A Belgian consensus on the definition of a treat-to-target outcome set in psoriasis management

OBJECTIVE

Treat-to-target (T2T) is an algorithm to reach a predefined outcome. Here, we define a T2T outcome for moderate-to-severe psoriasis vulgaris.

METHODS

Briefly, the study included a literature review, discussions with key opinion leaders, recruitment of additional dermatologists with experience in managing moderate-to-severe psoriasis, 3 eDelphi survey rounds and a patient focus group. Relevant topics were selected during discussions prior to the survey for the statements. Surveys were based on the eDelphi methodology for consensus-building using a series of statements. Consensus was defined as at least 80% of participants agreeing. A psoriasis patient focus group provided feedback on topic selection and outcome.

RESULTS

A total of 5 discussions were held, and 3 eDelphi rounds were conducted with an average of 19 participants per round. The T2T outcome was set assuming shared decision between patient and dermatologist, awareness and referral for comorbidities by the dermatologist and appropriate treatment adherence by the patient. We defined 'ideal' and 'acceptable' targets; the latter referring to conditions restricting certain drugs. The T2T outcome was multidimensional, including ≥ ΔPASI90/75 or PGA ≤ 1, itch VAS score ≤ 1, absence of disturbing lesions, DLQI ≤ 1/3, incapacity daily functioning VAS score ≤ 1, safety ≤ mild side-effects and full/mild tolerability of treatment for the ideal and acceptable target, respectively. Finally, time to achieve the T2T outcome was set at 12 weeks after initiation for all treatments. At all times, safety should not exceed the presence of mild side-effects.

CONCLUSION

With this novel T2T composite outcome for psoriasis, clinicians and patients can make shared decisions on the treatment goals they envisage, as a guidance for future treatment steps - leading to a tight control management of the disease.

Psoriasis: state of the art 2013

Psoriasis affects about 2 to 3% of the caucasian population. It is a chronic inflammatory disease affecting predominantly the skin with the involvement of autoimmune mediated mechanisms. Typical pathogenic features include an increased renewal of epidermal keratinocytes, the enlargement of the germinating compartment, papillomatosis, altered epidermal differentiation, angiogenesis, lymphangiogenesis and inflammatory infiltration. Several types of psoriasis are distinguished and may be present simultaneously in some patients. Up to 20 candidate genes have been evidenced in psoriasis. Genetic variability explains different types of the disease and influences response to therapeutics. Furthermore, psoriasis is triggered or aggravated by infections, traumatisms, medications, stress, tobacco, alcohol and endocrine factors. Severe psoriasis is frequently associated with co-morbidities as obesity, diabetes, metabolic syndrome and cardiovascular diseases. For this reason, the similar pathogenic mechanisms of psoriasis and other IMID's (Immune Mediated Inflammatory Diseases) and the use of systemic treatments shared with other specialties, an updated vision of psoriasis for the internist is mandatory.

Psoriasis: state of the art 2013

The treatment of psoriasis is mainly based on anti-inflammatory and/or anti-hyperproliferative agents. The topical steroids appeared in the fifties and were the first therapeutic breakthrough for psoriasis, followed by methotrexate and phototherapy in the sixties, photochemotherapy (PUVA) in the seventies and acitretin and cyclosporine in the eighties. The targeted biologic therapies represent a whole new era of therapeutic possibilities with a highly beneficial safety record. The choice of treatment depends on a large series of factors, including the type and extend of the psoriasis, the patient's preferences, co-medications, comorbidities and drug tolerance. This overview presents the currently available topical and systemic agents for treating psoriasis, including topical corticosteroids, vitamin D derivatives, UV-light based therapies, methotrexate, cyclosporine, acitretin, and the biologic agents such as the TNF antagonists etanercept, adalimumab and infliximab, as well as the anti-p40 IL12/23 agent ustekinumab. Newer, very promising, agents aiming the Th17 pathway are under development for psoriasis.

