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Kirtschig G, Singh S. Interventions for bullous pemphigoid: summary of a Cochrane Review. Br J Dermatol 2024; 190:277-279. [PMID: 37823405 DOI: 10.1093/bjd/ljad386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/24/2023] [Accepted: 10/29/2023] [Indexed: 10/13/2023]
Abstract
This is a summary of the Cochrane review on interventions for Bullous pemphigoid updated and published in 2023.
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Affiliation(s)
| | - Sanjay Singh
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi , India
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2
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Kirtschig G, Kinberger M. [Genital lichen sclerosus and lichen planus]. Dermatologie (Heidelb) 2024; 75:22-29. [PMID: 38133692 DOI: 10.1007/s00105-023-05267-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
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 a delay in diagnosing LS and LP and subsequently treatment is initiated late in the course of the disease, which will lead to scarring and a decreased 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.
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Affiliation(s)
- Gudula Kirtschig
- Medbase Gesundheitszentrum, Unterer Graben 1, 8500, Frauenfeld, Schweiz.
| | - Maria Kinberger
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
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3
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Singh S, Kirtschig G, Anchan VN, Chi CC, Taghipour K, Boyle RJ, Murrell DF. Interventions for bullous pemphigoid. Cochrane Database Syst Rev 2023; 8:CD002292. [PMID: 37572360 PMCID: PMC10421473 DOI: 10.1002/14651858.cd002292.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease. Oral steroids are the standard treatment. We have updated this review, which was first published in 2002, because several new treatments have since been tried. OBJECTIVES To assess the effects of treatments for bullous pemphigoid. SEARCH METHODS We updated searches of the following databases to November 2021: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched five trial databases to January 2022, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA RCTs of treatments for immunofluorescence-confirmed bullous pemphigoid. DATA COLLECTION AND ANALYSIS At least two review authors, working independently, evaluated the studies against the review's inclusion criteria and extracted data from included studies. Using GRADE methodology, we assessed the certainty of the evidence for each outcome in each comparison. Our primary outcomes were healing of skin lesions and mortality. MAIN RESULTS We identified 14 RCTs (1442 participants). The main treatment modalities assessed were oral steroids, topical steroids, and the oral anti-inflammatory antibiotic doxycycline. Most studies reported mortality but adverse events and quality of life were not well reported. We decided to look at the primary outcomes 'disease control' and 'mortality'. Almost all studies investigated different comparisons; two studies were placebo-controlled. The results are therefore based on a single study for each comparison except azathioprine. Most studies involved only small numbers of participants. We assessed the risk of bias for all key outcomes as having 'some concerns' or high risk, due to missing data, inappropriate analysis, or insufficient information. Clobetasol propionate cream versus oral prednisone Compared to oral prednisone, clobetasol propionate cream applied over the whole body probably increases skin healing at day 21 (risk ratio (RR 1.08, 95% confidence interval (CI) 1.03 to 1.13; 1 study, 341 participants; moderate-certainty evidence). Skin healing at 21 days was seen in 99.8% of participants assigned to clobetasol and 92.4% of participants assigned to prednisone. Clobetasol propionate cream applied over the whole body compared to oral prednisone may reduce mortality at one year (RR 0.73, 95% CI 0.53 to 1.01; 1 study, 341 participants; low-certainty evidence). Death occurred in 26.5% (45/170) of participants assigned to clobetasol and 36.3% (62/171) of participants assigned to oral prednisone. This study did not measure quality of life. Clobetasol propionate cream may reduce risk of severe complications by day 21 compared with oral prednisone (RR 0.65, 95% CI 0.50 to 0.86; 1 study, 341 participants; low-certainty evidence). Mild clobetasol propionate cream regimen (10 to 30 g/day) versus standard clobetasol propionate cream regimen (40 g/day) A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen probably does not change skin healing at day 21 (RR 1.00, 95% CI 0.97 to 1.03; 1 study, 312 participants; moderate-certainty evidence). Both groups showed complete healing of lesions at day 21 in 98% participants. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change mortality at one year (RR 1.00, 95% CI 0.75 to 1.32; 1 study, 312 participants; low-certainty evidence), which occurred in 118/312 (37.9%) participants. This study did not measure quality of life. A mild regimen of topical clobetasol propionate applied over the whole body compared to the standard regimen may not change adverse events at one year (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 309 participants; low-certainty evidence). Doxycycline versus prednisolone Compared to prednisolone (0.5 mg/kg/day), doxycycline (200 mg/day) induces less skin healing at six weeks (RR 0.81, 95% CI 0.72 to 0.92; 1 study, 213 participants; high-certainty evidence). Complete skin healing was reported in 73.8% of participants assigned to doxycycline and 91.1% assigned to prednisolone. Doxycycline compared to prednisolone probably decreases mortality at one year (RR 0.25, 95% CI 0.07 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 14; 1 study, 234 participants; moderate-certainty evidence). Mortality occurred in 2.4% (3/132) of participants with doxycycline and 9.7% (11/121) with prednisolone. Compared to prednisolone, doxycycline improved quality of life at one year (mean difference 1.8 points lower, which is more favourable on the Dermatology Life Quality Index, 95% CI 1.02 to 2.58 lower; 1 study, 234 participants; high-certainty evidence). Doxycycline compared to prednisolone probably reduces severe or life-threatening treatment-related adverse events at one year (RR 0.59, 95% CI 0.35 to 0.99; 1 study, 234 participants; moderate-certainty evidence). Prednisone plus azathioprine versus prednisone It is unclear whether azathioprine plus prednisone compared to prednisone alone affects skin healing or mortality because there was only very low-certainty evidence from two trials (98 participants). These studies did not measure quality of life. Adverse events were reported in a total of 20/48 (42%) participants assigned to azathioprine plus prednisone and 15/44 (34%) participants assigned to prednisone. Nicotinamide plus tetracycline versus prednisone It is unclear whether nicotinamide plus tetracycline compared to prednisone affects skin healing or mortality because there was only very low-certainty evidence from one trial (18 participants). This study did not measure quality of life. Fewer adverse events were reported in the nicotinamide group. Methylprednisolone plus azathioprine versus methylprednisolone plus dapsone It is unclear whether azathioprine plus methylprednisolone compared to dapsone plus methylprednisolone affects skin healing or mortality because there was only very low-certainty evidence from one trial (54 participants). This study did not measure quality of life. A total of 18 adverse events were reported in the azathioprine group and 13 in the dapsone group. AUTHORS' CONCLUSIONS Clobetasol propionate cream applied over the whole body is probably similarly effective as, and may cause less mortality than, oral prednisone for treating bullous pemphigoid. Lower-dose clobetasol propionate cream applied over the whole body is probably similarly effective as standard-dose clobetasol propionate cream and has similar mortality. Doxycycline is less effective but causes less mortality than prednisolone for treating bullous pemphigoid. Other treatments need further investigation.
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Affiliation(s)
- Sanjay Singh
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Vinayak N Anchan
- Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ching-Chi Chi
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Kathy Taghipour
- Department of Dermatology, Whittington Health NHS Trust, London, UK
| | - Robert J Boyle
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital & University of New South Wales, Sydney, Australia
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Simpson RC, Kirtschig G, Selk A, von Seitzberg S, Vittrup G, Bissonnette I, Kottner J, Lanthier J, Stanton C, Foster D, Promm M, Augenti A, Lauretti S, Thomas KS. Core outcome domains for lichen sclerosus: a CORALS initiative consensus statement. Br J Dermatol 2023; 188:628-635. [PMID: 36702803 DOI: 10.1093/bjd/ljac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/12/2022] [Accepted: 12/17/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Lichen sclerosus (LS) is a chronic inflammatory condition mainly affecting genital skin. It causes distressing symptoms that impact daily quality of life (QoL). It causes progressive anatomical changes and a potential risk of cancer. Published randomised controlled trials are of varying methodological quality and difficult to combine in meta-analyses. This is partly due to lack of agreed outcome measures to assess treatment response. Identification of core outcome sets (COSs), which standardise key outcomes to be measured in all future trials, is a solution to this problem. OBJECTIVES To obtain international agreement on which outcome domains should be measured in interventional trials of genital LS. METHODS Recommended best practice for COS domain development was followed: 1) Identification of potential outcome domains: a long-list was generated through up-to-date LSliterature search, including information collected during the LS Priority Setting Partnership. 2) Provisional agreement of outcome domains: A 3-stage multi-stakeholder international electronic-Delphi consensus study; 3) Final agreement of outcome domains: Online consensus meeting with international stakeholders including anonymised voting. RESULTS In total, 123 participants (77 patients, 44 health professionals, 2 researchers) from 20 countries completed 3 rounds of the electronic-Delphi study. 11 outcome domains were rated as 'critical' and were discussed at the online consensus meetings. The first set of consensus meetings involved 42 participants from 13 countries. Consensus was met for 'symptoms' (100% agreed) and 'quality of lif -LS specific' (92% agreed). After set two of meetings, involving 29 participants from 12 countries, 'Clinical (visible) signs' also met consensus (97% agreed). CONCLUSIONS The international community have agreed upon 3 key outcome domains to measure in all future LS clinical trials. We recommend that trialists and systematic reviewers incorporate these domains into study protocols with immediate effect. CORALS will now work with stakeholders to select an outcome measurement instrument per prioritised core domain.
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Affiliation(s)
- Rosalind C Simpson
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | | | | | | | - Ione Bissonnette
- CNM, MSN, co-author VulvovaginalDisorders.org, Massachusetts, USA
| | | | | | | | | | - Martin Promm
- Department of Pediatric Urology and Regensburg University, Germany
| | | | | | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Haßdenteufel K, Müller M, Gutsfeld R, Goetz M, Bauer A, Wallwiener M, Brucker SY, Joos S, Colombo MG, Hawighorst-Knapstein S, Chaudhuri A, Kirtschig G, Saalmann F, Wallwiener S. Long-term effects of preeclampsia on maternal cardiovascular health and postpartum utilization of primary care: an observational claims data study. Arch Gynecol Obstet 2023; 307:275-284. [PMID: 35482068 PMCID: PMC9836976 DOI: 10.1007/s00404-022-06561-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/01/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Preeclampsia occurs in up to 15% of pregnancies and constitutes a major risk factor for cardiovascular disease. This observational cohort study aimed to examine the association between preeclamptic pregnancies and cardiovascular outcomes as well as primary and specialized care utilization after delivery. METHODS Using statutory claims data we identified women with singleton live births between 2010 and 2017. Main outcomes included the occurrence of either hypertension or cardiovascular disease after one or more preeclamptic pregnancies, number of contacts to a general practitioner or cardiologist after delivery and prescribed antihypertensive medication. Data were analyzed using Cox proportional hazard regression models adjusted for maternal age, diabetes, dyslipidemia, and obesity. RESULTS The study cohort consisted of 181,574 women with 240,698 births. Women who experienced preeclampsia once had an increased risk for cardiovascular (hazard ratio, HR = 1.29) or hypertensive (HR = 4.13) events. In women affected by recurrent preeclampsia, risks were even higher to develop cardiovascular disease (HR = 1.53) or hypertension (HR = 6.01). In the following years after delivery, general practitioners were seen frequently, whereas cardiologists were consulted rarely (0.3 and 2.4%). CONCLUSION Women affected by preeclampsia experience an increased risk of developing chronic hypertension and cardiovascular disease, especially those with recurrent preeclampsia. Future medical guidelines should take this potential risk into account.
