First results from the multicentre study rehabilitation of occupational skin diseases--optimization and quality assurance of inpatient management (ROQ)

Background and objectives. The German stepwise procedure of handling occupational skin diseases (OSDs) offers interdisciplinary integrated (inpatient/outpatient) rehabilitation measures [tertiary individual prevention (TIP)] for severe OSD. In 2005, a prospective cohort multicentre study was started in order to evaluate TIP. Methods. One thousand seven hundred and eighty‐eight patients with severe OSD were treated and educated in five clinics with follow‐up before and 4 weeks after return to work. Results. During the inpatient phase, there was a significant improvement in the severity of OSD (Osnabrueck Hand Eczema Severity Index, p < 0.001) and in the quality of life (Dermatology Life Quality Index, p < 0.001). These effects were largely sustained during the outpatient follow‐up phase and in the 4 weeks after return to work. Among all patients, 89.4% used topical steroids before TIP, including 52.5% using high‐grade topical steroids; 93.2% of the patients were able to refrain from using topical steroids before returning to work. As a result of TIP, return to work was possible for 1587 patients (88.8%). Conclusions. The primary objectives of TIP (return to work, improvement of OSD, enhancement of quality of life, and reduction in the use of topical steroids) were successfully met. The long‐term follow‐up (1 and 3 years after TIP) will examine whether these favourable outcomes can be sustained.     

Multicenter study „Medical‐Occupational Rehabilitation Procedure Skin – optimizing and quality assurance of inpatient‐management (ROQ)”

Scientifically based prevention and patient management concepts in occupational dermatology have substantially improved during recent years. Currently the public statutory employers' liability insurance bodies fund a multi‐step intervention approach designed to provide quick preventive help for all levels of severity of occupational dermatoses. An administrative guideline (hierarchical multi‐step intervention procedure for occupational skin diseases –“Stufenverfahren Haut”) insures professional support and optimal patient orientation by the statutory insurers' representatives. For secondary prevention, the so‐called dermatologist's procedure (“Hautarztverfahren”) was recently updated in order to provide more rapid dermatologic consultations which are covered for by the public statutory employers' liability insurance bodies. Additionally, combined outpatient dermatologic and health‐educational intervention seminars (“secondary individual prevention”[SIP]) are offered to affected employees in a nationwide scheme. For those cases of occupational dermatoses in which these outpatient prevention measures are not successful, interdisciplinary inpatient rehabilitation measures have been developed (“tertiary individual prevention”[TIP]). TIP requires 3 weeks inpatient treatment including intensive health care instruction and psychological counseling, followed by outpatient treatment by the local dermatologist. In 2005, a German prospective cohort multicenter study (“Medical‐Occupational Rehabilitation Procedure Skin – optimizing and quality assurance of inpatient‐management”–“Medizinisch‐Berufliches Rehabilitationsverfahren Haut – Optimierung und Qualitätssicherung des Heilverfahrens”[ROQ]) started which will further standardize TIP and evaluate scientific sustainability in depth (3‐year dermatological follow‐up of 1,000 patients). The study is being funded by the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung [DGUV]).     

A 14‐year‐old girl with multiple,firm, dome‐shaped eroded nodules and itching on the limbs

The standard treatment of prurigo nodularis (PN) includes antihistamines, ultraviolet light, and topical and systemic corticosteroids; unfortunately, PN is notoriously resistant to the conventional therapy. Herewith is described one case of PN, which was initialized with herose as the first‐line therapy resulting in complete clinical clearance. Results of follow‐up examinations from 2005 to 2009 showed no evidence of recurrence. Findings indicate that herose monotherapy is a potentially promising therapeutic options for PN.     

