists contacted, 42 took part in the survey. There were 524 clinically suspected BCCs seen in 470 patients; 164 lesions in 146 patients showed pathology other than BCC and were excluded from analysis, thus leaving 360 lesions available for analysis. There was wide variation in waiting times among Scottish dermatology centres. BCCs were equally distributed between the sexes, and lesions most commonly presented in those aged 71-80 years. A diagnostic biopsy was taken in 22% of lesions, and the rest were treated definitively after a clinical diagnosis of BCC, of which 90% were confirmed on histology. Nodulocystic lesions were the most common type of tumour, comprising 48% of lesions, and most BCCs were located on the head and neck region. Correlation of the histological type of BCC and treatment received showed that nodulocystic and morpheic BCCs were managed as recommended. There were more superficial BCCs treated with surgical excision than expected (22 of 34 lesions). Four of 21 recurrent tumours and 9 of 81 tumours on high-risk areas of the face were managed with curettage and cautery or cryotherapy, rather than surgical excision. Of the 297 excised tumours, 25 (9%) were incompletely excised. All the high-risk tumours and incompletely excised tumours were offered follow-up in the dermatology clinics.

CONCLUSIONS

In general, BCCs are managed according to BAD guidelines in Scotland, but waiting times vary considerably.

Annual incidence and mortality of bullous pemphigoid in the Grampian Region of North-east Scotland

BACKGROUND

Data on the annual incidence of bullous pemphigoid (BP) in the U.K. are scarce.

OBJECTIVES

To estimate the annual incidence of BP in Grampian Region (North-east Scotland) and to assess the causes of mortality in this cohort of patients.

METHODS

Details were obtained of all patients with a diagnosis of BP recorded in the database of the Pathology Department, Aberdeen Royal Infirmary between January 1991 and December 2001. Community Health Index population data were obtained from the Grampian Health Board and the annual incidence and age- and sex-specific incidence were calculated. Mortality data were obtained from the Patient Administration System and causes of death obtained from the Office of the Registrar for Births and Deaths for Scotland.

RESULTS

Eighty-three patients met criteria for diagnosis of BP. The annual incidence of BP in Grampian region was estimated to be 14 cases per million per year. There was a clear and marked rise in the incidence in patients over the age of 80 years. Forty-eight per cent of patients with BP died within 2 years of diagnosis. The all-cause age-standardized mortality ratio was 576%. When compared with cause-specific mortality in the Grampian population over 60 years of age, respiratory disease accounted for a higher than expected number of deaths in our cohort of patients with BP (odds ratio 5.3, 95% confidence interval 3.0-9.4).

CONCLUSIONS

North-east Scotland appears to have a relatively high incidence of BP when compared with incidence rates in continental Europe. The mortality rate in patients with BP is considerable, especially within the first 2 years of diagnosis.

Treatment of psoriasis with topical sirolimus: preclinical development and a randomized, double-blind trial

BACKGROUND

Systemically administered sirolimus has demonstrated efficacy in psoriasis in a multicentre European study.

OBJECTIVES

To determine the efficacy and safety of topically applied sirolimus in treating psoriasis.

METHODS

In vitro studies were followed by a pilot study designed to determine if sirolimus penetrates human skin, and by a randomized, double-blind, left-right comparative, dose-ranging study consisting of treatment with 2.2% sirolimus for 6 weeks and 8% sirolimus for an additional 6 weeks in 24 patients with stable, chronic plaque psoriasis. The primary outcome measure was clinical score. Secondary measures were ultrasound plaque thickness, plaque erythema, and computerized image analysis of immunohistochemical stains for immunocytes and proliferating cells. Pharmacokinetics and blood chemistry monitoring for safety were also performed.

RESULTS

A significant reduction in the clinical score (P = 0.03) (mean score 9.1 following sirolimus vs. 11.2 in control) was achieved with topical sirolimus. Measurements of plaque thickness and erythema did not show significant improvement with treatment. Computerized image analysis of biopsies showed a significant reduction in CD4+ cells (P = 0.0054) and proliferating cells (stained by Ki-67) in the epidermis (P = 0.0153) with sirolimus treatment compared with control.

CONCLUSIONS

Topically applied sirolimus penetrates normal skin and may have some antipsoriatic and immunosuppressive activity.