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Affiliation(s)
- Kathrin Haßdenteufel
- Department of Obstetrics and Gynecology, Heidelberg University, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany
| | - Mitho Müller
- Department of Psychology, Ludwig Maximilian University, Munich, Germany
| | - Raphael Gutsfeld
- Department of Psychology, Ludwig Maximilian University, Munich, Germany
| | - Maren Goetz
- Department of General Pediatrics, University Children’s Hospital, Heidelberg, Germany
| | - Armin Bauer
- Department of Women’s Health, University Hospital Tuebingen, Tuebingen, Germany
| | - Markus Wallwiener
- Department of Obstetrics and Gynecology, Heidelberg University, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany
| | - Sara Y. Brucker
- Department of Women’s Health, University Hospital Tuebingen, Tuebingen, Germany
| | - Stefanie Joos
- Institute for General Practice and Interprofessional Healthcare, Eberhardt-Karls-University, Tuebingen, Germany
| | - Miriam Giovanna Colombo
- Institute for General Practice and Interprofessional Healthcare, Eberhardt-Karls-University, Tuebingen, Germany
| | | | - Ariane Chaudhuri
- Department of Health Promotion, AOK Baden-Wuerttemberg, Stuttgart, Germany
| | - Gudula Kirtschig
- Department of Health Promotion, AOK Baden-Wuerttemberg, Stuttgart, Germany
| | - Frauke Saalmann
- Department of Health Promotion, AOK Baden-Wuerttemberg, Stuttgart, Germany
| | - Stephanie Wallwiener
- Department of Obstetrics and Gynecology, Heidelberg University, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany
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6
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Colombo MG, Förster C, Wallwiener S, Hassdenteufel K, Hawighorst-Knapstein S, Kirtschig G, Chaudhuri A, Dally S, Joos S. Comorbidity, life-style factors and healthcare utilization in incident chronic kidney disease: sex-specific analyses of claims data. Nephrol Dial Transplant 2022; 38:722-732. [PMID: 35998324 PMCID: PMC9976763 DOI: 10.1093/ndt/gfac245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common in aging men and women. In contrast to other European countries, Germany lacks CKD registries. The aim of this study was to determine the incidence of CKD stages 2-5 in men and women in Germany. Furthermore, differences between the sexes in terms of comorbidities, potentially inappropriate medications (PIM), and healthcare utilization were examined. METHODS In this retrospective observational study, claims data from members of a statutory health insurance fund aged 18 years or older with incident CKD between 2011 and 2018 were analyzed. Incident CKD was defined as having two confirmed diagnoses of CKD stages 2-5 from outpatient care or one primary or secondary diagnosis from inpatient care. RESULTS The age- and sex-standardized incidence of all CKD stages was 945/100 000 persons between 2011 and 2018. Incident CKD, especially stages 3 and 4, occurred more frequently in women, while the incidence of stages 2 and 5 was higher in men. While women visited their GP more frequently and were prescribed PIMs more often, men were more likely to visit a nephrologist and were more often hospitalized after the incident CKD diagnosis. CONCLUSION More awareness needs to be raised towards the early detection of CKD and the use of PIMs, especially in women. Improved care coordination is needed to avoid an overprovision of patients with uncomplicated incident stages and ensure that patients with advanced CKD stages get timely access to specialist care.
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Affiliation(s)
| | - Christian Förster
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen, Germany
| | - Stephanie Wallwiener
- Department of Obstetrics and Gynecology, University Hospital of Heidelberg, Germany
| | | | | | - Gudula Kirtschig
- Allgemeine Ortskrankenkasse (AOK) Baden-Württemberg, Corporate division for Medical Care Design, Germany
| | - Ariane Chaudhuri
- Allgemeine Ortskrankenkasse (AOK) Baden-Württemberg, Corporate division for Medical Care Design, Germany
| | - Simon Dally
- Allgemeine Ortskrankenkasse (AOK) Baden-Württemberg, Corporate Division Control, Finances and Analytics, Germany
| | - Stefanie Joos
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen, Germany
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Giovanna Colombo M, Wetzel AJ, Haumann H, Dally S, Kirtschig G, Joos S. Polymyalgia Rheumatica. Dtsch Arztebl Int 2022; 119:411-417. [PMID: 35635433 PMCID: PMC9533703 DOI: 10.3238/arztebl.m2022.0218] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/15/2022] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Polymyalgia rheumatica (PMR) is among the most common inflammatory rheumatic diseases in older adults. Presumed risk factors include female sex, previous infections, and genetic factors. No epidemiological data on PMR in Germany have been available until now. METHODS This review is based on publications retrieved by a selective literature search in PubMed. Moreover, the administrative incidence and prevalence of PMR in the years 2011-2019 was determined from data of the AOK Baden-Württemberg statutory health insurance carrier for insurees aged 40 and older. In addition, we quantified the number of consultations with physicians involved in the diagnosis. RESULTS The annual age- and sex-standardized incidence and prevalence of PMR from 2011 to 2019 were 18.6/100 000 persons and 138.8/100 000 persons, respectively. The incidence was higher in women than in men (21.8/100 000 vs. 12.8/100 000 persons per year). 60% of the cases were diagnosed in primary care practices. The treatment of PMR with orally administered glucocorticoids usually results in a treatment response within a few days to weeks. Approximately 43% of patients experience recurrent symptoms within a year, requiring adjustment of the glucocorticoid dose. For older patients with impaired physical ability, additional non-pharmacological treatment with exercise programs plays an important role. CONCLUSION PMR usually takes an uncomplicated course under treatment and can be managed in primary care, but these patients are often multimorbid and require frequent follow-up. Along with research on the etiology of the disease, further studies are needed to identify the risk factors for a chronic course and to evaluate the potential effects of non-pharmacological measures.
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Affiliation(s)
| | - Anna-Jasmin Wetzel
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen
| | - Hannah Haumann
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen
| | - Simon Dally
- Department of Analytics and Data Science, AOK Baden–Württemberg, Stuttgart
| | | | - Stefanie Joos
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen
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Sprague KA, Sivesind TE, Szeto MD, Dellavalle RP, Kirtschig G. From the Cochrane Library: Interventions for mucous membrane pemphigoid and epidermolysis bullosa acquisita. J Am Acad Dermatol 2022; 86:e273-e274. [PMID: 35176396 DOI: 10.1016/j.jaad.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Kathryn A Sprague
- Chicago College of Osteopathic Medicine, Midwestern University, Chicago, Illinois
| | - Torunn E Sivesind
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mindy D Szeto
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Robert P Dellavalle
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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van der Meijden WI, Boffa MJ, Ter Harmsel B, Kirtschig G, Lewis F, Moyal-Barracco M, Tiplica GS, Sherrard J. 2021 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol 2022; 36:952-972. [PMID: 35411963 DOI: 10.1111/jdv.18102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/14/2022] [Indexed: 12/27/2022]
Affiliation(s)
- W I van der Meijden
- Department of Dermatology, Betsi Cadwaladr University Health Board, Bangor, UK
| | - M J Boffa
- Department of Dermatology, Mater Dei Hospital, Msida, Malta
| | - B Ter Harmsel
- Department of Gynaecology, Roosevelt kliniek, Leiden, The Netherlands
| | - G Kirtschig
- Gesundheitszentrum Frauenfeld, Frauenfeld, Switzerland
| | - F Lewis
- St John's Institute of Dermatology, Guy's and St Thomas' Hospital, London, UK
| | - M Moyal-Barracco
- Department of Dermatology, Tarnier-Cochin Hospital, Paris, France
| | - G-S Tiplica
- Dermatology 2, Colentina Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - J Sherrard
- Department of Sexual Health, Wycombe General Hospital, Bucks, UK
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10
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Kirtschig G, Lo S, Batchelor J. Pragmatic trials: lab meets bedside. Br J Dermatol 2019; 181:431-433. [PMID: 31475345 DOI: 10.1111/bjd.17889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- G Kirtschig
- Department of Dermatology, University of Marburg, Germany.,Medbase Frauenfeld, santémed Gesundheitszentren AG, Frauenfeld, Switzerland
| | - S Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Institute for Research and Medical Consultations (IRMC), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - J Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Lenton Lane, Nottingham, NG7 2NR, U.K
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Simpson RC, Cooper SM, Kirtschig G, Larsen S, Lawton S, McPhee M, Murphy R, Nunns D, Rees S, Tarpey M, Thomas KS. Future research priorities for lichen sclerosus - results of a James Lind Alliance Priority Setting Partnership. Br J Dermatol 2019; 180:1236-1237. [PMID: 30472735 PMCID: PMC6850137 DOI: 10.1111/bjd.17447] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- R C Simpson
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
| | - S M Cooper
- Department of Dermatology, Oxford University Hospitals, Oxford, U.K
| | | | | | - S Lawton
- Rotherham NHS Foundation Trust, Rotherham, U.K
| | - M McPhee
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
| | - R Murphy
- Department of Dermatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - D Nunns
- Department of Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, U.K
| | - S Rees
- University of Warwick, Warwick, U.K
| | - M Tarpey
- James Lind Alliance, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre (NETSCC), University of Southampton, Southampton, U.K
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
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12
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Koch R, Polanc A, Haumann H, Kirtschig G, Martus P, Thies C, Sundmacher L, Gaa C, Witkamp L, Joos S. Improving cooperation between general practitioners and dermatologists via telemedicine: study protocol of the cluster-randomized controlled TeleDerm study. Trials 2018; 19:583. [PMID: 30355358 PMCID: PMC6201508 DOI: 10.1186/s13063-018-2955-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Internationally, teledermatology has proven to be a viable alternative to conventional physical referrals. Travel cost and referral times are reduced while patient safety is preserved. Especially patients from rural areas benefit from this healthcare innovation. Despite these established facts and positive experiences from EU neighboring countries like the Netherlands or the United Kingdom, Germany has not yet implemented store-and-forward teledermatology in routine care. METHODS The TeleDerm study will implement and evaluate store-and-forward teledermatology in 50 general practitioner (GP) practices as an alternative to conventional referrals. TeleDerm aims to confirm that the possibility of store-and-forward teledermatology in GP practices is going to lead to a 15% (n = 260) reduction in referrals in the intervention arm. The study uses a cluster-randomized controlled trial design. Randomization is planned for the cluster "county". The main observational unit is the GP practice. Poisson distribution of referrals is assumed. The evaluation of secondary outcomes like acceptance, enablers and barriers uses a mixed-methods design with questionnaires and interviews. DISCUSSION Due to the heterogeneity of GP practice organization, patient management software, information technology service providers, GP personal technical affinity and training, we expect several challenges in implementing teledermatology in German GP routine care. Therefore, we plan to recruit 30% more GPs than required by the power calculation. The implementation design and accompanying evaluation is expected to deliver vital insights into the specifics of implementing telemedicine in German routine care. TRIAL REGISTRATION German Clinical Trials Register, DRKS00012944 . Registered prospectively on 31 August 2017.