Differential effects of a tertiary individual prevention programme for patients with occupational skin disease depending on diagnosis

Background Occupational skin disease (OSD) is common. Tertiary individual prevention programmes (TIP) aim at helping individuals with refractory OSD to remain active in the workforce. Evidence exists that these interventions improve skin protection behaviour related cognitions. However, it is not clear whether these effects generalize to all types of OSD. Objective To evaluate whether effects on socio‐cognitive determinants of skin protection behaviour vary between patients with work related atopic dermatitis (AD) and other work related skin diseases. Methods A total of 14 inpatients with work related AD and 87 inpatients with other work related skin diseases completed measures on socio‐cognitive determinants of skin protection behaviour before and after a 3‐week inpatient TIP. Mixed model analyses, using maximum‐likelihood estimation tested whether there were differential effects of the intervention on socio‐cognitive determinants of skin protection behaviour. Results Although patients with AD reported more favourable cognitions towards skin protection behaviour than patients with other skin diseases at admission, these cognitions deteriorated or remained on the same level. Patients with other forms of OSD on the other hand developed more favourable cognitions during the intervention. Conclusion Professionals working in the field of OSD should not cease to assist AD patients in achieving optimal skin protection behaviour. Tertiary individual prevention measures may need to pay more attention to the needs of individuals with an occupationally relevant AD. This may contribute to their being able to remain active in the workforce. The alternative would entail regular sick leave, poorer quality of life and economic hardship for the AD patient.     

Quality of life and health‐related utility analysis of adults with moderate and severe atopic dermatitis treated with tacrolimus ointment vs. topical corticosteroids

Background The purpose of this study was to measure change in quality of life (QoL) and estimate health‐related utility in adults with moderate and severe atopic dermatitis (AD) following the use of either tacrolimus ointment or topical corticosteroids. Methods Data were analysed from a double‐blind, randomized controlled trial comparing the treatment of adults with moderate and severe AD with either tacrolimus ointment or a standard corticosteroid regimen. Following randomisation, patients applied their medication twice‐daily for 6 months. Monthly assessments determined response and QoL. Health‐related utility (EQ5Dindex) was estimated by Monte Carlo simulation from SF‐12 responses via a published mapping algorithm. Results At baseline, estimated utility data were available for 926 (95%) of the intention‐to‐treat patients, 57% of whom had AD of moderate severity (43% severe). The mean age at baseline was 32.5 years (SD ± 11.8), 46.2% were male, with a mean EQ5Dindex for moderate cases of 0.770 (SD ± 0.157), and 0.665 (SD ± 0.225) for those with severe disease (P < 0.001). Patients treated with tacrolimus ointment showed significantly greater improvement in all but one domain of the SF‐36. At baseline, there was no difference in estimated utility between the two groups; however, a difference in utility in favour of tacrolimus ointment emerged after 1 month’s treatment (0.849 vs. 0.820; P = 0.004). Over the 6‐month study period, the mean, marginal utility difference between the study arms was 0.032 U (utility) in favour of tacrolimus (P < 0.001). Conclusion Treatment with 0.1% tacrolimus ointment rather than a standard topical corticosteroid ointment regimen was associated with clinically significant, incremental improvement in QoL, sustained over a 6‐month period. A within‐trial cost‐utility estimate based on study medication cost alone suggests that tacrolimus ointment is highly cost‐effective given existing willingness‐to‐pay thresholds.     

Long‐Term Follow‐Up of Pediatric Trachyonychia

Pediatric trachyonychia is an acquired nail disease that can cause distress to families. It is a poorly understood disease, and long‐term follow‐up data are lacking. We present an institutional review of 11 children with isolated pediatric trachyonychia followed over time. Children with the diagnosis of pediatric trachyonychia were identified and invited to participate. Pictures were taken on follow‐up and a questionnaire was answered. Exclusion criteria include having another diagnosis at the initial visit that causes nail dystrophy. Eleven patients with the diagnosis of pediatric trachyonychia were available for follow‐up. The mean age of appearance was 2.7 years (range 2–7 yrs) and the average follow‐up was 66 months (range 10–126 mos). Nine patients were treated with potent topical corticosteroids, one used only petrolatum, and one took vitamin supplements. One patient was found to have an additional skin and hair diagnosis of alopecia areata on follow‐up. On follow‐up, 82% noted improvement of the nails, whereas 18% noted no change. A majority of cases of pediatric trachyonychia are isolated and improve with time, regardless of treatment.     