[Home plants and allergies]

Allergic manifestations due to outdoor plants are relatively well known, contrary to those related to home plants. This review presents the various allergens linked to home plants that may be responsible for several allergic manifestations affecting the skin, the lungs, the eyes, and the rhinopharynx. The ficus and its family members constitute the principal sources of the incriminated allergens.

Scalp psoriasis: a review of current topical treatment options

The scalp is the most common site of disease involvement at the onset and throughout the course of psoriasis. For many patients, psoriasis of the scalp is the most difficult aspect of their disease; yet, despite a wide range of therapy options and an extensive literature base, scalp psoriasis remains difficult to treat, highlighting a long-standing unmet need for the effective treatment of scalp psoriasis. A review of past and current medical literature reveals that a number of interesting therapeutic approaches have been used in the treatment of scalp psoriasis. The diverse and sometimes extreme therapeutic approaches, the marginal benefit of many topical agents, the paucity of controlled studies evaluating the efficacy of topical agents in the treatment of scalp psoriasis and the high level of patient dissatisfaction with currently available treatments for psoriasis all support the need for new, effective and well-tolerated treatment options for scalp psoriasis.

[Anogenital condylomata in the children. Practice guidelines for a medical expertise]

Belgium has been confronted to cases of paedophilia for years. It seems adequate to suggest some guidelines in cases of a child or a teenager diagnosed with ano-genital warts during a consultation. They are not always the consequence of sexual abuse. Three contaminations are possible: ante natal and peri natal (in utero or during delivery), by direct contact (auto or hetero inoculation), through sexual contact. This trusted practitioners to handle this unusual situation from the child protection, to multidisciplinary management and judicial prosecution against suspect. When using some different way to know what kind of HPV type; it's possible to give some information about transmission and it's possible to do confrontations with the results of the lesions' suspect. It is also interesting to identify very highs oncogenic potential HPV for the survey's patient. Finally the most important is to know that the most recurrences result into reactivations from infra-clinically infections and are not new contaminations. It is important do not drop a new suspicion through hypothetic contaminator.

Efficacy results of a 52-week, randomised, double-blind, safety study of a calcipotriol/betamethasone dipropionate two-compound product (Daivobet/Dovobet/Taclonex) in the treatment of psoriasis vulgaris

BACKGROUND

The calcipotriol/betamethasone dipropionate two-compound product is safe and effective in the short-term treatment of psoriasis.

OBJECTIVE

The primary objective was to investigate the safety of two treatment regimens involving use of the two-compound product over 52 weeks. The efficacy results are presented here.

METHODS

Six hundred and thirty-four patients were randomised double-blind to treatment (once daily, when required) with either: 52 weeks of two-compound product (two-compound group), 52 weeks of alternating 4-week periods of two-compound product and calcipotriol (alternating group), or 4 weeks of two-compound product followed by 48 weeks of calcipotriol (calcipotriol group).

RESULTS

There was a trend towards a difference between treatments from the overall treatment effect for the percentage of satisfactory responses for each patient during the study (p = 0.071). This appeared to be due to the comparison of the two-compound and calcipotriol groups (p = 0.025).

CONCLUSION

There was a trend towards the efficacy of the two-compound product used for up to 52 weeks being better than that of 4 weeks of the two-compound product followed by 48 weeks of calcipotriol.

[Arsenical poisoning: how and why to diagnose it]

Arsenic is an ubiquitary element which has been widely used for centuries in different fields such as medicine, agriculture or industry. Acute or chronic exposure to As can lead to various dermatological and systemic disorders with a possibe latency over decades. The dermatological signs of As intoxication are important to detect since one of the potential complications is carcinoma.

[Psoriasis and psoriatic arthritis]

Psoriasis is a frequent multifactorial chronic skin disease that can lead to a decreased quality of life. Some patients also present arthritis. Those two complex inflammatory diseases share some of their characteristics, but several clinical manifestations can be distinguished in each of them. In addition to classical medications (constituted of topical treatments, methotrexate, ciclosporin and retinoids for cutaneous psoriasis and non steroidal anti-inflammatory drugs or methotrexate for psoriatic arthritis), they are the target of a new generation of therapies: the biologics.

