The efficacy of bimatoprost ophthalmic solution combined with NB-UVB phototherapy in non-segmental and segmental vitiligo: a single-blind randomized controlled study

Bimatoprost ophthalmic solution 0.03% (PGF2α analogues) combined with narrowband ultraviolet B (NB-UVB) was reported to be an effective treatment for vitiligo. To investigate the efficacy and safety of treatment for non-segmental/segmental vitiligo compared among bimatoprost ophthalmic solution 0.01% combined with NB-UVB phototherapy, bimatoprost monotherapy, and placebo. This single-blind randomized controlled study enrolled stable Thai vitiligo patients with at least three similarly sized lesions in the same anatomical area. The treatment duration was 6 months with 1- and 2-month post-treatment follow-ups. The 3 selected lesions on each patient were randomized to receive combination therapy, monotherapy, or placebo. The Vitiligo Area Scoring Index (VASI) was used to evaluate lesion response. Of the 25 initially enrolled subjects, 19 patients were analyzed. There were 13 and 6 non-segmental and segmental vitiligo cases, respectively. Eight and 11 cases had face/neck and non-face/neck lesions, respectively. Non-segmental vitiligo and non-face/neck vitiligo patients in the combination group had significant improvement in VASI score at 3 months, 6 months, and at the 2-month follow-up. No side effects were observed/reported. Bimatoprost combination therapy was shown to be safe and effective for treating Thai patients with non-segmental vitiligo in non-face/neck areas of the body.

Ultraviolet filters in sunscreens and cosmetic products-A market survey

BACKGROUND

As several reports have raised a variety of environmental, health, and safety issues related to ultraviolet (UV) filters, it is crucial to understand the trends in the exposure of the population to UV filters.

OBJECTIVE

To determine the frequency of UV filter usage in sunscreens and other cosmetic products in Thai market.

METHODS

We surveyed the UV filter labelling on sunscreens and cosmetic products sold in the Thai market. In all, 312 sunscreens and 1350 other cosmetic products were investigated.

RESULTS

Titanium dioxide was the most frequently used UV filter in both sunscreens (66.7%) and other cosmetic products (68.4%). Ethylhexyl methoxycinnamate was the most common organic UVB filter, whereas butyl methoxydibenzoylmethane was the most common organic UVA filter. In sunscreens aimed at children, bis-ethylhexyloxyphenol methoxyphenyl triazine was the most commonly used UV filter. The most frequent co-occurrence of UV filters was titanium dioxide and ethylhexyl methoxycinnamate.

CONCLUSIONS

Titanium dioxide was the most commonly used UV filter, which differs from the findings of previous surveys. Knowing the availability and frequency of each UV filter provides valuable information about consumer exposure levels, facilitates refinements of the allergen series in patch testing, and enhances the monitoring of adverse effects of UV filters.

Prevalence, concomitant reactions, and factors associated with fragrance allergy in Thailand

BACKGROUND

Fragrances are the most common cause of cosmetic contact allergy. Up-to-date information on contact allergy frequencies and relevance aids primary and secondary preventive measures.

OBJECTIVES

To determine the prevalence, associated factors, and concomitant reactions in fragrance allergy among Thais.

METHODS

This retrospective study collected data from 2012 to 2019. The patient characteristics of fragrance and nonfragrance allergy groups were compared. Concurrent positive reactions to fragrance allergens (fragrance mix [FM] I, FM II, Myroxylon pereirae resin and hydroxyisohexyl 3-cyclohexene carboxaldehyde) and other baseline-series allergens were analysed.

RESULTS

Of 1032 patients, 175 (17.0%) had fragrance allergy, with 57.7% of clinical relevance. FM I showed the highest prevalence (9.4%). The associated factors were being elderly, lesions on the extremities, metal allergy history, and long dermatitis duration. Contact allergies to epoxy resin and Compositae plants were significantly associated with fragrance allergy with an odds ratio of 5.95 (95% confidence interval [CI]: 5.21-6.80) and an odds ratio of 4.42 (95% CI: 1.58-12.36), respectively. No significant associations between colophonium (previously proposed as a fragrance marker) and fragrance allergens were found.