StabiEL: Stabilization of skin condition with Elidel – a patients’ satisfaction observational study addressing the treatment,with pimecrolimus cream,of atopic dermatitis pretreated with topical corticosteroid

Background The objective of this 4‐month multicentre observational study was to evaluate safety and efficacy of intermittent long‐term treatment of patients with atopic dermatitis (AD) with pimecrolimus cream 1% in the daily practice and to compare it with the preceding topical corticosteroid‐based therapy in retrospective. Patients and methods Overall severity of AD and individual symptoms were assessed in 3200 patients by the physician, whereas acceptance of treatment and satisfaction of patients was investigated using a patient questionnaire. Results The percentage of patients clear or almost clear of symptoms increased from 12% to 82%. Seventy‐four per cent of physician rated the treatment better than the preceding therapy, and 21% noted no difference. Seventy‐seven per cent of the patients asserted that long‐term intermittent treatment with pimecrolimus reduces the frequency of flares as opposed to less than 27% for topical corticosteroids. Patients also felt that pimecrolimus results in a higher improvement in quality of life; 84% stated that pimecrolimus stabilized the skin compared with 27% for topical steroids. Conclusion Intermittent treatment of AD patients with pimecrolimus cream 1% is effective and well tolerated, and results in higher patient satisfaction compared with topical corticosteroids in retrospective.     

Successful management of infliximab‐induced generalized pustular psoriasis without therapy discontinuation in a patient with psoriatic arthritis

While infliximab has been shown to be paradoxically associated with the development of pustular psoriasis in patients with rheumatoid arthritis, spondyloaripathies, juvenile idiopathic, and inflammatory bowel disease, there are few cases of pustular psoriasis induced by infliximab in patients with psoriasis. We here present a 55‐year‐old female patient with longstanding plaque psoriasis and psoriatic arthritis who developed generalized pustular psoriasis 1 month after the fifth infusion of infliximab. Given the lack of other side effects and the rapid initial response of the underlying psoriatic arthritis, we opted against discontinuing infliximab therapy, and the sixth infusion of infliximab was administered 10 days ahead of schedule. Topical corticosteroids were added for the management of pustular lesions on initial presentation. One week after the sixth infusion, the pustular psoriatic lesions almost completely disappeared. No recurrence of pustular psoriasis was observed during the 3‐month follow‐up. Our experience shows that pustular lesions associated with infliximab can be successfully managed with topical corticosteroids without discontinuing infliximab therapy or compromising therapeutic benefit seen upon the underlying condition.     

CARPE: a registry project of the German Dermatological Society (DDG) for the characterization and care of chronic hand eczema

Background: The aim of the CARPE (German acronym: C hronisches Ha ndekzem‐R egister zum P atienten‐Langzeitmanage ment; meaning: chronic hand eczema registry on long‐term patient management) registry is to investigate characteristics and treatment modalities in patients affected by chronic hand eczema in Germany. Methods: The registry was built up under the auspices of the German Dermatological Society (Deutsche Dermatologische Gesellschaft, DDG). Patients with chronic hand eczema are prospectively assessed by dermatolog‐ical examination and patient questionnaire. Socio‐economic data and data on diagnostics, skin status, severity and treatment of chronic hand eczema and atopy criteria are repeatedly assessed. Here, we present baseline characteristics of the first 515 patients. Results: 53.8 % of the patients were female, mean age was 47.3 years. The average duration of CHE was 7.7 years. 30.4 % had already received inpatient care, 31.2 % had been on sick leave in the past 12 months. 94.5 % had received topical corticosteroids prior to inclusion in the registry, 31.9 % topical calcineurin inhibitors, 38.3 % UV therapy, 28.6 % systemic antihistamines, 36.5 % systemic treatments, 14.9 % systemic corticosteroids, 25.8 % systemic retinoids. Conclusions: The CARPE project demonstrates the high medical burden and therapeutic challenge of chronic hand eczema and presents first data for health care research. Furthermore, the designed follow‐up study will present important data about the natural history and prognosis of this chronic skin disease.     