A 52-week randomized safety study of a calcipotriol/betamethasone dipropionate two-compound product (Dovobet® /Daivobet® /Taclonex® ) in the treatment of psoriasis vulgaris

BACKGROUND

The calcipotriol/betamethasone dipropionate two-compound product Dovobet/Daivobet/Taclonex(LEO Pharma A/S, Ballerup, Denmark) has been shown to be safe and effective in the treatment of psoriasis for up to 8 weeks. As psoriasis is a chronic disease, long-term treatment may be required, so there is a need to investigate the safety of its use over a longer period of time.

OBJECTIVES

To investigate the safety of two treatment regimens involving use of the two-compound product over 52 weeks in the treatment of patients with psoriasis.

METHODS

Patients (n = 634) were randomized double-blind to treatment with: (i) 52 weeks of the two-compound product (two-compound group); (ii) 52 weeks of alternating 4-week periods of the two-compound product and calcipotriol (alternating group); or (iii) 4 weeks of the two-compound product followed by 48 weeks of calcipotriol (calcipotriol group). Treatments in all groups were used once daily when required.

RESULTS

Adverse drug reactions (ADRs) occurred in 45 (21.7%) patients in the two-compound group, 63 (29.6%) in the alternating group and 78 (37.9%) in the calcipotriol group. The odds ratio for an ADR in the two-compound group relative to the calcipotriol group was 0.46 (95% confidence interval 0.30-0.70; P < 0.001). ADRs of concern associated with long-term topical corticosteroid use occurred in 10 (4.8%) patients in the two-compound group, six (2.8%) in the alternating group and six (2.9%) in the calcipotriol group; those with the highest incidence were skin atrophy, occurring in four (1.9%), one (0.5%) and two (1.0%) patients, respectively, and folliculitis, in three (1.4%), one (0.5%) and no patients, respectively.

CONCLUSIONS

Treatment with the two-compound product for up to 52 weeks appears to be safe and well tolerated whether used on its own or alternating every 4 weeks with calcipotriol treatment.

A novel method of comparing the healing properties of two hydrogels in chronic leg ulcers

Skin ulcers on the legs have a chronic, relapsing course and are often a significant management challenge. Novel methods of measuring and comparing the effects of different treatments can be of assistance in addressing this situation. A clinical pilot study using original methods was undertaken to compare the healing properties of the alginate gel Flaminal (test) and the hydrocolloid gel Intrasite (control) on chronic leg ulcers. The study was performed over a period of 28 days with two parallel groups of 10 patients. Both the surface (acetate tracing and planimetry) and the volume (Jeltrate mould impression and weighting) of each wound were measured at baseline and after 7, 14 and 28 days of treatment. On both parameters results were superior with the test product compared to the control, with volume reduction being the first parameter to change. Between groups, difference in wound volume reduction was detected as early as day 7 whereas difference in surface reduction was clearly apparent only at day 28. Correlation between wound surface and volume reductions was also better in the test group (r = 0.843 vs. 0.421) than in the control. In conclusion, this pilot study suggests that combining wound surface and volume evaluations allows a more precise analysis of the healing process in venous leg ulcers and that this method is able to detect very early differences in treatments even with limited sample size.

Epidermoid carcinoma and perforating necrobiosis lipoidica: a rare association

We report the case of a 33-year-old patient who had had insulin-dependent diabetes mellitus (IDDM) since he was 11 months old, and who presented with major perforating necrobiosis lipoidica (PNL) complicated by a well-differentiated epidermoid carcinoma. PNL is a rare clinical form of NL, always associated with diabetes. Only seven cases have been reported to date in the literature, and to the best of our knowledge, an association of epidermoid carcinoma and PNL has never been described. The development of a tumoral transformation on a classical NL plaque has only been described 12 times. The presence of an epidermoid carcinoma on a weakened background with permanent ulceration suggests that early surgical excision of the tumour and of the NL followed by a skin graft might be the treatment of choice. Radiotherapy seems to be a poor therapeutic option.

