Painful lower limb nodules as first symptom of resectable pancreatic acinar cell cancer: a case report

BACKGROUND

Pancreatic panniculitis is characterized by subcutaneous fat necrosis and is a rare presentation of an underlying pancreatic disease, appearing in approximately 2-3% of all patients with a pancreatic disease. The nodules usually involve the lower extremities. Pancreatic panniculitis is commonly associated with acute or chronic pancreatitis, and occasionally with pancreatic cancer, especially acinar cell carcinoma.

CASE PRESENTATION

A 77-year-old Caucasian woman with no significant medical history was referred to our center with multiple painful, itchy, and warm red/blue cutaneous nodules on the left lower leg. These skin lesions were consistent with the clinical diagnosis of panniculitis. The skin biopsy obtained showed a predominantly lobular panniculitis with fat necrosis of which the aspect was highly suspicious for pancreatic panniculitis. Further analysis revealed high lipase serum of > 3000 U/L (normal range < 60 U/L), and on computed tomography scan a mass located between the stomach and the left pancreas was seen. Endoscopic ultrasonography-guided fine-needle biopsy confirmed the diagnosis of acinar cell carcinoma. After discussing the patient in the pancreatobiliary multidisciplinary team meeting, laparoscopic distal pancreatectomy including splenectomy and en bloc wedge resection of the stomach due to tumor in-growth was performed. The cutaneous nodules on both legs disappeared 1-2 days after surgery. No long-term complications were reported during follow-up. One year after surgery, the patient presented with similar symptoms as preoperatively. Computed tomography scan showed local recurrence and distal metastases, which were subsequently confirmed by biopsy. She started with palliative folinic acid-fluorouracil-irinotecan-oxaliplatin chemotherapy but stopped after two cycles because of disease progression. The patient died 2 months later, 13 months after surgical resection.

CONCLUSION

This case illustrates the importance of clinically recognizing cutaneous nodules and pathological recognizing the specific microscopic changes as sign of a (malignant) pancreatic disease.

The use of lasers in vitiligo, an overview

Various types of lasers have been demonstrated to be effective in the treatment of vitiligo. The mode of action of these lasers is just as varied as the purpose of intervention. Many clinicians are not aware of the unique opportunity these lasers offer to improve the outcomes of vitiligo treatment. To date, no clear overview exists of the use of lasers in vitiligo treatment. Thus, the aim of this review is to discuss the various types of lasers and provide an overview of the evidence for their efficacy. We found good evidence from a systematic review that the excimer laser is effective, induces repigmentation rates comparable to NB‐UVB and has improved outcomes when combined with calcineurin inhibitors. Ablative lasers are commonly used for tissue graft or melanocyte–keratinocyte cell graft transplantation. They provide safe, fast and uniform denudation of the epidermis with propitious repigmentation outcomes. We found conflicting evidence from two systematic reviews regarding the efficacy of fractional ablative lasers for improving outcomes of NB‐UVB therapy, a systematic review including only fractional ablative lasers provided evidence for efficacy. Q‐switched nanosecond lasers have shown to be safe and effective for inducing depigmentation, although recurrence is common, and most studies were small and retrospective. Despite proven efficacy and safety, laser treatments are relatively expensive and suited for limited body surface areas and selected cases. Each type of laser has benefits and risks associated and should, therefore, be individually chosen based on location, extent, activity and type of vitiligo.

Complications of tattoos and permanent makeup: overview and analysis of 308 cases

BACKGROUND

Worldwide 10-20% of the population is tattooed. However, tattoo complications can occur, such as allergic tattoo reactions, infections, and manifestations of autoimmune dermatoses. Despite the growing popularity of tattoos and changes in tattoo ink composition over the last decades, little is known about these complications, its clinical aspects, pathomechanism, and relative occurrence.

OBJECTIVE

The aim of this article is to describe the types and clinical aspects of dermatological tattoo complications, its relative occurrence and underlying conditions.

METHODS

We performed a retrospective cohort study enrolling all patients with tattoo complications from the Tattoo Clinic. Tattoo complications were categorized into infections, inflammatory tattoo reactions, neoplasms, or miscellaneous reactions and correlated to clinical data.

RESULTS

Of the total of 326 patients, 301 patients were included with 308 complications. The majority of the complications were chronic: 91.9%. Allergic red tattoo reactions and chronic inflammatory black tattoo reactions (CIBTR) accounted for 50.2% and 18.2%, respectively, of all tattoo complications. Of these CIBTR reactions, extracutaneous involvement was found in 21.4%, including tattoo-associated uveitis (7.1%) and systemic sarcoidosis (14.2%). Of all black tattoo reactions, systemic sarcoidosis was found in 7.8%.

CONCLUSION

Tattoos can cause a wide range in complications that may start years after getting the tattoo. The most frequent tattoo reactions are allergic red tattoo reactions and chronic inflammatory black tattoo reactions, making these the most relevant for the dermatologist. CIBTR have a high percentage of multi-organ involvement, and therefore, screening for sarcoidosis, including ocular involvement, is advised.

Ablative laser surgery for allergic tattoo reactions: a retrospective study

Patients with allergic tattoo reactions are burdened with itch and have a reduced quality of life. Conservative treatment is often insufficient and little is known about treatment options to remove the responsible allergen. We aimed to address the effectiveness and safety of ablative laser therapy including measurement of patient's satisfaction, in patients with allergic reactions to tattoos. A retrospective study was conducted including patients with allergic tattoo reactions who were treated with a 10,600 nm ablative CO2 laser, either by full-surface ablation or fractional ablation. Clinical information originated from medical files and a 25-item questionnaire. Sixteen tattoo allergy patients were treated with a CO2 laser between January 2010 and January 2018. Fourteen patients completed the questionnaire. Ten patients were satisfied with laser treatment. On a visual analogue scale, pruritus and burning improved with a median of 5.5 and 4 points in the full surface ablation group and 3 points on both parameters in the fractional ablation group. Despite the relatively small group of patients, our results suggest that CO2 laser ablation improves itching, burning and impact on daily life in tattoo allergy.