CONCLUSIONS

The prevalence of fragrance contact allergy remains high and should be considered in old patients presenting with long-standing eczema on the extremities. Unlike reports from other countries, varied, significant, concomitant reactions were observed.

Impact of long-term systemic treatment for psoriasis on liver disease in psoriasis patients with coexisting hepatitis B virus infection

Continuously updated information is helpful for evaluating the safety of long-term systemic drug use in psoriasis patients with concomitant hepatitis B virus (HBV) infection. To investigate the impact of long-term systemic treatment for psoriasis on liver disease in psoriasis patients with HBV infection. Data of patients during 10-year period were recorded and analyzed. Sixty-six patients (46 males and 20 females) with a mean age of 58.5 ± 13.1 years were recruited. Our study estimated that the 5-year cumulative risks of developing cirrhosis and HCC were 30% and 5%, respectively, in patients receiving systemic treatments for psoriasis. Risks of cirrhosis and HCC were not significantly different between systemic and topical treatment groups. Thirty patients were prescribed systemic treatments (acitretin, methotrexate, ciclosporin, and anti-tumor necrosis factors). Three HBsAg+ patients developed viral reactivation (two patients with methotrexate and one patient with ciclosporin). The effects of systemic treatments for psoriasis on liver outcome in patients with coexisting HBV infection are needed to be determined. HBsAg+ patients are more likely to develop viral reactivation during systemic treatment for psoriasis than HBsAg- patients. Monitoring of liver enzymes and HBV DNA every 3 months is recommended during treatment and for 6 to 12 months after drug discontinuation.

Pediatric contact allergy: A comparative study with adults

BACKGROUND

Pediatric allergic contact dermatitis is increasing. The patch test allergens included in pediatric baseline series vary globally. The worldwide prevalence of pediatric reactions to allergens needs clarification.

OBJECTIVES

Identify the prevalence, associated factors, and culprit allergens for contact allergy among patch-tested Thai children, and compare with those for adults.

METHODS

Baseline series patch test results from 2010-2019 were collected for patients younger than 18 years of age. As a control group, sex-matched adult patients were randomly selected. The results and characteristics of the two groups were compared.

RESULTS

The median age of 112 patch tested pediatric patients was 16 (range 2-17) years. Of the children, 35.5% had at least one positive reaction, significantly less than the 56.6% for adults. The five most common pediatric allergens were nickel sulfate (12.1%), potassium dichromate (8.0%), methylisothiazolinone (7.1%), fragrance mix II (6.0%), and carba mix (5.4%). Although similar, the 10 most common allergens of the groups differed in order. Positive reactions to cosmetic allergens were significantly less frequent among the children. Many allergens remained entirely negative.

CONCLUSIONS

The prevalence of positive reactions was lower in children, varying by population and region. The top-10 pediatric and adult causative allergens were almost identical. We recommend using the same baseline patch test series for children and adults in our region.

The necessity of antinuclear antibody investigation in pre-phototherapy vitiligo patients: A retrospective study

BACKGROUND

Narrowband UVB (NBUVB) phototherapy is the cornerstone treatment for vitiligo. Before its initiation, some experts recommend antinuclear antibody (ANA) screening out of concern for either photosensitivity to NBUVB or autoimmune disease exacerbation during treatment. As vitiligo is considered an autoimmune disorder, ANAs can be positively found in the disease without any clinical importance. The necessity for ANA investigations for pre-phototherapy vitiligo patients is therefore questioned.

METHODS

We conducted a retrospective study to investigate vitiligo patients who had been checked for ANA before commencing NBUVB phototherapy. Demographic data-including vitiligo type and age of onset-were collected. Samples of ANA, anti-thyroglobulin, and anti-thyroid peroxidase were obtained. The phototherapy treatment protocol and cutaneous reactions to the phototherapy were also recorded.