[Vulvar lichen sclerosus]

Vulvar lichen sclerosus is a frequent mucocutaneous disease especially affecting 50 to 60 year-old women but with a possible onset at very young age. Symptoms are most disabling including pruritus and dyspareunia. Vulvar mucosa gradually becomes more white and atrophied. Degeneration into epidermoid carcinoma is possible. Treatment only consists of topical corticosteroids.

[Place of ivermectin in the treatment of scabies]

Ivermectin is the first oral treatment available for scabies. It is however not licensed for use in Belgium. In this article, we review its mechanism of action, its preferential indications among which crusted scabies and institutional outbreaks, its contra-indications and its advantages in comparison with topical treatments.

[How I treat...varicosities by sclerotherapy]

Sclerotherapy is a technique for the treatment of varicosities, vascular ectasia, and sometimes, leg varicose veins. This method is aesthetic and in some cases therapeutics and uses sclerosing agents, electrocoagulation and exceptionally LASER. These relatively simple methods are safe and efficient if they are applied with a rigorous procedure by well trained physicians.

Hyperkeratotic nail discoid lupus erythematosus evolving towards systemic lupus erythematosus: therapeutic difficulties

Nail changes occur in about 25% of systemic lupus erythematosus (SLE) cases. Onycholysis has been reported as the most frequent abnormality in SLE. Nailbed hyperkeratosis may be observed in both SLE and discoid lupus erythematosus (DLE). Involvement of the nail apparatus in DLE is extremely uncommon and never restricted to it. We report on a patient in whom the clinical features on the proximal nailfold were similar to those observed on the skin of a patient with typical DLE. This has, to the best of our knowledge, not yet been reported. The patient also exhibited a very distinctive prominent subungual hyperkeratosis. Interestingly, the patient developed biological alterations suggesting a systematization of the disease. Only a combination of systemic corticoids, retinoids and antimalarials was able to achieve nail improvement and this partial resistance to therapy may be explained by the very unusual subungual hyperkeratosis.

[How I treat... Belgian consensus document on the treatment of acne]

This article describes the consensus on the treatment of acne, reached by a Belgian working group. An effective treatment has to rely as much as possible on the pathophysiologic factors: the increased production of sebum, the abnormal desquamation (retention hyperkeratosis) of the epithelium of he sebaceous gland, the proliferation of Propionibacterium acnes and inflammation. The therapeutic arsenal contains topical as well as systemic drugs. This consensus gives an overview of both modalities and an algorithm is presented describing the practical approach to acne treatment.

[Non bullous impetigo: streptococcal or staphylococcal?]

Non bullous impetigo is very common among the pediatric population. It is caused by bacteria. For twenty years, Staphylococcus aureus has been the most frequently isolated organism (present in 80 % of non bullous impetigo lesions, it is the only pathogen cultured in 50 % of patients). The group A beta-haemolytic streptococcus is at the moment isolated alone in 3% of lesions and in association with S. Aureus in 30 % of patients. An epidemiologic change seems to have occurred. Until the early 1980s, group A beta-haemolytic streptococcus was indeed the most predominant etiologic agent causing non bullous impetigo. Unfortunately, the rate of resistance among staphylococci responsible of non bullous impetigo is increasing. As serious complications can follow this skin infection, an appropriate treatment is necessary combining local care, topical antibiotics and sometimes adjunction of systemic antibiotics.

Periungual lipoma: About three cases

Lipomas are one of the most common benign soft tissue tumors. The usual development sites are the neck, the torso, and the legs. Lipomas of the nail unit are extremely rare. Only five cases have been reported up to now, four in subungual locations and one in the lateral nail fold. We report three cases of peri-ungual lipomas, one on the digit and two on the toes. Two of them exhibited the histological features of perisudoral lipomas.