Development of a core outcome domain set for clinical research on capillary malformations (the COSCAM project)

Background

Due to a large variety in treatment outcomes reported in therapeutic trials and lacking patient‐relevant outcomes, it is hard to adequately compare and improve current therapies for patients with capillary malformations (CMs). The Core Outcome Set for Capillary Malformations (COSCAM) project aims to develop a core outcome set (COS) for use in future CM trials, in which we will first develop a core outcome (sub)domain set (CDS). Here, we describe the methods for the development of a CDS and present the results of the first development stage.

Methods

The COSCAM project is carried out according to the recommendations of the Cochrane Skin Core OUtcomes Set INitiative (CS‐COUSIN) and the Core Outcome Measures in Effectiveness Trials (COMET) initiative. During the first stage, we identified all potentially relevant outcome subdomains based on a systematic review, two focus group sessions and input from patient representatives of Dutch patient organizations and the COSCAM‐founding group. In stage two, we will present the subdomains in a three‐round e‐Delphi study and online consensus meeting, in which CM patients, parents/caregivers and CM experts worldwide rate the importance of the proposed subdomains, hereby finalizing the core outcome (sub)domains of the CDS.

Results

A total of 67 potential outcome subdomains were included; sixteen were previously used in the literature, 20 were proposed by Dutch patients and their parents/caregivers (n = 13) in focus group sessions and 38 were suggested by the experts of the COSCAM‐founding group. Seven were excluded because of overlap.

Conclusion

The final CDS may serve as a minimum standard in future CM trials, thereby facilitating adequate comparison of treatment outcomes. After this CDS development, we will select appropriate outcome measurement instruments to measure the core outcome subdomains.

Domains and outcomes of the core outcome set of congenital melanocytic naevi for clinical practice and research (the OCOMEN project): part 2

Background

Congenital melanocytic naevi (CMN) can have a great impact on patients’ lives owing to perceived stigmatization, and the risk of melanoma development and neurological complications. Development of a core outcome set (COS) for care and research in CMN will allow standard reporting of outcomes. This will enable comparison of outcomes, allowing professionals to offer advice about the best management options. In previous research, stakeholders (patients, parents and professionals) reached consensus on the core domains of the COS. To select the appropriate measurement instruments, the domains should be specified by outcomes.

Objectives

To reach consensus on the specific core outcomes describing the core domains pertaining to clinical care and research in CMN.

Methods

A list of provisional outcomes (obtained earlier) was critically reviewed by the Outcomes for COngenital MElanocytic Naevi (OCOMEN) research team and by relevant stakeholders through an online questionnaire, to refine this list and provide clear definitions for every outcome. When needed, discussion with individual participants was undertaken over the telephone or by email. During an online consensus meeting, stakeholders discussed the inclusion of potential outcomes. After the meeting, participants voted in two rounds for the inclusion of outcomes.

Results

Forty‐four stakeholders from 19 countries participated. Nine core outcomes were included in the COS relative to clinical care and 10 core outcomes for research.

Conclusions

These core outcomes will enable standard reporting in future care and research of CMN. This study facilitates the next step of COS development: selecting the appropriate measurement instruments for every outcome.

What is already known about this topic?

Congenital melanocytic naevi (CMN) can be associated with psychosocial burden and increased risk of melanoma and/or neurological complications.

Outcomes measured for research and care in CMN are heterogeneous, impeding comparison.

A core outcome set (COS) may enhance standardized use and reporting, and reduce selective reporting bias.

In previous research, relevant stakeholders reached consensus on what domains should be included in the core domain set (CDS).

What does this study add?

To select the appropriate measurement instruments for the domains included in the CDS, the domains should be further specified by outcomes.

We reached consensus on what outcomes should describe the domains of the CDS of CMN care and research.

Through a consensus procedure, including online discussions, online consensus meeting and voting, relevant stakeholders reached consensus on a limited number of core outcomes describing the core domains.

What are the clinical implications of this work?

Development of a COS will allow standard reporting of outcomes in future care and research of CMN.

This will enable pooling and comparison of outcomes, allowing guideline development of optimal management policy.

Linked Comment: M.V. Heppt et al. Br J Dermatol 2021; 185:881–882.

Plain language summary available online

Development of an international core domain set for medium, large and giant congenital melanocytic naevi as a first step towards a core outcome set for clinical practice and research

BACKGROUND

Medium, large and giant congenital melanocytic naevi (CMN) can impose a psychosocial burden on patients and families, and are associated with increased risk of developing melanoma or neurological symptoms. Lack of consensus on what outcomes to measure makes it difficult to advise patients and families about treatment and to set up best practice for CMN.

OBJECTIVES

Fostering consensus among patient representatives and professionals, we aim to develop a core outcome set, defined as the minimum set of outcomes to measure and report in care and all clinical trials of a specific health condition. We focused on the 'what to measure' aspect, the so-called core domain set (CDS), following the COMET and CS-COUSIN guidelines.

METHODS

We conducted a systematic review to identify outcomes reported in the literature. Focus groups with patient representatives identified patient-reported outcomes. All these outcomes were classified into domains. Through e-Delphi surveys, 144 stakeholders from 27 countries iteratively rated the importance of domains and outcomes. An online consensus meeting attended by seven patient representatives and seven professionals finalized the CDS.