Topical Imiquimod for the Treatment of Childhood Cutaneous Langerhans Cell Histiocytosis

Although topical steroids are considered first‐line treatment for cutaneous Langerhans cell histiocytosis (LCH), the appropriate therapy for refractory cases remains controversial. We report a 16‐month‐old girl with isolated cutaneous LCH refractory to treatment with topical corticosteroids and topical tacrolimus. Treatment was initiated with 5% topical imiquimod cream and the rash completely resolved after 5 months of therapy. There was no disease recurrence after more than 2 years of follow‐up. We present this case to highlight imiquimod as a novel therapeutic agent for the management of isolated cutaneous LCH in children.     

Orofacial granulomatosis in a 12‐year‐old girl successfully treated with intravenous pulse corticosteroid therapy and chloroquine

Orofacial granulomatosis, a rare disease in childhood, is characterized by orofacial swelling in the absence of systemic disease. We report the case of a 12‐year‐old girl with asymptomatic erythematous infiltration of her upper lip, cheeks, and chin that had persisted for more than 2 years; biopsy confirmed granuloma formation. Because a large area was affected, intralesional corticosteroids were inappropriate and six cycles of 3‐day intravenous pulse corticosteroid therapy (dexamethasone 1.5mg/kg), repeated once after 4 weeks, was given. Our patient also received oral chloroquine and topical emollients. At the end of the sixth pulse cycle, the infiltration had completely resolved, leaving slight residual erythema.     

Prospective,open‐label,rater‐blinded and self‐controlled pilot study of the treatment of proliferating superficial infantile hemangiomas with 0.5% topical timolol cream versus 595‐nm pulsed dye laser

Topical timolol and 595‐nm pulsed dye laser (PDL) are both widely used in the treatment of superficial infantile hemangiomas (IH). However, to date, there is no reliable study comparing the therapeutic outcomes between the two treatment options. We designed the present study to evaluate and compare the efficacy and safety of timolol cream and PDL in the treatment of superficial proliferating IH. Twenty‐one patients with superficial IH were included in the study. Each lesion was divided into two regions; one part was treated with 0.5% topical timolol cream four times daily, and the other part was treated monthly with PDL. Both treatments were continued for 2–6 months. Five independent and blinded assessors were asked to judge the results in both the topical timolol‐treated and PDL‐treated parts by comparing photographs taken before and after treatment. Both treatments resulted in significant clinical improvements after 3.39 sessions in the 2‐month follow up. The average visual evaluation showed that PDL had significantly better results than topical timolol (6.55 ± 2.26 to 4.98 ± 2.92, P < 0.01). No patients experienced permanent side‐effects during the treatment. Our short‐term study revealed that PDL had better results compared with topical timolol cream application in the treatment of superficial proliferating IH. Further studies with longer follow‐up time and larger sample size are required to validate our findings.     

Chondrodermatitis nodularis chronica helicis – a conservative therapeutic approach by decompression

Background: Chondrodermatitis nodularis chronica helicis is a rather common condition which substantially affects quality of life causing pain and sleeping disturbances. Surgical treatment is connected with a tendency to recurrence. Mechanical pressure is probably the main etiological factor. Patients and Methods: A prospective study was performed with 18 patients that were offered a non‐surgical treatment using a self‐made bandage of foam plastic which they applied during the night. Of these, 12 performed the treatment including follow‐up; 6 patients initially also consented, but they did not return after the initial visit. Results: 11 patients reported substantial reduction of pain within the first month; after an average of 1.75 months they were free of pain. All 8 patients with initial sleeping problems caused by pain reported undisturbed sleep after only one month. In 11 patients the lesions receded satisfactorily, in 9 patients completely, in 2 patients leaving small asymptomatic residual lesions. Recurrences appeared in 3 patients with 2 of them having been surgically pretreated at the same location. Conclusions: We recommend conservative treatment using protective padding as first line treatment for chondrodermatitis nodularis chronica helicis. The successful outcome achieved only by relief of pressure supports pressure as the main etiological factor in the development of the disease.     