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Affiliation(s)
- Roland Koch
- University Hospital Tübingen, Institute for General Practice and Interprofessional Care, Osianderstraße 5, 72076, Tübingen, Germany.
| | - Andreas Polanc
- University Hospital Tübingen, Institute for General Practice and Interprofessional Care, Osianderstraße 5, 72076, Tübingen, Germany
| | - Hannah Haumann
- University Hospital Tübingen, Institute for General Practice and Interprofessional Care, Osianderstraße 5, 72076, Tübingen, Germany
| | - Gudula Kirtschig
- University Hospital Tübingen, Institute for General Practice and Interprofessional Care, Osianderstraße 5, 72076, Tübingen, Germany.,AOK Baden-Württemberg Hauptverwaltung, Fachbereich Integriertes Leistungsmanagement, Presselstraße 19, 70191, Stuttgart, Germany
| | - Peter Martus
- University Hospital Tübingen, Institute for Clinical Epidemiology and Applied Biometry, Silcherstraße 5, 72076, Tübingen, Germany
| | - Christian Thies
- Reutlingen University, School of Informatics, Alteburgstraße 150, 72762, Reutlingen, Germany
| | - Leonie Sundmacher
- Ludwig-Maximilians-University München, Fachbereich Health Services Management, Schackstraße 4, 80539, Munich, Germany
| | - Carmen Gaa
- AOK Baden-Württemberg Hauptverwaltung, Fachbereich Integriertes Leistungsmanagement, Presselstraße 19, 70191, Stuttgart, Germany
| | - Leonard Witkamp
- Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.,KSYOS TeleMedisch Centrum, Bavinckhouse, Professor J.H. Bavincklaan 2-4, 1183 AT, Amstelveen, the Netherlands
| | | | - Stefanie Joos
- University Hospital Tübingen, Institute for General Practice and Interprofessional Care, Osianderstraße 5, 72076, Tübingen, Germany
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13
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Kirtschig G. Lichen Sclerosus-Presentation, Diagnosis and Management. Dtsch Arztebl Int 2018; 113:337-43. [PMID: 27232363 DOI: 10.3238/arztebl.2016.0337] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 02/15/2016] [Accepted: 02/15/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lichen sclerosus is a chronic inflammatory skin disease. It is thought to be underdiagnosed and undertreated. If it is not treated, lichen sclerosus is associated with a greater degree of scarring and an elevated risk of cancer in the genital area. METHODS This review is based on pertinent articles published up to October 2015 that were retrieved by a selective search in PubMed, Embase, and the Cochrane Library and on the European S3 guideline for lichen sclerosus. RESULTS Lichen sclerosus is mainly found in the anogenital area but can also be generalized. Extragenital involvement is reportedly present in 6% to 20% of patients. Neighboring mucous membranes, such as the vaginal or oral mucosa, are not typically affected. The disease is more common in women than in men, and occurs more often in adults than in children. About 10% of patients have other family members with the same condition. Anogenital lichen sclerosus often causes itching and pain. Functional impairment due to fissures and scars can arise over the course of the condition. The treatment of first choice is the local application of high-potency corticosteroids as early as possible (1/A). For boys and men in whom the condition does not remit after steroid treatment, circumcision is indicated (3/D). CONCLUSION Anogenital itching and clinical features such as erythema, white skin changes (such as hyperkeratosis and sclerosis), and fissures should arouse suspicion of lichen sclerosus. The diagnosis should be confirmed with a skin biopsy, and early, thorough treatment should be initiated. In this way, a mutilating disease course can be averted, and the risk of cancer can be lessened.
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Affiliation(s)
- Gudula Kirtschig
- Department of General Medicine and Interprofessional Care, University Hospital Tübingen
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14
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Abstract
Lichen sclerosus is a chronic, inflammatory dermatosis that usually affects the anogenital area. Early diagnosis and subsequent long-term anti-inflammatory treatment may reduce symptoms and signs and the risk of a mutilating course and the development of carcinomas.
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Affiliation(s)
- G Kirtschig
- Hautklinik, Universitätsklinikum Marburg & Gießen, Standort Marburg, Baldingerstraße, 35043, Marburg, Deutschland.
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15
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Mason JM, Chalmers JR, Godec T, Nunn AJ, Kirtschig G, Wojnarowska F, Childs M, Whitham D, Schmidt E, Harman K, Walton S, Chapman A, Williams HC. Doxycycline compared with prednisolone therapy for patients with bullous pemphigoid: cost-effectiveness analysis of the BLISTER trial. Br J Dermatol 2018; 178:415-423. [PMID: 28940316 DOI: 10.1111/bjd.16006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder associated with significant morbidity and mortality. Doxycycline and prednisolone to treat bullous pemphigoid were compared within a randomized controlled trial (RCT). OBJECTIVES To compare the cost-effectiveness of doxycycline-initiated and prednisolone-initiated treatment for patients with BP. METHODS Quality-of-life (EuroQoL-5D-3L) and resource data were collected as part of the BLISTER trial: a multicentre, parallel-group, investigator-blinded RCT. Within-trial analysis was performed using 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, there was no robust difference in costs or QALYs per patient at 1 year comparing doxycycline- with prednisolone-initiated therapy [net cost £959, 95% confidence interval (CI) -£24 to £1941; net QALYs -0·024, 95% CI -0·088 to 0·041]. However, the findings varied by baseline blister severity. For patients with mild or moderate blistering (≤ 30 blisters) net costs and outcomes were similar. For patients with severe blistering (> 30 blisters) net costs were higher (£2558, 95% CI -£82 to £5198) and quality of life poorer (-0·090 QALYs, 95% CI -0·22 to 0·042) for patients starting on doxycycline. The probability that doxycycline would be cost-effective for those with severe pemphigoid was 1·5% at a willingness to pay of £20 000 per QALY. CONCLUSIONS Consistently with the clinical findings of the BLISTER trial, patients with mild or moderate blistering should receive treatment guided by the safety and effectiveness of the drugs and patient preference - neither strategy is clearly a preferred use of National Health Service resources. However, prednisolone-initiated treatment may be more cost-effective for patients with severe blistering.
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Affiliation(s)
- J M Mason
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, U.K
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - T Godec
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - A J Nunn
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7BN, U.K
| | - M Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - D Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - K Harman
- Dermatology Department, Leicester Royal Infirmary, University Hospitals Leicester, Leicester, LE1 5WW, U.K
| | - S Walton
- Castle Hill Hospital, Castle Road, Cottingham, Hull, HU16 5JQ, U.K
| | - A Chapman
- Queen Elizabeth Hospital, Greenwich, London, SE18 4QH, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
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16
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Tio D, Kirtschig G, Hoekzema R, van Montfrans C. Lymphoedema in patients with lentigo maligna treated with imiquimod: a long-term adverse effect. Br J Dermatol 2017; 178:1441-1442. [PMID: 29274234 DOI: 10.1111/bjd.16267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D Tio
- Vrije Universiteit Medical Center, Amsterdam, the Netherlands
| | - G Kirtschig
- University Hospital of Marburg, Marburg, Germany
| | - R Hoekzema
- Vrije Universiteit Medical Center, Amsterdam, the Netherlands
| | - C van Montfrans
- Erasmus Universiteit Medical Center, Rotterdam, the Netherlands
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17
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Batchelor JM, Chapman A, Craig FE, Harman KE, Kirtschig G, Martin-Clavijo A, Ormerod AD, Walton S, Williams HC. 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. Br J Dermatol 2017; 177:e228-e234. [PMID: 29124728 DOI: 10.1111/bjd.15959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2017] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- J M Batchelor
- Centre of Evidence Based Dermatology, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
| | - A Chapman
- Department of Dermatology, Lewisham and Greenwich NHS Trust, London, U.K
| | - F E Craig
- Division of Applied Medicine, Aberdeen University, Aberdeen, U.K
| | - K E Harman
- Department of Dermatology, University Hospitals Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, U.K
| | - G Kirtschig
- Institute of General Practice and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - A Martin-Clavijo
- Department of Dermatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, U.K
| | - A D Ormerod
- Division of Applied Medicine, Aberdeen University, Aberdeen, U.K
| | - S Walton
- Department of Dermatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
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18
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Chalmers JR, Wojnarowska F, Kirtschig G, Mason J, Childs M, Whitham D, Harman K, Chapman A, Walton S, Schmidt E, Godec TR, Nunn AJ, Williams HC. A randomised controlled trial to compare the safety, effectiveness and cost-effectiveness of doxycycline (200 mg/day) with that of oral prednisolone (0.5 mg/kg/day) for initial treatment of bullous pemphigoid: the Bullous Pemphigoid Steroids and Tetracyclines (BLISTER) trial. Health Technol Assess 2017; 21:1-90. [PMID: 28406394 DOI: 10.3310/hta21100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder with increased morbidity and mortality in the elderly. OBJECTIVES To evaluate the effectiveness, safety and cost-effectiveness of a strategy of initiating BP treatment with oral doxycycline or oral prednisolone. We hypothesised that starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral prednisolone. DESIGN Pragmatic multicentre two-armed parallel-group randomised controlled trial with an economic evaluation. SETTING A total of 54 dermatology secondary care centres in the UK and seven in Germany. PARTICIPANTS Adults with BP [three or more blisters at two sites and positive direct and/or indirect immunofluorescence (immunoglobulin G and/or complement component 3 immunofluorescence at the dermal-epidermal junction)] and able to give informed consent. INTERVENTIONS Participants were allocated using online randomisation to initial doxycycline treatment (200 mg/day) or prednisolone (0.5 mg/kg/day). Up to 30 g/week of potent topical corticosteroids was permitted for weeks 1-3. After 6 weeks, clinicians could switch treatments or alter the prednisolone dose as per normal practice. MAIN OUTCOME MEASURES Primary outcomes: (1) the proportion of participants with three or fewer blisters at 6 weeks (investigator blinded) and (2) the proportion with severe, life-threatening and fatal treatment-related events at 52 weeks. A regression model was used in the analysis adjusting for baseline disease severity, age and Karnofsky score, with missing data imputed. Secondary outcomes included the effectiveness of blister control after 6 weeks, relapses, related adverse events and quality of life. The economic evaluation involved bivariate regression of costs and quality-adjusted life-years (QALYs) from a NHS perspective. RESULTS In total, 132 patients were randomised to doxycycline and 121 to prednisolone. The mean patient age was 77.7 years and baseline severity was as follows: mild 31.6% (three to nine blisters), moderate 39.1% (10-30 blisters) and severe 29.3% (> 30 blisters). For those starting on doxycycline, 83 out of 112 (74.1%) had three or fewer blisters at 6 weeks, whereas for those starting on prednisolone 92 out of 101 (91.1%) had three or fewer blisters at 6 weeks, an adjusted difference of 18.6% in favour of prednisolone [90% confidence interval (CI) 11.1% to 26.1%], using a modified intention-to-treat (mITT) analysis. Per-protocol analysis showed similar results: 74.4% compared with 92.3%, an adjusted difference of 18.7% (90% CI 9.8% to 27.6%). The rate of related severe, life-threatening and fatal events at 52 weeks was 18.2% for those started on doxycycline and 36.6% for those started on prednisolone (mITT analysis), an adjusted difference of 19.0% (95% CI 7.9% to 30.1%; p = 0.001) in favour of doxycycline. Secondary outcomes showed consistent findings. There was no significant difference in costs or QALYs per patient at 1 year between doxycycline-initiated therapy and prednisolone-initiated therapy (incremental cost of doxycycline-initiated therapy £959, 95% CI -£24 to £1941; incremental QALYs of doxycycline-initiated therapy -0.024, 95% CI -0.088 to 0.041). Using a willingness-to-pay criterion of < £20,000 per QALY gained, the net monetary benefit associated with doxycycline-initiated therapy was negative but imprecise (-£1432, 95% CI -£3094 to £230). CONCLUSIONS A strategy of starting BP patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control and considerably safer in the long term. The limitations of the trial were the wide non-inferiority margin, the moderate dropout rate and that serious adverse event collection was unblinded. Future work might include inducing remission with topical or oral corticosteroids and then randomising to doxycycline or prednisolone for maintenance. TRIAL REGISTRATION Current Controlled Trials ISRCTN13704604. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Gudula Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - James Mason
- Durham University, School of Medicine, Pharmacy and Health, Stockton-on-Tees, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Karen Harman
- University Hospitals Leicester, Dermatology Department, Leicester Royal Infirmary, Leicester, UK
| | | | | | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Thomas R Godec
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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19
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Williams HC, Chalmers JR, Nunn AJ, Kirtschig G, Schmidt E. The BLISTER study: possible overestimation of tetracycline efficacy - Authors' reply. Lancet 2017; 390:735-736. [PMID: 28831990 DOI: 10.1016/s0140-6736(17)31790-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/12/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham NG7 2NR, UK.