RESULTS

We reached consensus on six domains, four of which were applied to both care and research: 'quality of life', 'neoplasms', 'nervous system' and 'anatomy of skin'. 'Adverse events' was specific to care and 'pathology' to research.

CONCLUSIONS

We have developed a CDS for medium-to-giant CMN. Its application in reporting care and research of CMN will facilitate treatment comparisons. The next step will be to reach consensus on the specific outcomes for each of the domains and what instruments should be used to measure these domains and outcomes.

Donor to recipient ratios in the surgical treatment of vitiligo and piebaldism: a systematic review

Stabilized vitiligo resistant to conventional therapy (e.g. segmental vitiligo) and piebaldism lesions can be treated with autologous cellular grafting techniques, such as non-cultured cell suspension transplantation (NCST) and cultured melanocyte transplantation (CMT). These methods are preferred when treating larger surface areas due to the small amount of donor skin needed. However, the donor to recipient expansion ratios and outcomes reported in studies with cellular grafting vary widely, and to date, no overview or guideline exists on the optimal ratio. The aim of our study was to obtain an overview of the various expansion ratios used in cellular grafting and to identify whether expansion ratios affect repigmentation and colour match. We performed a systematic literature search in MEDLINE and EMBASE to review clinical studies that reported the expansion ratio and repigmentation after cellular grafting. We included 31 eligible clinical studies with 1591 patients in total. Our study provides an overview of various expansion ratios used in cellular grafting for vitiligo and piebaldism, which varied from 1:1 up to 1:100. We found expansion ratios between 1:1 and 1:10 for studies investigating NCST and from 1:20 to 1:100 in studies evaluating CMT. Pooled analyses of studies with the same expansion ratio and repigmentation thresholds showed that when using the lowest (1:3) expansion ratio, the proportion of lesions achieving >50% or >75% repigmentation after NCST was significantly better than when using the highest (1:10) expansion ratio (χ² P = 0.000 and χ² P = 0.006, respectively). Less than half of our included studies stated the colour match between different expansion ratios, and results were variable. In conclusion, the results of our study indicate that higher expansion ratios lead to lower repigmentation percentages after NCST treatment. This should be taken into consideration while determining which expansion ratio to use for treating a patient.

Evidence for efficacy of home-based narrowband ultraviolet B therapy

Linked Article: Thomas et al. Br J Dermatol 2021; 184:828–839.

Patients' perspective on current treatments and demand for novel treatments in vitiligo

BACKGROUND

The treatment of non-segmental vitiligo (NSV) remains a challenge. Current treatments often achieve suboptimal clinical results. To improve these treatment results, several new therapies are being developed and investigated. There is, however, little evidence on the actual need for novel therapies.

OBJECTIVE

To assess patients' perspective on current and novel therapies for vitiligo.

METHODS

A prospective questionnaire study was conducted in a large cohort of vitiligo patients that consecutively visited the outpatient clinic of the Amsterdam University Medical Centre between April 2017 and January 2019. Patients were requested to fill in a digital questionnaire on patient characteristics, disease burden, quality of life, efficacy and satisfaction of current treatments and aspects regarding new treatments.

RESULTS

A total of 325 vitiligo patients completed the questionnaire (60% response rate). Of the respondents, 94% believed that new and improved treatments are needed and 86% would be willing to participate in clinical trials investigating a new therapy. Sixty-nine per cent would agree on taking weekly injections if it led to effective treatment results. Of the patients that had received therapy before, 49% reported that the current treatments were not effective and 50% was not satisfied with the current treatments. Sixty-seven per cent of the patients experienced facial lesions as an extreme burden, whereas this was, 25%, 12% and 10% for lesions on the hands, trunk and feet, respectively. The emotional burden score was significantly higher in dark skin types compared with light skin types (respectively, 8 vs 5, U P < 0.05).

CONCLUSION

There is a substantial need for new vitiligo therapies. A considerable number of patients in our study are dissatisfied with current treatments and are emotionally burdened by the disease. Moreover, the vast majority demands novel treatments and is willing to participate in clinical trials.

Validation of a Patient Global Assessment for extent, severity and impact to define the severity strata for the Self Assessment Vitiligo Extent Score (SA-VES)

Background

The Self Assessment Vitiligo Extent Score (SA‐VES) is a validated, patient‐reported outcome measure to assess the body surface area affected with vitiligo. Information on how to translate the obtained score into extent, severity and impact strata (mild–moderate–severe) is still lacking. Stratification is helpful to define inclusion criteria for trials, enables comparison and pooling of trial results and can be used for epidemiological research.

Objectives

The aim was to develop extent, severity and impact strata for the SA‐VES based on validated anchor‐based questions.

Methods

In total, 315 patients with vitiligo (non‐segmental; age ≥ 16) recruited at the Ghent University Hospital (Belgium) completed a questionnaire that was conducted in cooperation with the Dutch Society for vitiligo patients to ensure content validity. First three anchor questions included in the questionnaire [Patient Global Assessment (PtGA) for vitiligo extent, severity and impact] were assessed for content validity, construct validity and intrarater reliability. Subsequently, the PtGAs were used to stratify the SA‐VES based on ROC analysis.

Results

For all PtGAs (PtGA extent, PtGA severity, PtGA impact), at least 75% of hypotheses evaluated for construct validity were confirmed. Intrarater reliability of all PtGAs was good to excellent (ICCs PtGA extent: 0.623; PtGA severity: 0.828; PtGA impact: 0.851). The optimal cut‐off values of the SA‐VES between the three global categories (mild/limited – moderate – severe/extensive) were 1.05% and 6.45% based on PtGA extent, 2.07% and 4.8% based on PtGA severity and 2% and 3.35% based on PtGA impact.