A novel two‐step kit for topical treatment of tinea pedis – an open study

Background Tinea pedis is a common skin disease affecting most of the population during their lifetime. Topical and systemic treatments give only temporary relief. Objective To evaluate the efficacy and safety of a new topical treatment for moderate‐to‐severe tinea pedis. Methods Fifty patients suffering from tinea pedis were treated in two stages: the active stage – single use of the novel topical solution for 45 min and novel cream twice weekly for 4 weeks; the preventive stage – cream application once weekly for 10 months. Results Forty‐five patients completed the active stage and achieved 76% cure rate. The medication was well tolerated; one patient dropped from the study because of very mild irritation. No other topical or systemic side effects were noted. Another five patients were lost to follow‐up during the preventive stage. The total cure rate after the preventive stage was 70%. Conclusions This novel treatment was found to be effective, well tolerated and safe in the treatment of moderate and severe tinea pedis during the active and the preventive stages.     

Cost‐efficacy and pharmacoeconomics of psoriatic patients in Japan: Analysis from a single outpatient clinic

Compared with topical corticosteroids, topical combined active vitamin D₃/corticosteroids and especially biologics are more expensive despite their marked efficacy in the treatment of psoriasis. The aim of the present study is to evaluate total costs as well as costs versus efficacy of various psoriasis treatments under the current Japanese health‐care insurance system. A prospective study was performed from the database of a single clinic located in Hokkaido Prefecture. Cost and quality of life of psoriatic patients were evaluated in a prospective manner during a total of 12 months from March 2017 until June 2018. Quality‐adjusted life year (QALY) of biologics was the highest among all treatments. Among the topical treatments, the cost versus efficacy of combined active vitamin D₃/corticosteroid was lowest (¥10 557/1 Psoriasis Area and Severity Index). Furthermore, incremental cost‐effectiveness ratio (ICER) of combined active vitamin D₃/corticosteroid was ¥1 024 031/QALY when compared with topical corticosteroid treatment alone. The topical combined active vitamin D₃/corticosteroid treatment showed the best cost‐efficacy in terms of medical economic burden.     

Follow‐up of actinic keratoses after shave biopsy by in‐vivo reflectance confocal microscopy – a pilot study

Background Monitoring of treatment efficacy after shave biopsy of actinic keratoses (AK) is often difficult, as clinical and dermoscopic features may not be reliable. Objectives  We investigated the applicability of in‐vivo reflectance confocal microscopy (RCM) for the follow‐up of AK after shave biopsy. Methods A total of 10 lesions were investigated by RCM before shave biopsy, after 3 and 12 months by two observers in agreement blinded to location, patients and time interval. Results At baseline all lesions showed typical clinical, dermoscopic and RCM criteria of AK. Three months after shave biopsy, all lesions presented clinically as normal skin (NS), but two lesions showed features suspicious for AK by RCM. After 12 months, one lesion of these two lesions changed into NS in RCM, whereas the other lesion progressed into clinical visible AK. At baseline, the two observers diagnosed 10 of 10 lesions correctly in RCM, after 3 months eight of 10 lesions and after 12 months all lesions were diagnosed correctly. Conclusions Our results suggest that RCM might be a useful tool in the follow‐up of AK after shave biopsy and might be used in inconclusive clinical and dermoscopic presentations of lesions after surgery or other treatment modalities.     