Nitric oxide function in the skin

Endogenously produced nitric oxide (NO) has a remarkably diverse range of biological functions, including a role in neurotransmission, smooth muscle relaxation, and the response to immunogens. Over the last 10 years, it has become clear that this extraordinary molecular messenger also plays a vital role in the skin, orchestrating normal regulatory processes and underlying some of the pathophysiological ones. We thought it pertinent to review the current literature concerning the possible function of NO in normal skin, its clinical and pathological significance, and the potential for therapeutic advances. The keratinocytes, which make up the bulk of the epidermis, constitutively express the neuronal isoform of NO synthase (NOS1), whereas the fibroblasts in the dermis and other cell types in the skin express the endothelial isoform (NOS3). Under certain conditions, virtually all skin cells appear to be capable of expressing the inducible NOS isoform (NOS2). The expression of NOS2 is also strongly implicated in psoriasis and other inflammatory skin conditions. Constitutive, low level NO production in the skin seems to play a role in the maintenance of barrier function and in determining blood flow rate in the microvasculature. Higher levels of NOS activity, stimulated by ultraviolet (UV) light or skin wounding, initiate other more complex reactions that require the orchestration of various cell types in a variety of spatially and temporally coordinated sets of responses. The NO liberated following UV irradiation plays a significant role in initiating melanogenesis, erythema, and immunosuppression. New evidence suggests that it may also be involved in protecting the keratinocytes against UV-induced apoptosis. The enhanced NOS activity in skin wounding (reviewed recently in this journal [Nitric oxide 7 (2002) 1]) appears to be important in guiding the infiltrating white blood cells and initiating the inflammation. In response to both insults, UV irradiation and skin wounding, the activation of constitutive NOS proceeds and overlaps with the expression of NOS2. Thus, at a macro-level, at least three different rates of NO production can occur in the skin, which seem to play an important part in organizing the skin's unique adaptability and function.

An audit of the value of patch testing and its effect on quality of life

We have assessed the value of patch testing from the patient's perspective and examined the impact of patch testing on their quality of life (QoL). 140 patients were recruited over 5 months. 2 questionnaires were designed to investigate the patient's views on patch testing. The 1st questionnaire was completed at the final visit to the clinic and the 2nd was posted 6 weeks later. The Dermatology Life Quality Index (DLQI) questionnaire was completed on both occasions. There was a significant improvement of the DLQI score in all patch-tested subjects (P = 0.003). Patients with involvement of the trunk had worse QoL. At the 4-day visit, 77 patients (55%) expressed the opinion that patch testing had been helpful. 6 weeks later, 71 patients replied. 47 patients were diagnosed as having allergic contact dermatitis: 87% of them found that patch testing had been useful, 91% were able to avoid the allergen(s) and 57% reported improvement/clearing in their skin condition. 58% of the 24 patients with negative results also found that patch testing had been beneficial. Overall, patient perception was that they understood verbal information (92%) better than written information (76%). Patch testing is beneficial to patients, leading to improved QoL. Patient perception was that they understood verbal advice better than written information.

The British standard series of contact dermatitis allergens: validation in clinical practice and value for clinical governance

BACKGROUND

All centres use an empirically determined set of 'standard' test allergens for patch testing that contain the commoner environmental sensitizers. Objectives To assess the validity of the British standard series of 12 allergens used in addition to the 23 already in the European standard series.

PATIENTS AND METHODS

Results for 3062 consecutive patients patch tested in seven centres across the United Kingdom during the year 2000 were analysed.

RESULTS

The additional allergens from the British series and positive rates were: methyl dibromoglutaronitrile 2.4%, carba mix 1.6%, tixocortol pivalate 1.5%, ethylenediamine 1.3%, cetearyl alcohol 0.8%, 2-bromo-2-nitropane-1,3-diol 0.8%, diazolidinyl urea 0.7%, chlorocresol 0.6%, budesonide 0.6%, fusidic acid 0.5%, imidazolidinyl urea 0.5%, and chloroxylenol 0.4%. The allergens with the lowest positive rate in the European standard series were primin at 0.6% and isopropyl-phenyl-para-phenylenediamine at 0.4%.

CONCLUSIONS

The 12 allergens in the British series should continue being tested as a standard addition to the European series within the U.K. The collection of data in this manner to allow comparisons between centres shows differences that reflect selection criteria and interpretation of results, and offers a useful tool for audit and clinical governance. Testing fewer than 1 : 2150 population may indicate underprovision of service. Similarly, rates of sensitization for nickel contact allergy above 26% and for fragrance mix above 16% (the upper 95% confidence intervals) should stimulate inquiry into the reasons behind this.

Subacute cutaneous lupus erythematosus associated with phenytoin

Subacute cutaneous lupus erythematosus is a well recognized subset of systemic lupus erythematosus. It is characterized by a nonscarring, papulosquamous or annular eruption in a photosensitive distribution. Several cases, thought to be caused by drugs, have been reported. We report a case of subacute cutaneous lupus erythematosus caused by phenytoin, which has not previously been associated with this condition.

Drug-induced urticaria. Recognition and treatment

Urticaria is the second most common cutaneous manifestation of drug allergy. Drug-induced urticaria is seen in 0.16% of medical inpatients and accounts for 9% of chronic urticaria or angioedema seen in dermatology outpatient departments. Occurring within 24 hours of drug ingestion, it is most commonly caused by penicillins, sulfonamides and nonsteroidal anti-inflammatory drugs. Drug-induced urticaria is seen in association with anaphylaxis, angioedema, and serum sickness. Diagnosis requires a detailed history, knowledge of the most likely agents sometimes supplemented with in vitro and skin testing. For mild reactions, avoidance of the causative drug and treatment with antihistamines will suffice. For anaphylactic shock, treatment with epinephrine (adrenaline), corticosteroids and antihistamines is required. Patients should be educated to inform medical staff about previous drug reactions, and to avoid these and cross-reacting drugs if possible. Medical staff need to routinely enquire about allergy and avoid unnecessary prescriptions.