Conclusion

This study provides the first guide for the interpretation of the numerical output obtained by the SA‐VES (vitiligo extent) and enables the translation into a global vitiligo grading for extent, severity and impact. As patients’ interpretation of vitiligo extent, severity and impact may vary amongst patients worldwide, future international studies will be required.

Reliability and validity of the Vitiligo Signs of Activity Score (VSAS)

Background

The associations between disease activity and several clinical signs in vitiligo have been described, but a widely accepted and validated scoring system is lacking.

Objectives

To validate the Vitiligo Signs of Activity Score (VSAS) for physicians.

Methods

Three visible clinical signs were scored on 15 body locations: confetti‐like depigmentation (c), Koebner phenomenon (k) and hypochromic areas/borders (h). The inter‐ and intrarater reliability of the global VSAS and VSAS subscores (c‐VSAS, k‐VSAS and h‐VSAS) were tested by four and three raters (physicians), respectively. Construct validity and feasibility were evaluated.

Results

The VSAS demonstrated good inter‐rater reliability, with an intraclass correlation coefficient (ICC) of 0·87 in the first round and 0·90 in the second round. The intrarater reliability ICCs were all ≥ 0·86. The inter‐rater reliabilities of the subscores were excellent for c‐VSAS and fair for k‐VSAS and h‐VSAS (ICC 0·83, 0·51 and 0·53, respectively, in the first round). Evidence for construct validity was provided. The completion time by the raters (median 2·18 min per patient) improved during the second round (median 1·33 min per patient). A limitation of the study is the low number of patients, mainly of skin phototypes II–III, from a single tertiary centre.

Conclusions

The VSAS appears to be a valid and reliable instrument to score visible clinical signs linked to disease activity in a standardized way.

What is already known about this topic?

Evidence exists for a possible link between several visible clinical signs in vitiligo and disease activity.

A widely accepted and validated scoring system to quantify these clinical signs is lacking.

What does this study add?

The Vitiligo Signs of Activity Score (VSAS) underwent preliminary validation and may assist quantification of visible clinical signs linked to disease activity in a standardized way in clinical practice and trials.

What are the clinical implications of this work?

VSAS may be used for future trials that aim to establish the clinical significance of the specific visible clinical signs in vitiligo in a more controlled setting.

Linked Comment:Eleftheriadou. Br J Dermatol 2020; 183:801–802.

What is already known about this topic?

Evidence exists for a possible link between several visible clinical signs in vitiligo and disease activity.

A widely accepted and validated scoring system to quantify these clinical signs is lacking.

What does this study add?

The Vitiligo Signs of Activity Score (VSAS) underwent preliminary validation and may assist quantification of visible clinical signs linked to disease activity in a standardized way in clinical practice and trials.

What are the clinical implications of this work?

VSAS may be used for future trials that aim to establish the clinical significance of the specific visible clinical signs in vitiligo in a more controlled setting.

Linked Comment:Eleftheriadou. Br J Dermatol 2020; 183:801–802.

Ultraviolet photography in vitiligo: image quality, validity and reliability

Background

For clinical care and research in vitiligo, photographs with the use of ultraviolet (UV) light or Wood's lamp are often made. Conventional cameras are insensitive to UV light. The use of a UV camera (UV photography) might improve image quality and ameliorate the assessment of target lesions in vitiligo.

Objectives

To determine image quality and the validity and reliability of UV photography for the assessment of vitiligo target lesions.

Methods

Images of patients with vitiligo were made with UV photography and a conventional camera, and lesions were drawn on graph paper and transparent sheets. Image quality was scored by vitiligo experts and medical interns. The intraclass correlation coefficients (ICCs) of the lesion size determined with UV photography combined with digital surface measurement and the other techniques were hypothesized to be above 0.6. The ICCs between UV images taken by the same physician and between two different physicians were calculated for determining inter‐ and intra‐reliability.

Results

In total, 31 lesions of 17 patients were included. Image quality was assessed as good or very good for 100% and 26% for UV photography and the conventional camera, respectively. ICCs of UV photography and the conventional camera, drawing the lesions on transparent sheets and graph paper, were 0.984, 0.988 and 0.983, respectively, confirming our hypotheses. The ICCs of the intra‐rater and inter‐rater were 0.999 and 0.998, respectively.

Conclusions

The results of this study indicate that the use of UV photography for the assessment of vitiligo lesions improves image quality and is valid and reliable.

Protocol for the development of core set of domains of the core outcome set for patients with congenital melanocytic naevi (OCOMEN project)

BACKGROUND

Having large congenital melanocytic naevi (CMN) is associated with a psychosocial burden on patients and their parents because of its remarkable appearance and the extra care it may require. Large CMN also pose an increased risk of malignant melanoma or neurocutaneous melanosis. There is a lack of international consensus on what important outcome domains to measure in relation to treatment. This makes it difficult to compare options, to properly inform patients and their parents, and to set up treatment policy for CMN. Therefore, we aim to develop a core outcome set (COS), i.e. the minimum set of outcomes that are recommended to be measured and reported in all clinical trials of a specific health condition. This COS can be used in the follow-up of CMN patients with or without treatment, in clinical research and practice.

