Position paper: Telemedicine in occupational dermatology – current status and perspectives

Teledermatology is the use of telecommunication technologies to exchange medical information for diagnosis, consultation, treatment and teaching in dermatology. While its use has been evaluated in a wide range of dermatological diagnoses, only few studies exist on its validity, diagnostic precision, feasibility, and cost‐effectiveness in occupational dermatology. However, these studies show a considerable potential for diagnosis, prevention, treatment support and follow‐up of patients with occupational skin diseases. Asynchronous (store and forward; SAF) or synchronous dermatology teleconsults could assist occupational medicine specialists not only in occupational preventive care, but also in the context of skin cancer screening in outdoor workers. Thus, teledermatology might contribute to earlier prevention and notification of occupational skin diseases. Modern smartphone apps with artificial intelligence technologies may also facilitate self‐monitoring in employees working in high‐risk jobs.     

Surgical outcomes in patients with cutaneous malignant melanoma in Europe – a systematic literature review

There is limited comparative evidence of the outcomes of different types of surgical management in patients with malignant melanoma in Europe. To address that gap we conducted a systematic literature review to summarize studies reporting outcomes of surgical procedures in patients with malignant melanoma in Europe. Medline was searched for European studies published in English, between 2004 and 2014 reporting surgical outcomes in adults with cutaneous malignant melanoma. We identified 23 studies that evaluated 18 332 patients treated surgically between 1979 and 2009 from 11 European countries. Most of the studies (21/23) were observational; the two remaining studies were randomized controlled trials (RCTs). Studies compared the effect of a range of surgical interventions on a range of clinical outcomes, more commonly overall survival (OS) and disease‐free survival (DFS)/recurrence‐free survival (RFS). Wider excisions were not associated with improved survival in patients with melanoma thickness ≥2 mm in both studies (RCTs), however, recent results based on long‐term follow‐up data associate 3 cm excision margins (vs. 1 cm) with favourable survival outcomes. There was some evidence that complete lymph node dissection after positive sentinel lymph node offers survival benefits over therapeutic lymph node dissection. Sentinel lymph node biopsy was not shown to be associated with significant OS benefits, however, it was overly related with higher rates of DFS/RFS. This review highlights the difficulties of making comparisons between different types of surgical procedures for malignant melanoma. As surgery remains the main treatment, this is an important field, and further evidence, particularly from RCTs, is needed.     

Treatment of necrobiotic xanthogranuloma – a systematic review

Necrobiotic xanthogranuloma (NXG) is an uncommon non‐Langerhans cell histiocytosis involving skin and extracutaneous tissues. The lesions are usually asymptomatic and commonly appear in the periorbital area. Paraproteinemia is closely associated with NXG and its pathogenesis remains unclear. NXG prognosis is poor with several treatments showing variable results. Treatment of monoclonal gammopathy with alkylating agents does not necessarily influence the activity of the skin disease and vice versa. The aim of this systematic review is to summarize all reported treatments of necrobiotic xanthogranuloma of the skin, with or without underlying malignant condition and based on articles from the PubMed database using the query ‘necrobiotic xanthogranuloma treatment’, both in English and German, about ‘human’ subjects and published between 1980 and 2014, documenting adequate treatment for NXG. Mainly individual case reports, small case series and retrospective studies were found. Treatment options include topical and systemic corticosteroids, thalidomide, high‐dose intravenous immunoglobulin (IVIG), chlorambucil, cyclophosphamide, fludarabine, rituximab, melphalan, infliximab, interferon alpha, cladribine, hydroxychloroquine, azathioprine, methotrexate, laser therapy, radiotherapy, surgery, PUVA, plasmapheresis and extracorporeal photopheresis. Randomized controlled trials and studies on long‐term outcomes after treatment were not found and are necessary to focus on in the future.     

