Quality of life in non‐melanoma skin cancer

Basal cell carcinoma and squamous cell carcinoma are the most common malignancies and are classified under the umbrella of non‐melanoma skin cancer (NMSC). NMSC exerts a small but appreciable decrement in quality of life (QOL). The impact posed may arise from the tumour itself or as a result of treatment, and through symptoms, functional limitations, cosmetic burden and auxiliary considerations such as cost and disturbance to the activities of daily living. Researchers have evaluated this burden using a variety of outcome measures including generic, dermatology‐specific and disease‐specific instruments. The skin cancer index represents a promising disease‐specific patient‐reported outcome measure in this setting. To overcome some of the constraints inherent to disease‐specific instruments, and to allow comparisons with other diseases, utility weightings have been developed. Utility weightings represent a cardinal measure for a specific health status and are established through methods such as the standard gamble, willingness‐to‐pay and time trade‐off, and have also been employed to generate utility weightings for NMSC. Utilities are becoming increasingly important as a means of comparing health states across medicine and are of particular importance from a health‐care policy perspective as they are used for resource allocation. The small but definite impact on the individual's QOL posed by NMSC should be a clinical consideration for physicians and it should be recognised by researchers as a potential outcome measure.     

EADV Taskforce's recommendations on measurement of health‐related quality of life in paediatric dermatology

The impact of skin conditions in children can profoundly affect a variety of lifestyle parameters that may have important personal consequences. Several national guidelines for children with different skin conditions recommend health‐related quality of life (HRQoL) measurement as part of the assessment process. HRQoL also plays an important role in educational programmes for children with chronic skin conditions and their parents. In this paper, the EADV Taskforce on Quality of life provides researchers and clinicians data on the achievements in this field, as well as the peculiarities of HRQoL assessment in children, and an overview of the most commonly used and validated generic, dermatology‐specific and disease‐specific instruments related to paediatric dermatology. Finally, an analysis of the current problems of HRQoL assessment in children with skin diseases and directions for future studies are also discussed. The main goal of this paper is to help dermatologists decide which HRQoL instrument to use with children, depending on the context.     

Comorbidities and health‐related quality of life in Spanish patients with moderate to severe psoriasis: A cross‐sectional study (Arizona study)

Psoriasis is a common, chronic inflammatory immunologically mediated disease of the skin, showing a high prevalence of associated comorbidities, and strongly affecting patients' health‐related quality of life (HR‐QOL), with profound impact on the psychological aspect. We aimed to establish the correlation between HR‐QOL and the associated comorbidities in patients with moderate to severe psoriasis in Spain. A cross‐sectional, observational, epidemiological study was conducted at 68 dermatology‐based centers across Spain. From October 2010 to June 2011, all adult patients diagnosed with moderate to severe psoriasis at least 6 months prior to the study visit and receiving or not receiving treatment for psoriasis were eligible for inclusion. A total of 1022 patients were included. The study population showed mean 36‐item short‐form (SF‐36) physical and mental health scores and Dermatological Life Quality Index (DLQI) of 49.7, 46.2 and 5.3, respectively. The multiple linear regression models showed that patients with moderate to severe psoriasis and a diagnosis of psoriatic arthritis (PsA), hypertension, diabetes mellitus, sleep disturbances or obesity were found to have lower SF‐36 health physical scores. Female patients with depression or anxiety disorders had lower SF‐36 health mental scores. Patients diagnosed with moderate to severe psoriatic disease and associated anxiety disorder had greater DLQI scores. Moderate to severe psoriasis has a significant burden on the HR‐QOL of patients. Regardless of sex, patients with several comorbidities such as PsA, hypertension or obesity were found to have worse scores in the physical component of the QOL questionnaire, whilst women were more affected in the mental health component than men.     

Quality of life in alopecia areata: a disease‐specific questionnaire

Background Alopecia areata (AA) is an autoimmune disease affecting about 2% of the population, which has a considerable impact on quality of life (QoL). There are no disease‐specific questionnaires to assess QoL in patients suffering from AA. Objective To validate a new disease‐specific questionnaire for AA, named AA‐QLI, and to compare the consequent Quality of Life Index (QLI) with the commonly known Dermatology Life Quality Index (DLQI) to verify if it can provide a more comprehensive tool for patients. Methods A total of 50 patients affected by AA were administered both the AA‐QLI, created by us, and the well‐known DLQI. With the aim to detect suitable QLI, we propose to use two multivariate analyses:

• ? a principal component analysis approach on the data collected with both questionnaires to compare their capability to measure the QoL;
• ? a structural equation modelling on our AA‐QLI to identify which category of symptoms mostly affects the QoL.