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham NG7 2NR, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Gudula Kirtschig
- Institute of General Medicine and Interprofessional Care, University of Tübingen, Tübingen, Germany; Centre of Evidence Based Dermatology, University of Nottingham, Nottingham NG7 2NR, UK
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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20
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Albrecht J, Kirtschig G, Matin RN, Samimi M, Batchelor JM. Positive about negative: no need for a pink cloud of fluff and justifications. Br J Dermatol 2017; 177:1-3. [PMID: 28731247 DOI: 10.1111/bjd.15644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J Albrecht
- Division of Dermatology, Department of Medicine, J.H. Stroger Jr Hospital of Cook County, 1900 West Polk Street, Chicago, IL, 60612, U.S.A.,Department of Dermatology, Rush University Medical Center, 1900 West Polk Street, Chicago, IL, 60612, U.S.A
| | - G Kirtschig
- Department of Dermatology, University Hospital Gießen & Marburg GmbH, Baldingerstraße, Marburg, 35043, Germany
| | - R N Matin
- Department of Dermatology, Churchill Hospital, Oxford, OX3 7LE, U.K
| | - M Samimi
- Department of Dermatology, University Hospital of Tours, University Francois Rabelais, Tours, France.,ISP 1282 INRA-University of Tours, Tours, France
| | - J M Batchelor
- Centre of Evidence Based Dermatology, King's Meadow Campus, Lenton Lane, Nottingham, NG7 2NR, U.K
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21
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Williams HC, Wojnarowska F, Kirtschig G, Mason J, Godec TR, Schmidt E, Chalmers JR, Childs M, Walton S, Harman K, Chapman A, Whitham D, Nunn AJ. Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic, non-inferiority, randomised controlled trial. Lancet 2017; 389:1630-1638. [PMID: 28279484 PMCID: PMC5400809 DOI: 10.1016/s0140-6736(17)30560-3] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 11/07/2016] [Accepted: 11/22/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Bullous pemphigoid is a blistering skin disorder with increased mortality. We tested whether a strategy of starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral corticosteroids. METHODS We did a pragmatic, multicentre, parallel-group randomised controlled trial of adults with bullous pemphigoid (three or more blisters at two or more sites and linear basement membrane IgG or C3). Participants were randomly assigned to doxycycline (200 mg per day) or prednisolone (0·5 mg/kg per day) using random permuted blocks of randomly varying size, and stratified by baseline severity (3-9, 10-30, and >30 blisters for mild, moderate, and severe disease, respectively). Localised adjuvant potent topical corticosteroids (<30 g per week) were permitted during weeks 1-3. The non-inferiority primary effectiveness outcome was the proportion of participants with three or fewer blisters at 6 weeks. We assumed that doxycycline would be 25% less effective than corticosteroids with a 37% acceptable margin of non-inferiority. The primary safety outcome was the proportion with severe, life-threatening, or fatal (grade 3-5) treatment-related adverse events by 52 weeks. Analysis (modified intention to treat [mITT] for the superiority safety analysis and mITT and per protocol for non-inferiority effectiveness analysis) used a regression model adjusting for baseline disease severity, age, and Karnofsky score, with missing data imputed. The trial is registered at ISRCTN, number ISRCTN13704604. FINDINGS Between March 1, 2009, and Oct 31, 2013, 132 patients were randomly assigned to doxycycline and 121 to prednisolone from 54 UK and seven German dermatology centres. Mean age was 77·7 years (SD 9·7) and 173 (68%) of 253 patients had moderate-to-severe baseline disease. For those starting doxycycline, 83 (74%) of 112 patients had three or fewer blisters at 6 weeks compared with 92 (91%) of 101 patients on prednisolone, an adjusted difference of 18·6% (90% CI 11·1-26·1) favouring prednisolone (upper limit of 90% CI, 26·1%, within the predefined 37% margin). Related severe, life-threatening, and fatal events at 52 weeks were 18% (22 of 121) for those starting doxycycline and 36% (41 of 113) for prednisolone (mITT), an adjusted difference of 19·0% (95% CI 7·9-30·1), p=0·001. INTERPRETATION Starting patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control in bullous pemphigoid and significantly safer in the long-term. FUNDING NIHR Health Technology Assessment Programme.
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Affiliation(s)
- Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.
| | | | - Gudula Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK; Institute of General Medicine and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Thomas R Godec
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | | | - Karen Harman
- Dermatology Department, Leicester Royal Infirmary, Leicester, UK
| | - Anna Chapman
- Dermatology Department, Queen Elizabeth Hospital, Greenwich, London, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at University College London, London, UK
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22
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Chi CC, Kirtschig G, Aberer W, Gabbud JP, Lipozenčić J, Kárpáti S, Haustein UF, Wojnarowska F, Zuberbier T. Updated evidence-based (S2e) European Dermatology Forum guideline on topical corticosteroids in pregnancy. J Eur Acad Dermatol Venereol 2017; 31:761-773. [DOI: 10.1111/jdv.14101] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 12/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- C.-C. Chi
- Department of Dermatology; Chang Gung Memorial Hospital; Linkou and College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - G. Kirtschig
- Department of Dermatology; University of Marburg; Marburg Germany
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - J.-P. Gabbud
- Dermatologist, retired from private practice; Bern Switzerland
| | - J. Lipozenčić
- Department of Dermatology and Venereology; Zagreb University Hospital Center and School of Medicine; Zagreb Croatia
| | - S. Kárpáti
- Department of Dermatology, Venereology and Dermato-oncology; Semmelweis University; Budapest Hungary
| | - U.-F. Haustein
- Department of Dermatology, Venerology and Allergology; University of Leipzig; Leipzig Germany
| | - F. Wojnarowska
- Nuffield Department of Clinical Medicine; University of Oxford; Oxford UK
| | - T. Zuberbier
- Allergy-Centre-Charité; Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
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van der Meijden WI, Boffa MJ, Ter Harmsel WA, Kirtschig G, Lewis FM, Moyal-Barracco M, Tiplica GS, Sherrard J. 2016 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol 2017; 31:925-941. [PMID: 28164373 DOI: 10.1111/jdv.14096] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 12/14/2016] [Indexed: 12/21/2022]
Abstract
Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).