Radiation‐induced morphea – a literature review

Radiation‐induced morphea (RIM) is a rare and under‐recognized skin complication of radiotherapy. It is commonly wrongly diagnosed as other dermatological conditions or malignancy because of similar clinical characteristics. This literature review analyses 66 cases that have been reported in the literature since 1989. The clinical appearance often includes pain and disfiguration of affected area, which may influence the patient's quality of life. There is no clear connection between the radiotherapy dose, the fractionation scheme, the use of a boost, age, the presence of other dermatological conditions or other connective tissue diseases and the occurrence of RIM. Its pathogenesis is still unclear, but several theories are proposed to explain this phenomenon. The available data suggest that the abnormally high secretion of some cytokines (interleukin 4, interleukin 5, transforming growth factor) induced by radiation causes an extensive fibrosis after an activation of fibroblasts. Histological confirmation is crucial in distinguishing RIM from similar‐looking diseases, such as chronic radiation dermatitis, cancer recurrence, radiation, recall dermatitis, new carcinoma or cellulitis. There is no clear treatment regimen for this condition. Clinical outcome after therapy is often unsatisfactory. The commonly used methods and agents include: topical and systemic steroids, calcineurin inhibitors, systemic immunosuppressants including methotrexate, tacrolimus, heparin, hyaluronidase, phototherapy (UVA, UVA1, UVB, PUVA), systemic antibiotics, imiquimod, mycophenolate mofetil, photophoresis. The differential diagnosis is challenging and requires a multidisciplinary approach to avoid misdiagnosis and to plan appropriate treatment.     

Influence of cigarette smoking on pemphigus – a systematic review and pooled analysis of the literature

Epidemiological evidence suggests that smoking cigarettes may be beneficial in pemphigus, but no systematic evaluation exists to corroborate this assumption. Therefore, a systematic literature review with pooled data analysis of the smoking status in patients with pemphigus was conducted. Electronic searches using PubMed from inception to November 2017 identified 13 reports meeting predetermined inclusion and exclusion criteria. Most were case–control studies partly reporting that pemphigus vulgaris and foliaceus occurred less frequently in current and former smokers. Studies also indicated that duration of smoking and number of cigarettes smoked were lower in patients with pemphigus than controls and that remission may be achieved sooner in those who smoke. However, although a generally low prevalence of smoking was demonstrated in patients with pemphigus, which was lower than in controls by pooled analysis, some investigations found no difference regarding the smoking status compared with non‐pemphigus subjects. One study demonstrated more severe mucosal involvement in non‐smoking patients with pemphigus, whereas another observed no difference in the rate of cutaneous or mucosal lesions between smokers and non‐smokers with pemphigus. This review indicates that smoking may be a possible protective factor in pemphigus, although some compromised study methodologies yet hinder any firm conclusion. Further investigations with a refined quality design are required to resolve the so far partly conflicting results in this area.     

Treatment of generalized granuloma annulare – a systematic review

Granuloma annulare (GA) is a benign inflammatory skin disease. Localized GA is likely to resolve spontaneously, while generalized GA (GGA) is rare and may persist for decades. GGA usually is resistant to a variety of therapeutic modalities and takes a chronic course. The objective of this study was to summarize all reported treatments of generalized granuloma annulare. This is a systematic review based on MEDLINE, Embase and Cochrane Central Register search of articles in English and German and a manual search, between 1980 and 2013, to summarize the treatment of generalized granuloma annulare. Most medical literature on treatment of GGA is limited to individual case reports and small series of patients treated without a control group. Randomized controlled clinical studies are missing. Multiple treatment modalities for GGA were reported including topical and systemic steroids, PUVA, isotretinoin, dapsone, pentoxifylline, hydroxychloroquine, cyclosporine, IFN‐γ, potassium iodide, nicotinamide, niacinamide, salicylic acid, dipyridamole, PDT, fumaric acid ester, etanercept, infliximab, adalimumab. While there are numerous case reports of successful treatments in the literature including surgical, medical and phototherapy options, well‐designed, randomized, controlled clinical trials are required for an evidence‐based treatment of GGA.     