METHODS

In the Outcomes for Congenital Melanocytic Nevi (OCOMEN) projects, we follow the recommendations from the Core Outcome Measures in Effectiveness Trials (COMET) initiative and the Cochrane Skin Core Outcomes Set Initiative (CS-COUSIN). This project entails the following: (i) a systematic review to identify the previous reported outcomes in literature; (ii) focus groups with national and international patients and parents to identify patient-important outcomes; (iii) classification of outcomes into outcome domains; (iv) e-Delphi surveys in which stakeholders (patients/parents and professionals) can rate the importance of domains and outcomes; and (v) an online consensus meeting to finalize the core outcome domains of the COS.

RESULTS

The results will be disseminated by means of publication in a leading journal and presentations in international meetings or conferences. We engage international experts in CMN, both patients and professionals, to ensure the international utility and applicability of the COS.

A systematic review of outcome reporting in laser treatments for dermatological diseases

The standardization of outcome reporting is crucial for interpretation and comparison of studies related to laser treatment of skin disorders. In collaboration with the Cochrane Skin-Core Outcome Set Initiative (CS-COUSIN), a procedure has been proposed to find consensus on the most important generic outcome domains (what to measure) for implementation in the international Laser TrEAtment in Dermatology (LEAD) registry. As the first step in the development of a generic outcome set for the LEAD registry, we undertook a systematic review to identify outcomes, outcome measurement instruments, methods and definitions reported in recently published literature of laser treatments for skin disorders. A systematic search was conducted and generated a total of 707 papers. We assessed 150 studies including all types of studies involving laser treatments for the skin. Two researchers independently extracted the type, definition and frequency of all outcomes and used outcome measurement instruments. We identified 105 verbatim outcomes that were categorized into eight domains recommended by the COMET framework: appearance, long-term effects, physician and patient-reported physical signs, satisfaction, health-related quality of life, psychological functioning and adverse events. Heterogeneity in outcome reporting (e.g. categories and outcome measurement instruments) was high, and definitions were insufficiently reported. There was a clear under representation of life impact domains, including satisfaction (23%) quality of life (3%) and psychological functioning (1%). Outcome reporting concerning laser treatments for the skin is heterogeneous. Standardized outcomes are needed for improving evidence synthesis. Results of this review will be used in the next step to reach consensus between stakeholders on the outcome domains to be implemented in the LEAD registry.

Port wine stain treatment outcomes have not improved over the past three decades

BACKGROUND

Since the early '80s, the pulsed dye laser has been the standard treatment tool for non-invasive port wine stain (PWS) removal. In the last three decades, a considerable amount of research has been conducted to improve clinical outcomes, given that a fraction of PWS patients proved recalcitrant to laser treatment. Whether this research actually led to increased therapeutic efficacy has not been systematically investigated.

OBJECTIVE

To analyse therapeutic efficacy in PWS patients globally from 1986 to date.

METHODS

PubMed was searched for all available PWS trials. Studies with a quartile percentage improvement scale were included, analysed and plotted chronologically. Treatment and patient characteristics were extracted. A mean clearance per study was calculated and plotted. A 5-study simple moving average was co-plotted to portray the trend in mean clearance over time. The data were separately analysed for multiple treatment sessions in previously untreated patients.

RESULTS

Sixty-five studies were included (24.3% of eligible studies) comprising 6207 PWS patients. Of all patients, 21% achieved 75-100% clearance. Although a few studies reported remarkably good outcomes in a subset of carefully selected patients, there was no upward trend over time in mean clearance.

CONCLUSION

The efficacy of PWS therapy has not improved in the past decades, despite numerous technical innovations and pharmacological interventions. With an unwavering patient demand for better outcomes, the need for development and implementation of novel therapeutic strategies to clear all PWS is as valid today as it was 30 years ago.

UV light set-ups for vitiligo photography, a comparative study on image quality and ease of use

Background

Ultraviolet (UV) light is an essential tool to assess the extent, spreading and staging of vitiligo. Different UV light set‐ups are used for vitiligo photography, including the following: (i) hand‐held Wood’s lamps; (ii) soft boxes with UV lamps; (iii) UV flash attached to the camera; and (iv) high output UV flash.

Objective

Our objective was to compare UV light set‐ups for vitiligo photography regarding image quality and ease of use.

Methods

Patients with vitiligo lesions with unclear borders were included. Two images were made with all four UV set‐ups per patient, for a large and a small area. Image quality was scored separately by three blinded vitiligo experts on five criteria: overall quality, clearness of borders, contrast and sharpness and for larger areas the shadows. The two professional medical photographers were asked to score the ease of use for each set‐up.

Results

A total of 88 photos were assessed from 11 patients. For larger areas, the frequency of a ‘good’ or ‘very good’ overall quality rating was 12.1% (Wood’s), 6.1% (soft boxes), 15.2% (camera flash) and 78.8% (high output flash). For smaller areas, the score ‘good’ or ‘very good’ was given to 54.5%, 3%, 66.6% and 84.8% in the same order. For the shadow criteria, each set‐up scored below 40% on a 'good' or 'very good' score. The high output flash was scored as most easy to use by the photographers.

Conclusion

When comparing four different UV light set‐ups for vitiligo photography, we concluded that the UV set‐ups strongly influenced the quality scores of the obtained images. The high output flash scored best for both small and large areas and for ease of use. For small areas, Wood’s lamp and camera flash were acceptable. All set‐ups scored badly for shadows, and more research is needed to find the optimal exposure to avoid shadows.

Reference method for digital surface measurement of target lesions in vitiligo: a comparative analysis

BACKGROUND

Objective measurement of target lesions in vitiligo is important for clinical practice and trials, yet no preferred tool has been defined. Reported digital tools have shortcomings related to feasibility aspects and often lack information on validity, reliability and responsiveness. Moreover, studies are not yet based on ultraviolet (UV) photography.