[Xanthomas]

Xanthomas are cutaneous lesions due to a local accumulation of spumous cells in the dermal tissue or the tendons. Histologically, they are characterized by the presence of histiocytes, fibroblasts, macrophages and Touton cells full of lipids. Xanthomas may be found on any part of the body and are usually yellow-orange in color. They may or may not be associated to hyperlipoproteinemia which may be genetic or secondary. A blood test and a complete physical examination are necessary in case such a lesion is discovered. When there is no hyperlipemia some types of xanthomas may be associated to rare diseases. Xanthomas are classified according to their clinical features.

[Urticaria and systemic diseases]

Urticaria is a transient eruption of erythematous or oedematous swelling of the dermis and is usually associated with itching which clinically is very easy to diagnose. However, it causes several etiological, pathophysiological and therapeutic problems. We will develop the acute and chronic urticaria as well as their different associations with systemic diseases. Some current data concerning chronic idiopathic autoimmune urticaria is reviewed. The management and therapeutics will be discussed.

[Medication of the month. Tazarotene 0.05%-0.1% (Zorac)]

Since April 28th, a new topical retinoid is available in Belgium: tazarotene (Zorac) gel (Pierre Fabre). It exists at two concentrations: 0.05% or 0.1%. It is the first receptor-selective topical retinoid. It is indicated in the treatment of plaque-type psoriasis. In the USA, tazarotene is also licensed for use in the treatment of acne and several studies show its efficacy for the treatment of other skin diseases like photodamage and ichthyoses.

[Hand, foot and mouth disease, a not so benign affection: clinical reminder and potential complications]

Hand-foot-and-mouth disease is an infection appearing in epidemics and due, in most cases, to Coxsackie-virus A16 and/or Enterovirus 71 or, less often, to other Coxsackie-virus serotypes. The symptomatology mostly consists in vesicular eruption of the anterior part of the buccal mucosa as well as of hands and feet. Its evolution, although often benign, can include cardiopulmonary and neurological complications. The latter complications require a quickly detection and treatment, and prevention of virus transmission to other people must be adequate.

[Sutures in skin surgery]

Dermatologists performing skin surgery mostly use the square knot. Other underused or even forgotten suturing techniques may still be helpful in some instances. We shall emphasize some simple techniques such as the horizontal mattress suture, the "cross stitch", the "corner stitch" (half buried mattress suture), the buried dermal suture, the buried vertical mattress suture, the continuous mattress suture and the running intradermal suture. In given circumstances, all of them may improve suturing and promote healing. Technical aspects, advantages and disadvantages of each type of suture will be briefly described.

[Ectodermal dysplasias]

The ectodermal dysplasias form a heterogeneous group of rare and complex genetic diseases with different ectodermal derivates abnormalities. The aim of this paper is to present briefly the anhidrotic form or Christ-Siemens-Touraines's syndrome and the hidrotic form or Clouston's syndrome.

[Green nail syndrome or chloronychia]

"Green nails" or chloronychia is an infection mostly caused by Pseudomonas ueruginosa but also by other bacterial or fungal contamination. The clinical appearance consists in a typical triad: green discoloration of the nail plate associated with proximal chronic paronychia and disto-lateral onycholysis. Exposition to moist environment, microtraumatisms, oaychotillomania and associated nail diseases such as psoriasis may promote infection by Pseudomonas. Treatment consists in cutting of the detached nail plate, brushing the nail bed with a 2% sodium hypochlorite solution twice daily and eviction of the repeated immersions by wearing cotton and latex gloves.

Raynaud phenomenon after treatment of verruca vulgaris of the sole with intralesional injection of bleomycin

Intralesional injection of bleomycin (BLM) for the treatment of warts resistant to all conventional therapies is of certain interest because of the drug's low toxicity and its efficacy. However, delayed side effects may appear, particularly Raynaud phenomenon. Accordingly, some precautions must be taken in patients with vascular or collagen diseases and, as a precaution, pregnant or lactating women and infants should not be treated with this drug.