Cost‐of‐illness of melanoma in Europe – a systematic review of the published literature

Malignant melanoma accounts for the vast majority of skin cancer deaths. Primary prevention is used to increase knowledge about skin cancer and set incentives for a change in behaviour, which leads to a decrease in cases. Primary prevention may be cost‐effective or even cost saving. Cost‐of‐illness (COI) studies provide information on such potential savings. The purpose of this study is to give an overview on COI studies in European countries and to compare the COI in total and by cost categories. The results can be used to model potential cost savings from prevention. We conducted a systematic literature research in PubMed using the PRISMA checklist. All costs were converted into Euro and adjusted for the reference year 2012. For the ranking of countries according to their COI, all costs were adjusted for the purchasing power parity. All studies focusing on stage III–IV melanoma include information on hospital, hospice, and outpatient treatment. Costs for the treatment of advanced melanoma range between € 2972 in Italy and € 17 408 in Sweden after adjusting for purchasing power parity. Most studies on stage I–IV melanoma include costs of hospitalization, outpatient treatment and general practitioner consultation. Direct costs range from € 923 in Sweden to € 9829 in Denmark. Three articles also include information on indirect costs. Mortality costs vary between € 3511 in Sweden and € 20 408 in England, morbidity costs between € 103 in Sweden and € 4550 in England. We showed that costs for the treatment of skin cancer are moderately high in the included countries. Since after publication of the articles new costly drugs were approved in Europe, treatment costs of melanoma in Europe may be expected to have risen in the last few years, which means that there is a high expectable potential for prevention programmes to become cost‐effective or even cost saving.     

Treatment of acquired reactive perforating dermatosis – a systematic review

Reactive perforating dermatosis is a rare chronic skin disease defined by the transepidermal elimination of collagen and/or elastin. In the acquired form in adults, it is frequently associated with diseases such as diabetes and chronic renal failure. No systematic reviews of treatment options are available for this disease. The aim of this systematic review is to summarize all reported treatment options for acquired reactive perforating dermatosis (ARPD). This is a systematic review based on a MEDLINE search of articles in English and German from 1990 to 2016. Most medical literature on the treatment of ARPD is limited to individual case reports and small series of patients. Various therapies that have been tried include antihistamines, topical keratolytics, corticosteroids, tretinoin, oral drugs such as allopurinol or antibiotics, and phototherapy or photochemotherapy. While there are no specific criteria for the evidence‐based selection of treatment options for ARPD, the first priority in management of these conditions should be treatment of an underlying disease if present. None of the described modalities has been approved for first‐line therapy. It is recommended to choose a combination of drugs that reduce itching and assist in the resolution of the skin lesions at the same time.     

Teledermatology in the times of COVID‐19 – a systematic review

The COVID‐19 pandemic restricts the care of dermatological patients in many ways. Teledermatology such as video consultation or “store‐and‐forward” teledermatology could at least partly compensate for this. This systematic review summarizes all published studies on teledermatology during the COVID‐19 pandemic. It is based on a MEDLINE search for articles from 2020 in English and German. Two surveys among dermatologists from the USA and India showed that more than 80 % offered teledermatology. Among German dermatologists 17.5 % of 480 respondents offered online video consultation, 11.3 % offline consultation (store and forward) and 10.0 % both. Five cohort studies on teledermatology during the pandemic were identified. Three of them investigated teledermatology in chronic dermatoses (acne, inflammatory skin diseases), one dealt with the care of oncological patients with dermatological complications, and one analyzed teleconsultation in suspected COVID‐19 cases. In all studies, teledermatology largely reduced the number of personal consultations. The results indicate that the limitations of personal dermatological care of patients with skin diseases during the COVID‐19 pandemic can be at least partially compensated by an extension of teledermatology. Findings from the use of teledermatology during the pandemic should be employed to improve the use and acceptance of teledermatology by patients and dermatologists.     

Deprescribing in dermatology: a systematic review of current dermatological guidelines

The term “deprescribing” refers to the systematic process of identifying, tapering, and discontinuing individually ineffective and/or potentially harmful drugs. Considering various aspects, the present review addresses the concept of “deprescribing” in the context of recommendations for use of systemic drugs contained in current dermatological guidelines. Overall, 16 sets of guidelines developed under the auspices of the German Society of Dermatology (DDG) were reviewed. Our analysis shows that many guidelines contain no or insufficient information in terms of deprescribing systemic drugs. We therefore propose that future guidelines and guideline updates should include standardized recommendations for discontinuation or dose adjustment of systemic therapies.     