RESULTS

Among 85 Thai vitiligo patients, the ANA prevalence was 35.3%. The speckled ANA pattern was the most common, and the large majority of patients (80%) had a titer of ≤1:100. Factors associated with positive ANA were female gender and positive anti-thyroglobulin. There were no statistical differences between the phototoxic reactions or phototoxic doses of NBUVB of the ANA-positive vitiligo and ANA-negative vitiligo groups. No cases of SLE were detected in ANA-positive group.

CONCLUSIONS

ANA positivity was not correlated with the incidence or dose of phototoxic reaction in phototherapy treated vitiligo, and it may not a predictive factor for SLE diagnosis in vitiligo. ANA might therefore not need to be routinely checked in pre-phototherapy in vitiligo, unless there are clinical suspicions of an autoimmune disease. However, ANA might be involved in part of the cutaneous photoadaptation response to phototherapy.

Assessment of the quality of life (QoL) of patients with dermatitis and the impact of patch testing on QoL: A study of 519 patients diagnosed with dermatitis

BACKGROUND

Dermatitis can impair the quality of life (QoL) of patients. Knowledge of the QoL-associated factors and the impact of patch testing on QoL is limited.

OBJECTIVES

To identify demographic and clinical factors affecting QoL, and to measure the impact of patch testing on QoL of dermatitis patients.

METHODS

The data and Dermatology Life Quality Index (DLQI) questionnaires of 519 dermatitis patients were analyzed. Of these, 107 underwent patch testing and completed the questionnaires two times (once before testing and again 60 days afterward).

RESULTS

The overall mean (±standard deviation) DLQI was 9.5 (±6.4). Patients aged 20 to 59 years and those who had more frequent disease exacerbations demonstrated significantly higher DLQIs. For each DLQI question, being female and aged 20 to 59 years were associated with impairments of various aspects of life, whereas the anatomical site of dermatitis impacted each question differently. The DLQI scores of the patients undergoing patch testing decreased significantly, irrespective of whether the test results were positive or negative.

CONCLUSIONS

Being of a working age and having more frequent disease exacerbations had negative QoL impacts. In addition, patch testing improved almost every aspect of the DLQI.

Delayed Pressure Urticaria: A Systematic Review of Treatment Options

BACKGROUND

Delayed pressure urticaria (DPU) is characterized by recurrent erythematous and often painful swelling after the skin is exposed to sustained pressure. Treatment is challenging. Antihistamines, the first-line and only approved treatment, are often not effective.

OBJECTIVE

To systematically review the treatment options for DPU.

METHOD

A literature search of electronic databases for all relevant articles published till April 29, 2019, was conducted using the search terms "delayed pressure urticaria" and "pressure urticaria." This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

RESULTS

Twenty-one studies (8 randomized controlled trials [RCTs], 10 retrospective cohort studies, and 3 open-label prospective studies) were included. Second-generation H₁ antihistamines (sgAHs) were effective in 3 RCTs. The combination of an sgAH and montelukast (2 RCTs) or an sgAH and theophylline (1 non-RCT) was more effective than the sgAH alone. The disease improved with omalizumab (4 non-RCTs), sulphones (3 non-RCTs), oral prednisolone (1 RCT and 2 non-RCTs), intravenous immunoglobulin (1 non-RCT), and gluten-free diet (1 non-RCT). There are no studies on updosing of antihistamines over standard dosage in DPU.

CONCLUSIONS

Overall, the quality of studies on DPU is low. Because of the lack of other evidence, antihistamines remain the first-line therapy. Updosing of sgAHs could be considered in patients with uncontrolled symptoms on the basis of the extrapolation of evidence from chronic spontaneous urticaria, even though there is no evidence of its efficacy over standard dosage. Addition of montelukast may be considered. Omalizumab or sulphones may be used in treatment-resistant patients. High-quality DPU studies should be conducted.

How do we treat psoriasis patients with hepatitis C infections in real-world situations? A retrospective analysis of 34 patients

BACKGROUND

There is still relatively limited data on psoriasis and hepatitis C virus (HCV) infections.

OBJECTIVE

This study investigated the clinical characteristics and treatment of psoriasis patients with HCV infections in real-world practice.

METHODS

Medical records of all psoriasis patients with HCV infections who attended the outpatient clinic at Siriraj Hospital over a 10-year period were retrospectively reviewed.