OBJECTIVES

To assess the reliability, validity and feasibility of two functions in ImageJ for measurement of target lesions, based on three different types of images including UV pictures.

METHODS

Planimetric measurements were performed on photographs with and without UV, and lesion contours on transparent sheets of 52 vitiligo lesions from 10 patients with vitiligo. The ImageJ functions 'wand' and 'threshold' were used by three and four assessors, respectively. Inter- and intrarater reliability, hypothesis testing for construct validity, and feasibility were evaluated.

RESULTS

The inter- and intrarater reliability for the 'wand' and 'threshold' functions were excellent [intraclass correlation coefficient (ICC) > 0·9] for measurement on pictures (with or without UV). The highest agreement (ICC > 0·95) and lowest variance were obtained for measurements on transparent sheets. All four hypotheses for construct validity were confirmed for all measurements. Overall, all measurement methods scored satisfactorily for user-friendliness. However, measurements on transparent sheets were preferred and the completion time was significantly faster.

CONCLUSIONS

This study confirmed the reliability, validity and feasibility of two functions in ImageJ to measure target lesions in vitiligo. Based on the feasibility and included three-dimensional aspects, transparent sheets measured with the ImageJ 'wand' function can be proposed for future trials as a reference method to investigate the criterion validity of other digital instruments.

Interrater and intrarater agreement of confocal microscopy imaging in diagnosing and subtyping basal cell carcinoma

BACKGROUND

Reflectance confocal microscopy (RCM) imaging can be used to diagnose and subtype basal cell carcinoma (BCC) but relies on individual morphologic pattern recognition that might vary among users.

OBJECTIVES

We assessed the inter-rater and intrarater agreement of RCM in correctly diagnosing and subtyping BCC.

METHODS

In this prospective study, we evaluated the inter-rater and intrarater agreement of RCM on BCC presence and subtype among three raters with varying experience who independently assessed static images of 48 RCM cases twice with four-week interval (T1 and T2). Histopathologic confirmation of presence and subtype of BCC from surgical excision specimen was defined as the reference standard.

RESULTS

The inter-rater agreement of RCM for BCC presence showed an agreement of 82% at T1 and 84% at T2. The agreements for subtyping BCC were lower (52% for T1 and 47% for T2). The intrarater agreement of RCM for BCC presence showed an observed agreement that varied from 79% to 92%. The observed agreements for subtyping varied from 56% to 71%.

CONCLUSIONS

In conclusion, our results show that RCM is reliable in correctly diagnosing BCC based on the assessment of static RCM images. RCM could potentially play an important role in BCC management if accurate subtyping will be achieved. Therefore, future clinical studies on reliability and specific RCM features for BCC subtypes are required.

Diagnostic accuracy of confocal microscopy imaging vs. punch biopsy for diagnosing and subtyping basal cell carcinoma

Background

In vivo reflectance confocal microscopy (RCM) is a promising non‐invasive skin imaging technique that could facilitate early diagnosis of basal cell carcinoma (BCC) instead of routine punch biopsies. However, the clinical value and utility of RCM vs. a punch biopsy in diagnosing and subtyping BCC is unknown.

Objective

To assess diagnostic accuracy of RCM vs. punch biopsy for diagnosing and subtyping clinically suspected primary BCC.

Methods

A prospective, consecutive cohort of 100 patients with clinically suspected BCC were included at two tertiary hospitals in Amsterdam, the Netherlands, between 3 February 2015 and 2 October 2015. Patients were randomized between two test‐treatment pathways: diagnosing and subtyping using RCM imaging followed by direct surgical excision (RCM one‐stop‐shop) or planned excision based upon the histological diagnosis and subtype of punch biopsy (standard care). The primary outcome was the agreement between the index tests (RCM vs. punch biopsy) and reference standard (excision specimen) in correctly diagnosing BCC. The secondary outcome was the agreement between the index tests and reference standard in correctly identifying the most aggressive BCC subtypes.

Results

Sensitivity to detect BCC was similar for RCM and punch biopsy (100% vs. 93.94%), but a punch biopsy was more specific than RCM (79% vs. 38%). RCM expert evaluation for diagnosing BCC had a sensitivity of 100% and a specificity of 75%. The agreement between RCM and excision specimen in identifying the most aggressive BCC subtype ranged from 50% to 85% vs. 77% by a punch biopsy.

Conclusion

Reflectance confocal microscopy and punch biopsy have comparable diagnostic accuracy to diagnose and subtype BCC depending on RCM experience. Although experienced RCM users could accurately diagnose BCC at a distance, we found an important difference in subtyping BCC. Future RCM studies need to focus on diagnostic accuracy, reliability and specific criteria to improve BCC subtype differentiation.

One-stop-shop with confocal microscopy imaging vs. standard care for surgical treatment of basal cell carcinoma: an open-label, noninferiority, randomized controlled multicentre trial

BACKGROUND

Routine punch biopsies are considered to be standard care for diagnosing and subtyping basal cell carcinoma (BCC) when clinically suspected.

OBJECTIVES

We assessed the efficacy of a one-stop-shop concept using in vivo reflectance confocal microscopy (RCM) imaging as a diagnostic tool vs. standard care for surgical treatment in patients with clinically suspected BCC.

METHODS

In this open-label, parallel-group, noninferiority, randomized controlled multicentre trial we enrolled patients with clinically suspected BCC at two tertiary referral centres in Amsterdam, the Netherlands. Patients were randomly assigned to the RCM one-stop-shop (diagnosing and subtyping using RCM followed by direct surgical excision) or standard care (planned excision based on the histological diagnosis and subtype of a punch biopsy). The primary outcome was the proportion of patients with tumour-free margins after surgical excision of BCC.