Results The scores of both the questionnaires are quite close, except for a few cases. Statistical analysis shows a higher specificity of the AA‐QLI for evaluating QoL. Among the three areas in which AA‐QLI is divided, ‘Relationship’ has a major impact on the QLI, followed by ‘Subjective symptoms’; ‘Objective signs’ has a lower weight on the QLI. Conclusion AA‐QLI is a good instrument to evaluate the real impact of AA on QoL. It can be helpful both for the physician and for the patient.     

Impact of ustekinumab on health‐related quality of life and sexual difficulties associated with psoriasis: results from two phase III clinical trials

Background Ustekinumab, a human anti‐interleukin‐12/23 monoclonal antibody, has been shown to effectively treat moderate‐to‐severe psoriasis which significantly affects health‐related quality of life (HRQoL), including patients’ sexual lives. Objectives The aim of this study was to determine if sexual difficulties associated with psoriasis are related to disease severity and whether sexual difficulties improve with skin disease during ustekinumab treatment. Methods  In phase III PHOENIX 1 and 2 trials, psoriasis patients were randomized to ustekinumab (n = 1334) at weeks 0 and 4 and q12 weeks thereafter or placebo (n = 662) at weeks 0 and 4 with crossover to ustekinumab at week 12. Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were used to assess psoriasis severity and patient‐reported HRQoL respectively. Based on DLQI Question #9, impaired sexual function was defined as ‘very much’ or ‘a lot’ of sexual difficulties. Results At baseline, mean DLQI was 12.0, indicating a very large negative effect on patients’ lives. Impaired sexual function was reported by 22.6% (women = 27.1%; men = 20.8%) and was significantly associated with increased psoriasis severity. At week 12, ustekinumab‐treated patients had a greater mean improvement in DLQI (?9.13 vs. ?0.53 with placebo, P < 0.001) and the proportion of patients with impaired sexual function decreased from 22.4% to 2.7% compared with no change with placebo (P < 0.001). Patients with greater PASI improvement experienced a greater reduction of sexual difficulties due to psoriasis. A similar pattern of improved sexual function was observed at weeks 24–28 in placebo crossover patients. Conclusions Ustekinumab treatment is associated with significant improvement in HRQoL and sexual difficulties due to psoriasis.     

Host risk factors for the development of multiple non‐melanoma skin cancers

Non‐melanoma skin cancer (NMSC) is the most common cancer in the US, and having multiple lesions conveys substantial cost and morbidity for the individual involved. Although there are data available on risk factors for NMSC, there are currently few studies that identify specific risk factors for development of multiple NMSCs. We evaluated host risk factors for multiple NMSCs among men (Health Professionals Follow‐up Study) and women (Nurses’ Health Study). Compared with individuals with a single NMSC, having greater number of sunburns was a risk factor for developing ≥2 NMSCs [≥10 sunburns, cumulative relative risk (RR) = 1.21, 95% confidence interval (CI): 1.07–1.36] and a higher risk of developing ≥11 NMSCs (≥10 sunburns, RR = 2.33, 95% CI: 1.57–3.46). Inability‐to‐tan was associated with risk of developing ≥2 NMSCs (cumulative RR = 1.29, 95% CI: 1.18–1.40) and a higher risk of developing ≥11 NMSCs (RR = 1.91, 95% CI: 1.50–2.43). Men had an increased risk of developing ≥2 NMSCs (cumulative RR = 1.53, 95% CI: 1.40–1.66). Risk of developing 2–4, 5–10 and ≥11 NMSCs increased with age. Other risk factors for developing ≥2 NMSCs included red natural hair colour (cumulative RR = 1.23, 95% CI: 1.07–1.42), family history of melanoma (cumulative RR = 1.15, 95% CI: 1.03–1.28), and having ≥6 nevi on the left arm (cumulative RR = 1.22, 95% CI: 1.07–1.40). In conclusion, physicians caring for individuals with incident NMSCs may consider paying special attention to those at highest risk for developing additional tumours, especially males and those with a history of ≥10 lifetime sunburns, by performing routine full skin examinations and counselling for aggressive photoprotection.     

Frozen section diagnosis for non‐melanoma skin cancers: correlation with permanent section diagnosis

Frozen section pathology is routinely used for margin assessment of non‐melanoma skin cancer (NMSC). Frozen section can also be used for the primary diagnosis of several skin lesions. Limited data exist on the accuracy of frozen section in the diagnosis of NMSC. We performed a retrospective chart review of 300 cases in which frozen section diagnoses were compared with permanent section diagnoses of NMSC. Frozen section and permanent section pathology were concordant 83.3% of the time, with the highest concordance rates noted for basal cell carcinoma (145/153, 95%). Our results show a high level of concordance between frozen section and corresponding permanent section pathology diagnosis for NMSC. The rapidity of frozen section tissue processing and pathology reporting makes this technique useful in dermatologic practice for immediate diagnosis and management of NMSC. Further studies should explore strategies to decrease or eliminate discrepancies between frozen and permanent section diagnosis.