[A non-infectious pyodermatitis: Pyoderma gangrenosum]

Pyoderma gangrenosum (PG) is a rare chronic inflammatory skin disease characterized by the recurring development of necrotizing and painful ulcers. The skin lesions appear spontaneously or after minor traumatic injuries. Sites of predilection include the lower limbs and the trunk but any part of the body may be affected. PG is not an infectious disease; although the etiology is not completely understood, an immune disturbance is certainly involved. An underlying systemic disorder is associated in up to 50% of the cases, specially inflammatory bowel diseases, arthritis, paraproteinemias and hematologic malignancies. Chronic venous or arterial ulcers as well as bacterial gangrene are the most frequent false diagnoses. A right diagnosis, based upon the distinctive clinical features and a compatible histology, is essential to avoid surgical procedure that often tends to exacerbed the process. Because of its persistent and recurrent nature, systemic long-term therapy based upon corticosteroids associated with sulfones or immunosuppressive agents is required.

Cyclosporin in atopic dermatitis: review of the literature and outline of a Belgian consensus

This paper reflects the consensus reached among Belgian professors of dermatology on the place of cyclosporin (CsA) in the treatment of atopic dermatitis (AD). Existing therapeutic modalities and ways to evaluate efficacy of treatment are reviewed briefly. Based on data from the literature and personal experience, guidelines for the use of CsA in AD are proposed. CsA can be prescribed in recalcitrant cases of AD on a short-term basis, both in adults and children. Long-term treatment, up to 1 year, should be considered only in exceptional cases that cannot be controlled by short-time therapy. Contraindications, drug interactions and necessary controls during treatment are also discussed.

[Epidemiology, physiopathology and treatment of a frequent ailment: tinea pedis]

Tinea pedis is an infection of the stratum corneum caused by dermatophytes. Nowadays, fitness centers, saunas, subtropical swimming pools and sport-shoes are more and more fashionable and are certainly responsible for the increase of cases of tinea pedis as dermatophytes grow preferentially in warm and humid environments. The clinical aspect is affected by several factors such as the host reaction to the infection, the virulence of the infective strain, species, and some local and environmental factors. If a dermatophytosis is suspected, it is mandatory to validate the provisional diagnosis by demonstration of the fungus (by culture or/and microscopic examination) to avoid useless and expensive treatments. The new antifungal molecules are very effective, well tolerated and allow short course of therapy improving the compliance of the patient in clinical practice. Relapse of tinea pedis is very common but could be avoided by several simple preventive measures of hygiene.

[Dermatological particularities and pathologies of premature infants]

In contrast with the full-term infant, the skin of the preterm neonate is structurally and functionally immature, especially birth occurred before 30 weeks gestation. The inefficiency of the epidermal barrier may result in dehydration, thermal instability and toxic reactions from percutaneous absorption of topically applied agents. An increased risk for bacteremia and sepsis exist because of the easily injured skin, combined with compromised immunity. The present article summarizes the consequences of this skin immaturity and the different means to avoid them. We shall also describe 2 pathologies more frequent in premature infants: sclerema neonatorum and acquired zinc deficiency.

[Bilateral subungual metastasis from squamous cell carcinoma of the lung: a diagnostic trap!]

We report a bilateral metastasis of the fifth nail unit of the hand in a man with primary squamous-cell carcinoma of the lung. The presence of fingertip metastasis may be the first manifestation of an internal neoplasm and is related to a poor prognosis, with a survival rate of less than 50% after 6 months. Therefore, physicians should be aware of this condition when examining patients with similar unusual lesions.

[Pharma-clinics. How I treat ... periungual warts]

Warts are common benign lesions for which no specific antiviral treatment is available. In some cases, patients and doctors can be put off by poor results. Before selecting any treatment for peri- and subungual warts, it is of utmost importance to bear in mind the risk of damaging the nail matrix. This paper reviews the advantages and inconveniences of the current available treatments in this location.

[Pharma-Clinics. The drug of the month. Adapalene (Differin gel)]

Adapalene is a new topical retinoid derived from naphthoic acid with a selective effect on the epidermis. It is indicated for treatment of acne vulgaris, alone or with other antiacneic topicals. It displays comedolytic and anti-inflammatory activities. The only frequent adverse event is a mild skin irritation during the first two weeks of treatment.