RESULTS

Of the 95 patients included, 73 (77%) had a BCC histologically confirmed using a surgical excision specimen. All patients (40 of 40, 100%) in the one-stop-shop group had tumour-free margins. In the standard-care group tumour-free margins were found in all but two patients (31 of 33, 94%). The difference in the proportion of patients with tumour-free margins after BCC excision between the one-stop-shop group and the standard-care group was -0·06 (90% confidence interval -0·17-0·01), establishing noninferiority.

CONCLUSIONS

The proposed new treatment strategy seems suitable in facilitating early diagnosis and direct treatment for patients with BCC, depending on factors such as availability of RCM, size and site of the lesion, patient preference and whether direct surgical excision is feasible.

[Extended abstractCutaneous Adverse Reactions to Tattoos]

INTRODUCTION

Tattooing involves the introduction of exogenous pigment into the dermis. Worldwide, tattoos are one of the most popular forms of permanent body art. In the Netherlands, 8-10% of the population older than 12 years old has a tattoo. A wide variety of cutaneous adverse effects can occur in tattoos, these can cause serious symptoms. However, recognition and appropriate knowledge of diagnosis and treatment is still frequently insufficient in many medical practitioners.

CASE DESCRIPTION

The first case concerns a 57-year-old female, who developed an itching swelling in the red part of a tattoo on the left arm. Histology of a punch biopsy showed a pseudolymphomatous reaction. This plaque-like allergic reaction was successfully treated with intralesional injection of corticosteroids.

CONCLUSION

Here we described four cases of cutaneous adverse reactions to tattoos. Allergic reactions in tattoos can present in a wide variety of clinical and histological patterns. The symptoms are often chronic itch and can appear weeks, months or years after placing the tattoo. Allergic reactions are uniformly manifested in one particular colour. Clinically, the reactions can present in a plaque-like, hyperkeratotic or rarely ulcerative or generalised reaction. In spite of changes to the compounds in tattoo inks, allergic reactions are still mostly observed to red ink. Treatment options are topical corticosteroids, intralesional injection of corticosteroids, laser treatment or dermatome shaving.

The validity, reliability and acceptability of the SAVASI; a new self-assessment score in vitiligo

BACKGROUND

Vitiligo is a common depigmenting skin disorder that can influence a patient's quality of life. Although patient-orientated medicine is an emerging concept, a self-assessment tool to assess the degree of depigmentation in vitiligo is not yet available. Therefore, we developed the SAVASI, a self-assessment tool that uses the same basic principles as the VASI.

OBJECTIVE

To assess the validity, reliability and acceptability of the SAVASI.

METHODS

To assess the validity of the SAVASI, we compared the scores assessed by the patient with the scores of the VASI assessed by the physician. To assess the intra-rater reliability, the correlation between the baseline SAVASI and the SAVASI after 2 weeks was calculated. To assess the acceptability, patients indicated the time needed to complete the SAVASI and the patient assessed the difficulty of the questionnaire on a five-point scale. The Skindex-29 was used to determine the quality of life. The overestimation of the SAVASI compared to the VASI was calculated by subtracting the VASI scores off from the SAVASI scores.

RESULTS

A high correlation between the VASI and the SAVASI (ICC 0.97, 95% CI: 0.95-0.98) was found in 60 patients. The intra-rater reliability of the SAVASI (ICC 0.75, 95% CI 0.54-0.87) was adequate in 31 patients. Fifty (83%) of the patients completed the questionnaire within 10 min and only five (8%) of the patients considered the SAVASI hard. We found no correlation between overestimation of the SAVASI score and the Skindex-29 score.

CONCLUSION

The SAVASI is a valid, reliable and acceptable self-assessment tool to measure the degree of depigmentation in vitiligo. With the SAVASI the degree of depigmentation can reliably be assessed by the patient themselves which can be useful in large (epidemiological) studies. Furthermore, this could contribute to the patient's disease insight and therapy loyalty.

Provoking factors, including chemicals, in Dutch patients with vitiligo

BACKGROUND

In vitiligo, many provoking factors have been described, but epidemiological data, especially on the role of contact with chemicals, are scarce.

OBJECTIVE

To obtain an insight into the patient-reported factors provoking vitiligo, including contact with chemicals.

METHODS

A retrospective cohort study was conducted on all 1264 patients with vitiligo who visited the Netherlands Institute for Pigment disorders from January 2003 to December 2007. Patients for whom an exogenous provoking factor was recorded were sent a questionnaire. Subsequently, patients who mentioned a chemical provoking factor were contacted to elucidate the alleged causal relationship between exposure to the chemical and the onset of vitiligo.

RESULTS

A total of 300 out of the 1264 patients indicated that provoking factors had played a role in their disease. Two hundred and forty-six patients were sent a questionnaire, which was returned by 177 (response rate of 72%). Emotional stress was indicated as a provoking factor in 98 patients (55.4%), 51 patients (28.8%) recorded sunburn, 34 patients (19.2%) recorded mechanical factors and 20 patients (11.3%) other factors. Of 29 patients (16.4%) who indicated a chemical factor, a presumed causal relationship could be corroborated in four. The chemicals involved were para-tertiary butylphenol (n = 2), captan (n = 1) and diphencyprone (n = 1).

CONCLUSION

The majority of the patients with vitiligo from this study did not mention provoking factors, but the ones who did point to emotional stress in more than half of the cases. Of the 29 patients who assigned chemical provoking factors, solvents were mainly indicated. However, a presumed relationship with the chemical could be corroborated in only four patients.