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Affiliation(s)
| | - M J Boffa
- Department of Dermatology, Sir Paul Boffa Hospital, Floriana, Malta
| | - W A Ter Harmsel
- Department of Gynaecology, Roosevelt kliniek, Leiden, The Netherlands
| | - G Kirtschig
- University Hospital of Tübingen, Tübingen, Germany
| | - F M Lewis
- St John's Institute of Dermatology, Guy's and St Thomas' Hospital, London and Frimley Health NHS Trust, London, UK
| | - M Moyal-Barracco
- Department of Dermatology, Tarnier-Cochin Hospital, Paris, France
| | - G S Tiplica
- Dermatology 2, Colentina Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - J Sherrard
- Department of Sexual Health, Churchill Hospital, Oxford, UK
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Kirtschig G. In Reply. Dtsch Arztebl Int 2017; 114:24. [PMID: 28447932 PMCID: PMC5400005 DOI: 10.3238/arztebl.2017.024b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Gudula Kirtschig
- *Institute for General Medicine and Interprofessional Care Faculty of Medicine, University of Tübingen,
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Affiliation(s)
- Ching-Chi Chi
- Department of Dermatology and Centre for Evidence-Based Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Shu-Hui Wang
- Department of Dermatology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Gudula Kirtschig
- Institute of General Medicine and Interprofessional Care, University of Tübingen, Tübingen, Germany
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Kirtschig G, Becker K, Günthert A, Jasaitiene D, Cooper SM, Chi CC, Kreuter A, Rall KK, Aberer W, Riechardt S, Casabona F, Powell J, Brackenbury FA, Erdmann R, Lazzeri M, Barbagli G, Wojnarowska F. Response to Letter by Prof. C.B.B. Bunker. J Eur Acad Dermatol Venereol 2016; 31:e104-e105. [PMID: 27401731 DOI: 10.1111/jdv.13821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/18/2016] [Indexed: 11/30/2022]
Affiliation(s)
- G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.,Institute of General Medicine and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - K Becker
- Office for Paediatric surgery, Bonn, Germany
| | - A Günthert
- Deptartment of Obstetrics and Gynecology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - D Jasaitiene
- Department of Skin and Venereal Diseases, Republican Hospital of Panevezys, Panevezys, Lithuania
| | - S M Cooper
- Department of Dermatology, Oxford University Hospitals NHS Trust and University of Oxford, Oxford, UK
| | - C-C Chi
- Department of Dermatology, Chang Gung Memorial Hospital, Chiayi, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - A Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, University Witten/Herdecke, Oberhausen, Germany
| | - K K Rall
- Department of Gynaecology, Universitäts-Frauenklinik, Tübingen, Germany
| | - W Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - S Riechardt
- Departments of Urology and paediatric Urology, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - F Casabona
- S. C. Chirurgia Plastica, Chirurgia Plastica Rigenerativa, Ospedale Andrea Gallino, Genova-Pontedecimo, Italy
| | - J Powell
- Department of Dermatology, Hampshire Hospitals foundation Trust, Basingstoke, UK
| | | | - R Erdmann
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Lazzeri
- Department of Urology, Istituto Clinico Humanitas IRCCS Clinical and Research Hospital, Rozzano Milano, Italy
| | - G Barbagli
- Centre for Reconstructive Urethral Surgery, Arezzo, Italy
| | - F Wojnarowska
- Department of Dermatology, Oxford University Hospitals NHS Trust and University of Oxford, Oxford, UK
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27
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Kirtschig G, Cooper S, Aberer W, Günthert A, Becker K, Jasaitiene D, Chi CC, Kreuter A, Rall K, Riechardt S, Casabona F, Powell J, Brackenbury F, Erdmann R, Lazzeri M, Barbagli G, Wojnarowska F. Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus. J Eur Acad Dermatol Venereol 2016; 31:e81-e83. [DOI: 10.1111/jdv.13740] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - S. Cooper
- Department of Dermatology; Oxford University Hospitals NHS Trust and University of Oxford; Oxford UK
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - A. Günthert
- Department of Obstetrics and Gynecology; Cantonal Hospital of Lucerne; Lucerne Switzerland
| | - K. Becker
- Office for Paediatric surgery; Bonn Germany
| | - D. Jasaitiene
- Department of Skin and Venereal Diseases of Republican Hospital of Panevezys; Panevezys Lithuania
| | - C.-C. Chi
- Dermatology Department; Chang Gung Memorial Hospital; Chiayi, and College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - A. Kreuter
- Department of Dermatology, Venereology, and Allergology; HELIOS St. Elisabeth Hospital Oberhausen; Oberhausen Germany
| | - K. Rall
- Katharina Department of Gynaecology; Universitäts-Frauenklinik; Tübingen Germany
| | - S. Riechardt
- Department of Urology and paediatric Urology; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - F. Casabona
- Dirigente Medico; S. C. Chirurgia Plastica; Chirurgia Plastica Rigenerativa; Ospedale Andrea Gallino; Via Andrea Gallino; Genova-Pontedecimo Italy
| | - J. Powell
- Department of Dermatology; Hampshire Hospitals foundation Trust; Basingstoke UK
| | | | - R. Erdmann
- Klinik für Dermatologie; Venereologie und Allergologie; Campus Charité Mitte; Division of Evidence Based Medicine; Berlin Germany
| | - M. Lazzeri
- Center for Reconstructive Urethral Surgery; Via dei Lecci, 22, 52100 Arezzo Italy
| | - G. Barbagli
- Center for Reconstructive Urethral Surgery; Via dei Lecci, 22, 52100 Arezzo Italy
| | - F. Wojnarowska
- Nuffield Department of Clinical Medicine; John Radcliffe Hospital; University of Oxford; Oxford UK
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Meijer JM, Jonkman MF, Wojnarowska F, Wiliams HC, Kirtschig G. Current practice in treatment approach for bullous pemphigoid: comparison between national surveys from the Netherlands and the UK. Clin Exp Dermatol 2016; 41:506-9. [PMID: 26940484 DOI: 10.1111/ced.12831] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 11/30/2022]
Abstract
Treatment approaches for bullous pemphigoid (BP), the most common autoimmune skin blistering disease, are largely based on national and international guidelines. We conducted a national survey among dermatologists in the Netherlands to explore the current treatment of BP, and compared the results with those of a previously published survey from the UK. Almost all responders in the Netherlands (n = 175) used very potent topical corticosteroids, both as monotherapy and as adjunctive therapy. In contrast to UK dermatologists, the majority recommended whole-body application rather than local application to lesions. Systemic antibiotics were used by > 70% of responders. Half of the responders in the Netherlands considered systemic steroids the first-choice treatment, with the majority also using adjunctive therapy as a routine. Despite many similarities in treatment approach between the two countries, these surveys provide an important insight into the gap between actual and recommended practice at a country level in relation to the best external evidence.
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Affiliation(s)
- J M Meijer
- Department of Dermatology, Center for Skin Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - M F Jonkman
- Department of Dermatology, Center for Skin Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - H C Wiliams
- Center of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - G Kirtschig
- Institute of General Practice and Professional Care, University Hospital Tübingen, Tübingen, Germany
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Abstract
BACKGROUND Topical corticosteroids are the most frequently prescribed dermatological treatment and are often used by pregnant women with skin conditions. However, little is known about their safety in pregnancy. OBJECTIVES To assess the effects of topical corticosteroids on pregnancy outcomes in pregnant women. SEARCH METHODS This is an update of a review previously published in 2009. We updated our searches of the following databases to July 2015: the Cochrane Skin Group Specialised Register, the Cochrane Pregnancy and Childbirth Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 6), MEDLINE, EMBASE, and LILACS. We also searched five trials registers and checked the reference lists of included studies, published reviews, articles that had cited the included studies, and one author's literature collection, for further references to relevant RCTs. SELECTION CRITERIA Randomised controlled trials and cohort studies of topical corticosteroids in pregnant women, as well as case-control studies comparing maternal exposure to topical corticosteroids between cases and controls when studies reported pre-specified outcomes. The primary outcomes included mode of delivery, major congenital abnormality, birth weight, and preterm delivery (delivery before 37 completed weeks gestation); the secondary outcomes included foetal death, minor congenital abnormality, and low Apgar score (less than seven at 5 min). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two authors independently applied selection criteria, extracted data, and assessed the quality of the included studies. A third author was available for resolving differences of opinion. A further author independently extracted data from included studies that were conducted by authors of this systematic review. MAIN RESULTS We included 7 new observational studies in this update, bringing the total number to 14, including 5 cohort and 9 case-control studies, with 1,601,515 study subjects.Most studies found no causal associations between maternal exposure to topical corticosteroids of any potency and pregnancy outcomes when compared with no exposure. These outcomes included: mode of delivery (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.95 to 1.15, 1 cohort study, n = 9904, low quality evidence); congenital abnormalities, including orofacial cleft or cleft palate and hypospadias (where the urethral opening is on the underside of the penis) (RR 0.82, 95% CI 0.34 to 1.96, 2 cohort studies, n = 9512, low quality evidence; and odds ratio (OR) 1.07, 95% CI 0.71 to 1.60, 1 case-control study, n = 56,557); low birth weight (RR 1.08, 95% CI 0.86 to 1.36; n = 59,419, 4 cohort studies; very low quality evidence); preterm delivery (RR 0.93, 95% CI 0.81 to 1.08, 4 cohort studies, n = 59,419, low quality evidence); foetal death (RR 1.02, 95% CI 0.60 to 1.73, 4 cohort studies, n = 63,885, very low quality evidence); and low Apgar score (RR 0.84, 95% CI 0.54 to 1.31, 1 cohort study, n = 9220, low quality evidence).We conducted stratified analyses of mild or moderate potency, and potent or very potent topical corticosteroids, but we found no causal associations between maternal exposure to topical corticosteroid of any potency and congenital abnormality, orofacial clefts, preterm delivery, or low Apgar score. For low birth weight, although the meta-analysis based on study-level data was not significant for either mild to moderate corticosteroids (pooled RR 0.90, 95% CI 0.74 to 1.09, 3 cohort studies, n > 55,713) or potent to very potent corticosteroids (pooled RR 1.58, 95% CI 0.96 to 2.58, 4 cohort studies, n > 47,651), there were significant differences between the two subgroups (P = 0.04). The results from three of the individual studies in the meta-analysis indicated an increased risk of low birth weight in women who received potent to very potent topical corticosteroids. Maternal use of mild to moderate potency topical steroids was associated with a decreased risk of foetal death (pooled RR 0.70, 95% CI 0.64 to 0.77, 2 studies, n = 48,749; low quality evidence), but we did not observe this effect when potent to very potent topical corticosteroids were given during pregnancy (pooled RR 1.14, 95% CI 0.69 to 1.88, 3 studies, n = 37,086, low quality evidence).We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group approach to rate the overall quality of the evidence. Data from observational studies started at low quality. We further downgraded the evidence because of imprecision in low birth weight and inconsistency in foetal death. Lower quality evidence resulted in lower confidence in the estimate of effect for those outcomes. AUTHORS' CONCLUSIONS This update adds more evidence showing no causal associations between maternal exposure to topical corticosteroids of all potencies and pregnancy outcomes including mode of delivery, congenital abnormalities, preterm delivery, foetal death, and low Apgar score, which is consistent with the previous version of this review. This update provides stratified analyses based on steroid potency; we found no association between maternal use of topical corticosteroids of any potency and an increase in adverse pregnancy outcomes, including mode of delivery, congenital abnormality, preterm delivery, foetal death, and low Apgar score. Similar to the previous version of the review, this update identified a probable association between low birth weight and maternal use of potent to very potent topical corticosteroids, especially when the cumulative dosage of topical corticosteroids throughout the pregnancy is very large, which warrants further investigation. The finding of a possible protective effect of mild to moderate topical corticosteroids on foetal death could also be examined.
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Affiliation(s)
- Ching‐Chi Chi
- Chang Gung Memorial HospitalDepartment of Dermatology and Centre for Evidence‐Based Medicine6, Sec West, Chia‐Pu RoadPuzihChiayiTaiwan61363
- Chang Gung UniversityCollege of MedicineTaoyuanTaiwan
| | - Shu‐Hui Wang
- Far Eastern Memorial HospitalDepartment of Dermatology21, Sec 2, Nanya S RdBanciao DistrictNew Taipei CityTaiwan220
| | | | - Gudula Kirtschig
- University of TübingenInstitute of General Medicine and Interprofessional CareTübingenGermany
| | - Emily Davies
- Amersham Hospital, Buckinghamshire Healthcare NHS TrustDepartment of Dermatology100 Gilbert Scott CourtWhielden StreetAmershamBuckinghamshireUKHP7 0JD
| | - Cathy Bennett
- Coventry UniversityCentre for Technology Enabled Health Research (CTEHR)Priory StreetCoventryUKCV1 5FB
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Kirtschig G, Becker K, Günthert A, Jasaitiene D, Cooper S, Chi CC, Kreuter A, Rall KK, Aberer W, Riechardt S, Casabona F, Powell J, Brackenbury F, Erdmann R, Lazzeri M, Barbagli G, Wojnarowska F. Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus. J Eur Acad Dermatol Venereol 2015. [PMID: 26202852 DOI: 10.1111/jdv.13136] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.