Gram‐negative bacterial toe web infection – a systematic review

Gram‐negative bacterial toe web infection (GNBTWI) is a frequent therapeutic challenge in clinical practice with high recurrence rates and frequent need of systemic drugs. The aim of this systematic review was to provide an updated overview and evidence‐based data on pathogens, risk factors and treatment of GNBTWI along with promoting a consistent international terminology. This systematic review is based on a search in PubMed database for English and German articles published between 1980 and 2016. A total of seven articles were considered appropriate for inclusion in this review regarding to treatment and outcome. Throughout the medical literature, a variety of terms for bacterial toe web infections is used. Only few data on the incidence of GNBTWI were published. GNBTWI has been shown to have a significant male predominance. Pseudomonas aeruginosa is the most commonly identified organism beside a high mixed infection rate. We identified the following predisposing factors: interdigital tinea, occlusion and humidity, history of self‐medication with antifungals, antibiotics and glucocorticosteroids. As for treatment, debridement of macerated skin lesions and the hyperkeratotic rim showed good response in three published cases. Bacteriological workup of swabs including an antibiogram is recommended for identification of the proper topical and systemic therapy. Autosensitization dermatitis and frequent recurrences are common complications of GNBTWI. Despite the fact, that GNBTWI is an accepted disease entity, scarce data on GNBTWI exist in the medical literature. Randomized controlled trials are missing although needed for evidence‐based therapy. To facilitate communication and exchange of updates of GNBTWI, we promote the suggested terminology for bacterial toe web diseases.     

Nonattendance in a dermatology clinic – a large sample analysis

Background Previous studies have described factors determining non‐attendance at dermatology appointments in small sample sizes. Objective To perform an analysis of factors associated with non‐attendance in a dermatology clinic in a larger sample. Methods Factors determining non‐attendance were examined in 52 604 consecutive first‐time visits to a dermatology clinic over a period of 44 months. Results Non‐attendance proportion was 27.6%. Among children, non‐attendance was associated with waiting for an appointment < 7 days [odds ratio (OR), 1.44], Bedouin sector (OR, 1.30), rural Jewish sector (OR, 0.45) and the treating physician. Among adults, non‐attendance was associated with female gender (OR, 1.08), age < 55 years (OR, 1.65), waiting time for an appointment < 7 days (OR, 1.44), timing of the appointment between 1 and 4 pm (OR, 1.13), Bedouin sector (OR, 1.63), rural Jewish sector (OR, 0.46) and the treating physician. Conclusion Non‐attendance is common among Bedouins, adult female patients and young adults and is more likely as waiting times become longer. Strategies to reduce non‐attendance are needed.     

Atopic dermatitis and alcohol use – a meta‐analysis and systematic review

While several maternal exposures have been associated with an increased risk of atopic dermatitis (AD) in offspring, the effect of alcohol use during pregnancy on the risk of AD in offspring is unclear. Furthermore, it is unclear whether adults with AD have an increased alcohol use, although other poor health behaviours have been associated with AD including smoking and physical inactivity as well as psychiatric disease. In this systematic review and meta‐analysis, the association between alcohol use and AD was investigated in two ways: 1) whether alcohol use (drinkers versus abstainers) during pregnancy is associated with AD in offspring and 2) whether AD is associated with increased alcohol use. The medical databases PubMed, EMBASE and Web of Science were searched, and data extraction was carried out by two independent reviewers. Eighteen studies were included in the qualitative analysis (comparing alcohol drinkers to abstainers), and 12 studies were included in the quantitative analysis. There was a positive association between alcohol use during pregnancy and development of AD in offspring (pooled odds ratio [OR] 1.16; 95% confidence interval [CI] 1.09–1.24). However, there was no consistent association between AD in adults and adolescents and alcohol use (pooled OR 1.06; 95% CI 0.92–1.23). There is a need for future well‐designed prospective studies to firmly establish the association between alcohol use and AD.     

Elastolysis mediodermalis – case report and review of literature

Elastolysis mediodermalis is a rare disorder typically observed in middle‐aged women. Sites of predilection are the trunk and upper arms. The clinical picture varies and may appear as cigarette paper‐like wrinkling, perifollicular protrusions or reticular erythema. In contrast to the different clinical morphology, there is a consistent histology, i. e. localized, band‐shaped, and rarely focal loss of elastic fibers in the middle dermis. The etiology of elastolysis mediodermalis is unclear. UV radiation or immunological mechanisms may increase the release of matrix metalloproteinases, leading to a degradation of elastic fibers. There is no effective treatment for this condition.