Guidelines for the management of vitiligo: the European Dermatology Forum consensus

The aetiopathogenic mechanisms of vitiligo are still poorly understood, and this has held back progress in diagnosis and treatment. Up until now, treatment guidelines have existed at national levels, but no common European viewpoint has emerged. This guideline for the treatment of segmental and nonsegmental vitiligo has been developed by the members of the Vitiligo European Task Force and other colleagues. It summarizes evidence-based and expert-based recommendations (S1 level).

Long-pulsed 1064 nm Nd:YAG laser improves hypertrophic port-wine stains

BACKGROUND

Hypertrophic port-wine stains (PWS) usually respond poorly to pulsed dye laser treatment. The long-pulsed 1064 nm Nd:YAG laser can target deeper situated vessels and may therefore be more effective.

OBJECTIVE

To evaluate the efficacy and safety of the Nd:YAG laser for the treatment of hypertrophic PWS.

METHODS

In a retrospective cohort study, all hypertrophic PWS patients treated with the Nd:YAG laser between 2005 and 2011 were invited for follow-up. Clinical improvement was assessed using Physician Global Assessment (PhGA) and Patient Global Assessment (PGA).

RESULTS

Assessment was obtained in 32 of 44 eligible patients (mean age 51.4 years), after a mean of 2.8 (SD ± 2.1) Nd:YAG laser treatments. Good or excellent improvement of hypertrophy was found in a majority of patients, both by PhGA (91%) and PGA (93%). Good or excellent improvement of colour was found in 63% of patients by PhGA, and in 87% by PGA. Recurrence of hypertrophy was seen in three patients. All but two patients would recommend Nd:YAG treatment to other patients. Mild to moderate scars were seen in seven patients, hypopigmentation in 14 patients.

CONCLUSION

The 1064 nm Nd:YAG laser is highly effective in the treatment of hypertrophic PWS with only a few treatments needed. Mostly mild side effects were seen in half of all patients. Hypertrophy seems to respond better than colour. To further improve colour, a combination with pulsed dye laser treatment is advisory. Observation of immediate clinical endpoints is important when using the Nd:YAG laser, to optimize outcomes and reduce side effects.

The prevalence of thyroid disease in patients with vitiligo: a systematic review

BACKGROUND

Thyroid disease has been suggested to be associated with vitiligo. However, the outcomes of prevalence studies on thyroid disease in vitiligo vary widely.

OBJECTIVES

To summarize and critically appraise current evidence of the prevalence of thyroid diseases in vitiligo.

METHODS

A systematic review was performed searching the electronic databases OVID MEDLINE, OVID EMBASE and PubMed. Guidelines for the critical appraisal of studies on prevalence of a health problem were adapted to evaluate the methodological quality of the included studies. Results were analysed in a meta-analysis with a risk ratio (RR).

RESULTS

Forty-eight studies published between 1968 and 2012 met the inclusion criteria. Most of the studies (50%) were of fair methodological quality, whereas 18 studies (38%) were of poor quality and six studies (12%) were of good quality. Thyroid disease, autoimmune thyroid disease and presence of thyroid-specific autoantibodies showed a mean prevalence of, respectively, 15·1%, 14·3% and 20·8% in patients with vitiligo and an RR of, respectively, 1·9, 2·5 and 5·2 (all statistically significant). This review shows an increased prevalence and an increased risk of (autoimmune) thyroid disease in patients with vitiligo compared with nonvitiligo. This risk seems to increase with age.

CONCLUSIONS

Clinicians should be aware of this increased risk in patients with vitiligo and should be attentive for symptoms of thyroid disease. To make recommendations on screening for thyroid disease in patients with vitiligo future research of good methodological quality, including differentiation of vitiligo types and the use of standardized outcome measures, is needed.

Low yield of routine screening for thyroid dysfunction in asymptomatic patients with vitiligo

BACKGROUND

Nonsegmental vitiligo is considered to be an autoimmune disease and is known to be associated with other autoimmune diseases, particularly affecting the thyroid. Screening patients with nonsegmental vitiligo for thyroid function and for the presence of thyroid autoantibodies has been recommended.

OBJECTIVE

To investigate the prevalence of thyroid dysfunction and thyroid peroxidase-specific (TPO) antibodies in a large cohort of patients with nonsegmental vitiligo in order to help decide whether routine screening is justified.

METHODS

A total of 434 adults with nonsegmental vitiligo who were referred to our institute were enrolled. Thyroid function and anti-TPO antibody titres were assessed in those patients who had no history of thyroid disease or recent thyroid screening.

RESULTS

Forty-three patients had already been diagnosed with thyroid dysfunction, and in 27 patients the general practitioner had performed a thyroid function test with negative results <3months previously. In these patients, thyroid function assessment was not repeated. The remaining 364 patients were screened for thyroid dysfunction. Overt hypothyroidism was newly diagnosed in three (0·8%) patients; subclinical disease was found in 10 (2·7%) patients and increased levels of TPO antibodies, without thyroid disease, were found in 49 (13·5%) patients. An elevated risk for thyroid disease was found among older women and in women with a positive family history of thyroid disease.

CONCLUSION

The overall prevalence of thyroid dysfunction in adult patients with nonsegmental vitiligo was higher than reported in the general population. However, the number of newly diagnosed cases with overt and subclinical thyroid dysfunction in our population was low. Most patients had already been diagnosed by their general practitioner and had symptoms indicative for thyroid disease. Thyroid disease was found predominantly among older women and in subjects with a positive family history of thyroid disease. Thyroid screening including anti-TPO antibodies is advisable in these high-risk subpopulations.