RESULTS

Of 34 patients, 26 and 8 patients were men and women, respectively with a mean age of 57.0 ± 8.7 (range, 42.2-77.2) years. The median age of psoriasis onset was 42.7 ± 12.7 (range, 8-67.25) years. With a median follow-up period of 13.6 years, cirrhosis and hepatocellular carcinoma were found in 67.6% and 29.4% of the patients, respectively. The interferon used for HCV treatment exacerbated the psoriasis in 20% of those patients. Conventional treatments and anti-tumor necrosis factors (anti-TNFs) were used in strict collaboration with hepatologists. No patients experienced a worsening of their HCV infection.

CONCLUSION

Despite a limited number of patients, a male predominance and late-onset psoriasis were frequently observed. Although, interferon therapy for HCV can exacerbate psoriasis, it is not contraindicated. All conventional treatments and anti-TNFs can be used, provided that there is strict collaboration with hepatologists.

The efficacy of UVA1 phototherapy in psoriasis: Clinical and histological aspects

BACKGROUND

Although ultraviolet A1 (UVA1) phototherapy is available for nearly 30 years, only few studies have been conducted for plaque-type psoriasis.

OBJECTIVES

To determine the efficacy and safety of UVA1 phototherapy in psoriasis by assessing the clinical and histological outcomes.

METHODS

This open study enrolled 15 patients with moderate to severe plaque-type psoriasis. All of the patients had skin type IV. A whole-body UVA1 device consisting of 24 lamps, was irradiated at a medium dose of 50 J/cm² three-times weekly for 30 sessions. Topical and systemic psoriasis treatments were discontinued before and during treatment; patients could only use emollients and antihistamines until 1-month post-completion. Psoriasis Area and Severity Index (PASI) scores were determined at baseline; at sessions 10th, 20th and 30th; and 1 month after treatment. Four-millimetre punch biopsies were obtained from the same psoriasis lesion at baseline and session 30th. Changes in histopathological gradings and polymorphonuclear, lymphocyte and Langerhans cell numbers were monitored.

RESULTS

Twelve patients completed the study. The mean age was 41.3 years (range: 25-71). The median PASI scores at baseline, session 30th and 1-month post-treatment were 16 (8.2, 43.3), 11 (4.4, 43.3) and 9.2 (2.7, 36.4), respectively. Although the PASI scores had improved significantly by 1-month post-treatment (P = .006), the histological parameters demonstrated minimal changes. All patients tolerated the phototherapy well and the most common side effect was skin tanning.

CONCLUSIONS

While medium-dose UVA1 phototherapy demonstrated some efficacy in moderate to severe plaque-type psoriasis. However, it might not be an excellent choice.

Relevance of using length of stay as a key indicator to monitor emergency department performance: Case study from a rural hospital in Thailand

OBJECTIVE

The present study explores factors related to length of stay (LOS) in a rural public hospital in Thailand and assesses the feasibility of using LOS as an ED key performance indicator.

METHODS

Using a mixed-methods approach, qualitative methods (in-depth interviews, patients' chart review and participatory observations) were used to guide and elaborate findings from quantitative analysis of 555 electronic ED records.

RESULTS

Multivariate analysis revealed that age, Emergency Severity Index score and number of laboratory tests were significantly associated with LOS. The qualitative approach provided contradicting evidence on the linkage between LOS and patient outcomes. On the one hand, considering the 4 h rule, a child with asthma was referred to a tertiary care hospital because of deterioration after 4 h of ED care. On the other hand, a woman with sepsis was hospitalised with improved condition despite 7 h of ED care. Interviews revealed the waiting time to see doctors was probably the top priority issue for patients.

CONCLUSIONS

Factors related to LOS in a rural hospital in Thailand are similar and in contrast to those of a previous study in a medical school setting. Reasons for the discrepancy of findings and implications for improving ED services were discussed. Our data support the notion of controversy in using LOS as a key indicator of ED performance in this rural hospital setting. Thus, it is imperative to not rely on any single throughput or process indicators to monitor ED performance, but to take into account a set of indicators including patient outcomes.