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Affiliation(s)
- G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.,Institute of General Practice and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - K Becker
- (representing the Deutsche Gesellschaft für Kinderchirurgie), Office for Paediatric surgery, Bonn, Germany
| | - A Günthert
- (representing the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG), Deptartment of Obstetrics and Gynecology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - D Jasaitiene
- (representing the Lithuanian Association of Dermatovenereologists), Department of Skin and Venereal Diseases of Republican Hospital of Panevezys, Panevezys, Lithuania
| | - S Cooper
- Department of Dermatology, Oxford University Hospitals NHS Trust and University of Oxford, Oxford, UK
| | - C-C Chi
- Department of Dermatology, Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - A Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
| | - K K Rall
- Research Centre and Department for Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - W Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - S Riechardt
- (representing the Deutsche Gesellschaft für Urologie), Department of Urology and paediatric Urology, University of Hamburg, Hamburg, Germany
| | - F Casabona
- Dirigente Medico, S. C. Chirurgia Plastica, Chirurgia Plastica Rigenerativa, Ospedale Andrea Gallino, Genova-Pontedecimo, Italy
| | - J Powell
- Department of Dermatology, Hampshire Hospitals foundation Trust, Hampshire, UK
| | - F Brackenbury
- (patient representative) www.lichensclerosus.org, Association for Lichen Sclerosus and Vulval Health, Oxford, UK
| | - R Erdmann
- (development of the search strategy and performance of the literature search), Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence Based Medicine, Charite - Universitätsmedizin Berlin, Berlin, Germany
| | - M Lazzeri
- Centro Chirurgico Toscano, Arezzo, Italy
| | - G Barbagli
- Centro Chirurgico Toscano, Arezzo, Italy
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
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Chalmers JR, Wojnarowska F, Kirtschig G, Nunn AJ, Bratton DJ, Mason J, Foster KA, Whitham D, Williams HC. A randomized controlled trial to compare the safety and effectiveness of doxycycline (200 mg daily) with oral prednisolone (0.5 mg kg(-1) daily) for initial treatment of bullous pemphigoid: a protocol for the Bullous Pemphigoid Steroids and Tetracyclines (BLISTER) Trial. Br J Dermatol 2015; 173:227-34. [PMID: 25683592 DOI: 10.1111/bjd.13729] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease in older people, and is associated with significant morbidity and mortality. Oral corticosteroids are usually effective but the side-effects are thought to contribute to the high morbidity and mortality rate. Treatment with oral tetracyclines may be effective but high-quality, randomized controlled trials (RCTs) are needed to confirm this. OBJECTIVES To compare the effectiveness and safety of two strategies for treating BP. METHODS This is a two-arm, parallel group, 52-week RCT comparing doxycycline with prednisolone for initial treatment of BP. Dose is fixed for the initial 6 weeks of treatment (doxycycline 200 mg daily; prednisolone 0.5 mg kg(-1) daily), after which it can be adjusted according to need. A total of 256 patients with BP will be recruited in the U.K. and Germany. RESULTS The primary outcomes are: (i) effectiveness (assessor-blinded blister count at 6 weeks) and (ii) safety [proportion of patients experiencing ≥ grade 3 adverse events (i.e. severe, life: threatening or fatal) related to trial medication during the year of follow-up]. Primary effectiveness analysis will be an assessment of whether doxycycline can be considered noninferior to prednisolone after 6 weeks of treatment. Primary safety analysis is a superiority analysis at 12 months. Secondary outcomes include longer-term assessment of effectiveness, relapse rates, the proportion of patients experiencing any grade of adverse events related to treatment, quality of life and cost-effectiveness. CONCLUSIONS The trial will provide good evidence for whether the strategy of starting BP treatment with doxycycline is a useful alternative to prednisolone.
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Affiliation(s)
- J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus Lenton Lane, Nottingham, NG7 2NR, U.K
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, Oxford University, Oxford, OX3 7BN, U.K
| | - G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus Lenton Lane, Nottingham, NG7 2NR, U.K
| | - A J Nunn
- Medical Research Council Clinical Trials Unit, Aviation House 125 Kingsway, London, WC2B 6NH, U.K
| | - D J Bratton
- Medical Research Council Clinical Trials Unit, Aviation House 125 Kingsway, London, WC2B 6NH, U.K
| | - J Mason
- School for Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Stockton on Tees, TS17 6BH, U.K
| | - K A Foster
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, C Floor South Block, Nottingham, U.K
| | - D Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, C Floor South Block, Nottingham, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus Lenton Lane, Nottingham, NG7 2NR, U.K.,Dermatology Department, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, U.K
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Kirtschig G, van Meurs T, van Doorn R. Twelve-week treatment of lentigo maligna with imiquimod results in a high and sustained clearance rate. Acta Derm Venereol 2015; 95:83-5. [PMID: 24696093 DOI: 10.2340/00015555-1861] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Topical imiquimod cream is increasingly applied in the treatment of lentigo maligna (LM), in particular for large lesions where surgery may lead to disfiguring scars. Published studies suggest that more frequent and prolonged treatment with topical imiquimod is associated with higher efficacy. In this study we prospectively treated 27 patients suffering from LM on the face with imiquimod 5% cream using an intensive treatment regimen consisting of daily applications for 12 weeks inducing skin inflammation for at least 10 weeks. Twenty-four patients completed the treatment as recommended, 23 were available for follow-up (mean 39 months). Clinical and histo-pathological clearance was observed in 20 patients after a mean of 14 weeks of treatment. Notably, histopathological examination of a skin biopsy showed clearance of the LM in all 24 patients, including those who still showed some hyperpigmentation at 4 weeks off treatment. A clinical recurrence occurred in only 1 of the 23 patients available at follow-up. These findings suggest that the efficacy of imiquimod can be improved by implementing a more intensive treatment regimen. Randomized controlled trials are needed to confirm our results and establish the role of topical imiquimod in the treatment of LM.
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Affiliation(s)
- Gudula Kirtschig
- Centre of Evidence-Based Dermatology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
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Taghipour K, Mohd Mustapa MF, Highet AS, Venning VA, Kirtschig G. The approach of dermatologists in the UK to the treatment of bullous pemphigoid: results of a national survey. Clin Exp Dermatol 2013; 38:311-3. [PMID: 23517364 DOI: 10.1111/ced.12042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2012] [Indexed: 11/30/2022]
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Venning V, Taghipour K, Mohd Mustapa M, Highet A, Kirtschig G, Hughes J, McLelland J, McDonagh A, Punjabi S, Buckley D, Nasr I, Swale V, Duarte Williams C, McHenry P, Wagle S, Amin S, Davis R, Haveron S. British Association of Dermatologists’ guidelines for the management of bullous pemphigoid 2012. Br J Dermatol 2012; 167:1200-14. [DOI: 10.1111/bjd.12072] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- V.A. Venning
- Department of Dermatology, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, U.K
| | - K. Taghipour
- Department of Dermatology, Whittington Hospital, Magdala Avenue, London N19 5NF, U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London W1T 5HQ, U.K
| | - A.S. Highet
- York Hospital, Wigginton Road, York YO31 8HE, U.K
| | - G. Kirtschig
- Vrije Universtiteit, PO Box 7057, Amsterdam NL‐1007 MB, the Netherlands
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van der Steen LP, Bakema JE, Sesarman A, Florea F, Tuk CW, Kirtschig G, Hage JJ, Sitaru C, van Egmond M. Blocking Fcα receptor I on granulocytes prevents tissue damage induced by IgA autoantibodies. J Immunol 2012; 189:1594-601. [PMID: 22802416 DOI: 10.4049/jimmunol.1101763] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IgA represents the most prominent Ab class at mucosal surfaces and the second most prevalent Ab in human blood after IgG. We recently demonstrated that cross-linking of the granulocyte IgA FcR (FcαRI) by IgA induces a chemotactic-driven positive-feedback migration loop, hereby amplifying recruitment of granulocytes to IgA deposits. Therefore, we postulated that aberrant IgA-Ag complexes, which can be found in tissues in IgA-mediated diseases, are responsible for tissue damage by inducing continuous granulocyte migration and activation. Using an IgA-dependent skin-blistering disease as a model system, we demonstrated colocalization of FcαRI-positive granulocyte infiltrates with IgA in cryosections of lesional skin of patients suffering from this disease. Furthermore, we showed granulocyte migration to IgA deposits injected in human skin explants and in murine skin of FcαRI transgenic mice in vivo. Importantly, ex vivo migration and tissue damage were inhibited by blocking FcαRI, indicating that these events are dependent on the interaction of IgA autoantibodies with FcαRI. Thus, interrupting the granulocyte migration loop by blocking FcαRI reduces tissue damage in diseases with aberrant IgA-immune complexes. As such, our results may lead to development of new therapies for IgA-mediated chronic inflammatory diseases, hereby decreasing severe morbidity and improving quality of life for these patients.
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Affiliation(s)
- Lydia P van der Steen
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, 1081 BT Amsterdam, The Netherlands
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Taghipour K, Kirtschig G, Palace J, Groves RW, Venning V, Wojnarowska F. The association of multiple sclerosis with bullous pemphigoid: is there a shared antigen response? J Am Acad Dermatol 2012; 67:160-1. [PMID: 22703914 DOI: 10.1016/j.jaad.2012.01.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Revised: 01/20/2012] [Accepted: 01/28/2012] [Indexed: 11/20/2022]
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Bratton DJ, Nunn AJ, Wojnarowska F, Kirtschig G, Sandell A, Williams HC. The value of the pragmatic-explanatory continuum indicator summary wheel in an ongoing study: the bullous pemphigoid steroids and tetracyclines study. Trials 2012; 13:50. [PMID: 22540678 PMCID: PMC3423061 DOI: 10.1186/1745-6215-13-50] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 04/27/2012] [Indexed: 11/25/2022] Open
Abstract
Background The Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) tool is intended to be used in the design phase of trials to help investigative teams design trials in-line with their purpose. Our team applied this tool to an ongoing trial (BLISTER) to determine whether the initial suggestion among some team members that the trial could be described as largely pragmatic was the consensus. Methods Each of the six members of the BLISTER trial team was sent a blank PRECIS wheel to independently complete. The results obtained were averaged and plotted on a single PRECIS wheel to illustrate the degree of pragmatism of the trial. Results The trial team found that the design of the trial was closest to the pragmatic end of the pragmatic-explanatory continuum. The strongest consensus was found on the ‘flexibility of the comparison intervention’ and ‘practitioner adherence’ domains (SD = 13). The trial team appeared to disagree most on the ‘eligibility criteria’ (SD = 35) and ‘participant compliance’ (SD = 31) domains, although the large standard deviations were a result of a single outlier in the two domains. Conclusion The PRECIS tool can be used to retrospectively determine the pragmatism of a trial provided enough expertise and information on the trial is available. Illustrating the design of a trial on the PRECIS wheel can help research users more easily identify studies of interest. We hope our recommendations for applying this useful tool will encourage others to consider using it when designing, conducting and reporting studies. Trial registration Current Controlled Trials http://www.controlled-trials.com/ISRCTN13704604
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Affiliation(s)
- Daniel J Bratton
- Centre of Evidence-Based Dermatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Chi CC, Kirtschig G, Baldo M, Lewis F, Wang SH, Wojnarowska F. Systematic review and meta-analysis of randomized controlled trials on topical interventions for genital lichen sclerosus. J Am Acad Dermatol 2012; 67:305-12. [PMID: 22483994 DOI: 10.1016/j.jaad.2012.02.044] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 02/02/2012] [Accepted: 02/09/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lichen sclerosus (LS) is a chronic inflammatory dermatosis that occurs mainly in the anogenital area and causes itching and soreness. Progressive destructive scarring may result in burying of the clitoris in females and phimosis in males. Affected people have an increased risk of genital cancers. OBJECTIVE We sought to assess the effects of topical interventions for genital LS. METHODS We undertook a systematic review and meta-analysis using the methodology of the Cochrane Collaboration. RESULTS We included 7 randomized controlled trials with a total of 249 participants covering 6 treatments. Clobetasol propionate 0.05% was better than placebo in treating genital LS (participant-rated improvement/remission of symptoms: risk ratio 2.85 [95% confidence interval {CI} 1.45-5.61]; investigator-rated global degree of improvement: standardized mean difference [SMD] 5.74 [95% CI 4.26-7.23]) as was mometasone furoate 0.05% (change in clinical grade of phimosis: SMD -1.04 [95% CI -1.77 to -0.31]). We found no evidence supporting the efficacy of topical androgens and progesterone. There were no differences between pimecrolimus and clobetasol propionate in relieving symptoms through change in pruritus (SMD -0.33 [95% CI -0.99 to 0.33]) and burning/pain (SMD 0.03 [95% CI -0.62 to 0.69]). However, pimecrolimus was less effective than clobetasol propionate in improving gross appearance (investigator-rated global degree of improvement: SMD -1.64 [95% CI -2.40 to -0.87]). LIMITATIONS Most of the included studies were small. CONCLUSIONS The current limited evidence supports the efficacy of clobetasol propionate, mometasone furoate, and pimecrolimus in treating genital LS. Further randomized controlled trials are needed.
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Affiliation(s)
- Ching-Chi Chi
- Department of Dermatology and Center for Evidence-Based Medicine, Chang Gung Memorial Hospital-Chiayi, Chang Gung University College of Medicine, Chiayi, Taiwan
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Abstract
BACKGROUND Erosive lichen planus (ELP) affecting mucosal surfaces is a chronic autoimmune disease of unknown aetiology. It is often more painful and debilitating than the non-erosive types of lichen planus. Treatment is difficult and aimed at palliation rather than cure. Several topical and systemic agents have been used with varying results. OBJECTIVES To assess the effects of interventions in the treatment of erosive lichen planus affecting the oral, anogenital, and oesophageal regions. SEARCH METHODS We searched the following databases up to September 2009: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched reference lists of articles and online trials registries for ongoing trials. SELECTION CRITERIA We considered all randomised controlled trials (RCTs) that evaluated the effectiveness of any topical or systemic interventions for ELP affecting either the mouth, genital region, or both areas, in participants of any age, gender, or race. DATA COLLECTION AND ANALYSIS The primary outcome measures were as follows:(a) Pain reduction using a visual analogue scale rated by participants; (b) Physician Global Assessment; and (c) Participant global self-assessment.Changes in scores at the end of therapy compared with baseline were analysed. MAIN RESULTS A total of 15 RCTs were identified, giving a total of 473 participants with ELP. All studies involved oral ELP only. Six of the 15 studies included participants with non-erosive lichen planus. In these studies, only the erosive subgroup was included for intended subgroup analysis. We were unable to pool data from any of the nine studies with only ELP participants or any of the six studies with the ELP subgroup, due to small numbers and the heterogeneity of the interventions, design methods, and outcome variables between studies. One small study involving 50 participants found that 0.025% clobetasol propionate administered as liquid microspheres significantly reduced pain compared to ointment (Mean difference (MD) -18.30, 95% confidence interval (CI) -28.57 to -8.03), but outcome data was only available in 45 participants. However, in another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (MD -1.40, 95% CI -1.86 to -0.94). Aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo in a study involving 45 ELP participants (Risk ratio (RR) 6.16, 95% CI 2.35 to 16.13). In a study involving 20 ELP participants, 1% pimecrolimus cream was 7 times more likely to result in a strong improvement as rated by the Physician Global Assessment when compared to vehicle cream (RR 7.00, 95% CI 1.04 to 46.95).There is no overwhelming evidence for the efficacy of a single treatment, including topical steroids, which are the widely accepted first-line therapy for ELP. Several side-effects were reported, but none were serious. With topical corticosteroids, the main side-effects were oral candidiasis and dyspepsia. AUTHORS' CONCLUSIONS This review suggests that there is only weak evidence for the effectiveness of any of the treatments for oral ELP, whilst no evidence was found for genital ELP. More RCTs on a larger scale are needed in the oral and genital ELP populations. We suggest that future studies should have standardised outcome variables that are clinically important to affected individuals. We recommend the measurement of a clinical severity score and a participant-rated symptom score using agreed and validated severity scoring tools. We also recommend the development of a validated combined severity scoring tool for both oral and genital populations.
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Affiliation(s)
- Suzanne Cheng
- Queen's Medical CentreDepartment of DermatologyNottinghamUKNG7 2UH
| | - Gudula Kirtschig
- University of TübingenInstitute of General Medicine and Interprofessional CareTübingenGermany
| | - Susan Cooper
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LJ
| | - Martin Thornhill
- University of Sheffield School of Clinical DentistryClinical Academic Unit of Oral and Maxillofacial Medicine and SurgeryClaremont CrescentSheffieldUKS10 2TA
| | - Jo Leonardi‐Bee
- The University of NottinghamDivision of Epidemiology and Public HealthClinical Sciences BuildingNottingham City Hospital NHS Trust Campus, Hucknall RoadNottinghamUKNG5 1PB
| | - Ruth Murphy
- Sheffield Children's NHS Foundation TrustDepartment of Dermatology, Sheffield Children's HospitalSheffieldUKS10 2JF
- Sheffield Teaching Hospitals NHS Foundation TrustDepartment of DermatologySheffieldUK
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Abstract
BACKGROUND Lichen sclerosus is a chronic, inflammatory skin condition that most commonly occurs in adult women, although it may also be seen in men and children. It primarily affects the genital area and around the anus, where it causes persistent itching and soreness. Scarring after inflammation may lead to severe damage by fusion of the vulval lips (labia); narrowing of the vaginal opening; and burying of the clitoris in women and girls, as well as tightening of the foreskin in men and boys, if treatments are not started early. Affected people have an increased risk of genital cancers. OBJECTIVES To assess the effects of topical interventions for genital lichen sclerosus and adverse effects reported in included trials. SEARCH METHODS We searched the following databases up to 16 September 2011: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), LILACS (from 1982), CINAHL (from 1981), British Nursing Index and Archive (from 1985), Science Citation Index Expanded (from 1945), BIOSIS Previews (from 1926), Conference Papers Index (from 1982), and Conference Proceedings Citation Index - Science (from 1990). We also searched ongoing trial registries and scanned the bibliographies of included studies, published reviews, and papers that had cited the included studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of topical interventions in genital lichen sclerosus. DATA COLLECTION AND ANALYSIS Two authors independently selected trials, extracted data, and assessed the risk of bias. A third author was available for resolving differences of opinion. MAIN RESULTS We included 7 RCTs, with a total of 249 participants, covering 6 treatments. Six of these RCTs tested the efficacy of one active intervention against placebo or another active intervention, while the other trial tested three active interventions against placebo.When compared to placebo in one trial, clobetasol propionate 0.05% was effective in treating genital lichen sclerosus in relation to the following outcomes: 'participant-rated improvement or remission of symptoms' (risk ratio (RR) 2.85, 95% confidence interval (CI) 1.45 to 5.61) and 'investigator-rated global degree of improvement' (standardised mean difference (SMD) 5.74, 95% CI 4.26 to 7.23).When mometasone furoate 0.05% was compared to placebo in another trial, there was a significant improvement in the 'investigator-rated change in clinical grade of phimosis' (SMD -1.04, 95% CI -1.77 to -0.31).Both trials found no significant differences in reported adverse drug reactions between the corticosteroid and placebo groups. The data from four trials found no significant benefit for topical testosterone, dihydrotestosterone, and progesterone. When used as maintenance therapy after an initial treatment with topical clobetasol propionate in another trial, topical testosterone worsened the symptoms (P < 0.05), but the placebo did not.One trial found no differences between pimecrolimus and clobetasol propionate in relieving symptoms through change in pruritus (itching) (SMD -0.33, 95% CI -0.99 to 0.33) and burning/pain (SMD 0.03, 95% CI -0.62 to 0.69). However, pimecrolimus was less effective than clobetasol propionate with regard to the 'investigator-rated global degree of improvement' (SMD -1.64, 95% CI -2.40 to -0.87). This trial found no significant differences in reported adverse drug reactions between the pimecrolimus and placebo groups. AUTHORS' CONCLUSIONS The current limited evidence demonstrates the efficacy of clobetasol propionate, mometasone furoate, and pimecrolimus in treating genital lichen sclerosus. Further RCTs are needed to determine the optimal potency and regimen of topical corticosteroids, examine other topical interventions, assess the duration of remission or prevention of flares, evaluate the reduction in the risk of genital squamous cell carcinoma or genital intraepithelial neoplasia, and examine the efficacy in improving the quality of the sex lives of people with this condition.
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Affiliation(s)
- Ching‐Chi Chi
- Chang Gung Memorial HospitalDepartment of Dermatology and Centre for Evidence‐Based Medicine6, Sec West, Chia‐Pu RoadPuzihChiayiTaiwan61363
| | - Gudula Kirtschig
- University of TübingenInstitute of General Medicine and Interprofessional CareTübingenGermany
| | - Maha Baldo
- University of OxfordNuffield Department of Clinical MedicineOxfordUK
| | - Fabia Brackenbury
- University of Nottinghamc/o Cochrane Skin GroupRoom A103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Fiona Lewis
- Heatherwood & Wexham Park NHS Foundation TrustDepartment of Dermatology, Wexham Park HospitalWexham StreetSloughUKSL2 4HL
- St Thomas' HospitalSt John's Institute of DermatologyWestminster Bridge RoadLondonUKSE1 7EH
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Chi CC, Kirtschig G, Aberer W, Gabbud JP, Lipozenčić J, Kárpáti S, Haustein UF, Zuberbier T, Wojnarowska F. Evidence-based (S3) guideline on topical corticosteroids in pregnancy. Br J Dermatol 2011; 165:943-52. [DOI: 10.1111/j.1365-2133.2011.10513.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease in the West. Oral steroids are the standard treatment.This is an update of the review published in 2005. OBJECTIVES To assess treatments for bullous pemphigoid. SEARCH STRATEGY In August 2010 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials), MEDLINE, EMBASE, and the Ongoing Trials registers. SELECTION CRITERIA Randomised controlled trials of treatments for participants with immunofluorescence-confirmed bullous pemphigoid. DATA COLLECTION AND ANALYSIS At least two authors evaluated the studies for the inclusion criteria, and extracted data independently. MAIN RESULTS We included 10 randomised controlled trials (with a total of 1049 participants) of moderate to high risk of bias. All studies involved different comparisons, none had a placebo group. In 1 trial plasma exchange plus prednisone gave significantly better disease control at 1 month (0.3 mg/kg: RR 18.78, 95% CI 1.20 to 293.70) than prednisone alone (1.0 mg/kg: RR 1.79, 95% CI 1.11 to 2.90), while another trial showed no difference in disease control at 6 months.No differences in disease control were seen for different doses or formulations of prednisolone (one trial each), for azathioprine plus prednisone compared with prednisone alone (one trial), for prednisolone plus azathioprine compared with prednisolone plus plasma exchange (one trial), for prednisolone plus mycophenolate mofetil or plus azathioprine (one trial), for tetracycline plus nicotinamide compared with prednisolone (one trial). Chinese traditional medicine plus prednisone was not effective in one trial.There were no significant differences in healing in a comparison of a standard regimen of topical steroids (clobetasol) with a milder regimen (RR 1.00, 95% 0.97 to 1.03) in one trial. In another trial, clobetasol showed significantly more disease control than oral prednisolone in people with extensive and moderate disease (RR 1.09, 95% CI 1.02 to 1.17), with significantly reduced mortality and adverse events (RR 1.06, 95% CI 1.00 to 1.12). AUTHORS' CONCLUSIONS Very potent topical steroids are effective and safe treatments for BP, but their use in extensive disease may be limited by side-effects and practical factors. Milder regimens (using lower doses of steroids) are safe and effective in moderate BP. Starting doses of prednisolone greater than 0.75 mg/kg/day do not give additional benefit, lower doses may be adequate to control disease and reduce the incidence and severity of adverse reactions. The effectiveness of adding plasma exchange, azathioprine or mycophenolate mofetil to corticosteroids, and combination treatment with tetracycline and nicotinamide needs further investigation.
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Affiliation(s)
- Gudula Kirtschig
- University of TübingenInstitute of General Medicine and Interprofessional CareTübingenGermany
- Nottingham University Hospitals NHS TrustCentre of Evidence Based DermatologyNottinghamUK
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Cathy Bennett
- Coventry UniversityCentre for Technology Enabled Health Research (CTEHR)Priory StreetCoventryUKCV1 5FB
| | - Dedee F Murrell
- St George Hospital & University of New South WalesDepartment of DermatologyBelgrave StKogarahSydneyNSWAustralia2217
| | | | - Nonhlanhla P Khumalo
- Groote Schuur HospitalDepartment of DermatologyAnzio RoadObservatoryCape TownWestern CapeSouth Africa7925
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Mandal D, Nunns D, Byrne M, McLelland J, Rani R, Cullimore J, Bansal D, Brackenbury F, Kirtschig G, Wier M. Guidelines for the management of vulvodynia. Br J Dermatol 2010; 162:1180-5. [DOI: 10.1111/j.1365-2133.2010.09684.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Chi CC, Wang SH, Kirtschig G, Wojnarowska F. Systematic review of the safety of topical corticosteroids in pregnancy. J Am Acad Dermatol 2010; 62:694-705. [PMID: 20117858 DOI: 10.1016/j.jaad.2009.09.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 08/11/2009] [Accepted: 09/03/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pregnant women may have skin conditions that require topical corticosteroids. However, little is known about their safety in pregnancy. OBJECTIVE We sought to evaluate the available evidence concerning the safety of topical corticosteroids in pregnancy. METHODS We systematically searched 17 databases and trial registers, and contacted pharmaceutical companies. Randomized controlled trials and cohort studies of topical corticosteroids in pregnant women, and case-control studies comparing maternal exposure to topical corticosteroids between patients and control subjects were included. The Newcastle-Ottawa Scale was used for quality assessment of included studies. RESULTS Seven studies, including two cohort and five case-control studies, were included. Most studies did not find significant associations of topical corticosteroids with congenital abnormality, preterm delivery stillbirth, and mode of delivery. One study found a significant association between first-trimester use of topical corticosteroids and orofacial cleft, and another study found a significant association between very potent topical corticosteroids and low birthweight. LIMITATIONS The available data were limited and mainly on orofacial cleft. The quality of evidence was generally low. CONCLUSIONS Currently limited and inconclusive data are unable to detect an association between topical corticosteroids and congenital abnormality, preterm delivery, or stillbirth. The current evidence shows no statistically significant difference between pregnant women who use and those who do not use topical corticosteroids. However, there does appear to be an association of very potent topical corticosteroids with low birthweight. Further cohort studies with comprehensive outcome measures, consideration of corticosteroid potency, dosage and indications, and a large sample size are needed.
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Affiliation(s)
- Ching-Chi Chi
- Department of Dermatology, Chang Gung Memorial Hospital-Chiayi, Chiayi, Taiwan
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Abstract
BACKGROUND Topical corticosteroids are the most frequently prescribed dermatological treatment and are frequently used by pregnant women with skin conditions. However, little is known about their safety in pregnancy. OBJECTIVES To assess the effects of topical corticosteroids on pregnancy outcomes. SEARCH STRATEGY On 5th May 2009 we searched the Cochrane Skin Group Specialised Register, the Cochrane Pregnancy and Childbirth Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (from 2003), and EMBASE (from 2005). We searched LILACS, CINAHL, British Nursing Index, SCI-EXPANDED, BIOSIS Previews, Conference Papers Index, and Conference Proceedings Citation Index-Science from inception to May 2009. We scanned the bibliographies of the included studies, published reviews, and articles that had cited the included studies. Pharmaceutical companies that have introduced an original topical corticosteroid product were contacted. SELECTION CRITERIA Randomised controlled trials and cohort studies of topical corticosteroids in pregnant women, and case-control studies comparing maternal exposure to topical corticosteroids between cases and controls were included where outcomes were those we had pre-specified. Outcomes included mode of delivery, congenital abnormality, birthweight, preterm delivery, stillbirth, and low Apgar score. DATA COLLECTION AND ANALYSIS Two authors independently applied selection criteria, extracted data, and assessed the quality of the included studies. A third author was available for resolving differences of opinion. MAIN RESULTS Seven studies, including 2 cohort and 5 case-control studies, of 659,675 participants were included. We did not undertake a meta-analysis due to considerable methodological heterogeneity. The available data was limited and mainly on orofacial cleft. Most studies did not find significant associations between topical corticosteroids and pregnancy outcomes including mode of delivery, congenital abnormality, preterm delivery, and stillbirth. One study found a significant association between first trimester topical corticosteroid use and orofacial cleft, and another found a significant association between very potent topical corticosteroids and low birthweight. Nevertheless, all the studies had drawbacks, and the quality of evidence was low to very low. AUTHORS' CONCLUSIONS Currently limited and inconclusive data are unable to detect an association between topical corticosteroids and congenital abnormality, preterm delivery, or stillbirth. The current evidence shows no statistically significant difference between pregnant women who use and those who do not use topical corticosteroids. However, there does appear to be an association of very potent topical corticosteroids with low birthweight. Cohort studies with comprehensive outcome measures, assessment of effects of corticosteroid potency and dose, application methods, and reasons for giving them, and a very large sample size are needed.
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Affiliation(s)
- Ching-Chi Chi
- Department of Dermatology, Chang Gung Memorial Hospital-Chiayi, Chang Gung University College of Medicine, 6, Sec West, Chia-Pu Road, Putz, Chiayi, Taiwan, 61363
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Abstract
Hypereosinophilic syndrome (HES) is a rare, heterogeneous group of systemic diseases characterized by sustained overproduction of eosinophils leading to variable end-organ damage. The skin is affected in 45-60% of patients and may be of diagnostic and prognostic value. In 1975, three criteria were suggested for the diagnosis of HES: (i) blood eosinophilia of > 1.5 x 10(9)/L present for > 6 months, (ii) no apparent cause for the hypereosinophilia, and (iii) signs of end-organ dysfunction. We present a patient with hypereosinophilia in whom a delay in diagnosing HES occurred, partly due to his atopic constitution. However, atopy is not associated with such high or longstanding eosinophilia.
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Affiliation(s)
- S Neve
- Department of Dermatology, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands.
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Vermaat H, Smienk F, Rustemeyer T, Bruynzeel DP, Kirtschig G. Anogenital allergic contact dermatitis, the role of spices and flavour allergy. Contact Dermatitis 2008; 59:233-7. [DOI: 10.1111/j.1600-0536.2008.01417.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
BACKGROUND Systemic glucocorticoids (GCs) are often needed to treat dermatologic patients. The long-term use of GCs, however, is associated with potentially severe side-effects. GC-induced osteoporosis (GIO) is one of the most serious complications, but the risk of the occurrence of GIO seems to be generally underestimated. AIM To provide an update of the recent advances in the prevention of GIO in dermatologic practice. METHODS Review of the literature and several European and US guidelines up to August 2007. RESULTS Data regarding the prevention and treatment of GIO are limited and guidelines for the prevention of GIO are not fully consistent. CONCLUSION The prophylaxis of osteoporosis needs to be started early during treatment with GCs. Calcium and vitamin D supplements in all patients on systemic GCs and bisphosphonates in patients who take GCs for more than 3 months are practical and effective measures.
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Affiliation(s)
- Hester Vermaat
- Department of Dermatology, Vrije Universiteit Medical Center, Amsterdam, Netherlands.
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Affiliation(s)
- Rob C Beljaards
- Department of Dermatology, Medisch Centrum Alkmaar, Alkmaar, The Netherlands
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Chi CC, Lee CW, Wojnarowska F, Kirtschig G. Perinatal safety of topical corticosteroids for pregnant women. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [DOI: 10.1002/14651858.cd007346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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