Low‐dose acitretin in Papillon–Lefèvre syndrome: treatment and 1‐year follow‐up

The Papillon–Lefèvre syndrome (PLS) is a rare, autosomal recessive disease that manifests with palmoplantar keratoderma and destructive periodontitis resulting in early onset periodontal breakdown in deciduous and permanent dentition. Management of this condition is difficult. Here we report one 11‐year‐old consanguineous Muslim boy suffering from PLS. After failing to get any benefit from methotrexate, three cycles of acitretin, each for 2 months, were given 1 month apart. In each cycle, acitretin (25 mg) was given every other day. At the end of the third cycle, treatment was stopped for 4 months to observe the extent of relapse. Thereafter, acitretin (25 mg) was given twice weekly for 4 months and then the patient was followed up for 1 year. Treatment with acitretin resulted in excellent improvement of periodontitis, increase in the alveolar bone height, and periodontal attachment. Improvement remained stable at the end of 1‐year follow‐up. There was excellent (>75%) improvement in keratoderma at the end of active therapy. Mild worsening of palmoplantar keratoderma was noticed whenever the drug was stopped. It improved when the drug was restarted. Other areas remained stable. At the end of 1‐year follow‐up, good improvement (50%) in palmoplantar keratoderma was achieved.     

Quality of psoriasis care in Germany – results of the national study PsoHealth 2007

Background: Many different forms of treatment are available for psoriasis. The German standard is the national AWMF S3 guideline. A national survey on psoriasis care in 2005 indicated deficits in psoriasis care in Germany. Aim: Assessment of the health care situation of patients with psoriasis in Germany. Methods: Nation‐wide cross‐sectional study, in 142 dermatological practices and clinics. The following data were documented: a) Doctor Questionnaire: Treatment, illnesses, clinical characteristics and severity (PASI). b) Patient Questionnaire: Quality of life (QoL), patient relevant therapeutic benefits and satisfaction with the quality of the care. A panel of experts developed and analyzed 8 criteria as indicators of the quality of care. Results: Of the 2009 evaluated patients, 11.6% suffered from severe psoriasis (PASI > 20) and 27.4% from moderate psoriasis (PASI 10–20). The average PASI value was 10.1, and the DLQI 7.5. 32.2% of patients had a serious reduction in their QoL (DLQI > 10). The share of patients with preceding systemic therapy was 47.3%, in severe psoriasis 62.1%, while 20.1% of the patients had received inpatient treatment. The average number of days absent from work was 3.4. Compared to 2005, all 8 indicators improved. Conclusion: Significant numbers of psoriasis patients show serious quality of life reductions and high grades of clinical severity. In comparison to 2005, there has been a notable, nation‐wide improvement in psoriasis care.     

Long‐term follow‐up of photodynamic therapy with a self‐adhesive 5‐aminolaevulinic acid patch: 12 months data

Background Photodynamic therapy with a self‐adhesive 5‐aminolaevulinic acid (5‐ALA) patch shows high efficacy rates in the treatment of mild to moderate actinic keratosis (AK) in short term trials. Objectives The purpose of the trial was to follow up patients after successful 5‐ALA patch‐PDT at 3 month intervals over a total period of 12 months. Patients who had received placebo‐PDT or cryosurgery served for comparison. Patients/methods Three months after therapy, 360 patients from two separate randomized parallel group phase III studies (one superiority trial vs. placebo‐PDT, one noninferiority trial vs. cryosurgery) were suitable for the follow‐up study. Patients had to show at least one successfully treated AK lesion after initial therapy. A total of 316 patients completed the follow‐up. Results Twelve months after a single treatment, 5‐ALA patch‐PDT still proved superior to placebo‐PDT and cryosurgery (P < 0·001 for all tests). On a lesion basis, efficacy rates were 63% and 79% for PDT, 63% for cryosurgery and 9% and 25% for placebo‐PDT. Recurrence rates of patch‐PDT proved superior to those of cryosurgery (per protocol set: P = 0·011, full analysis set: P = 0·049). While 31% of cryosurgery lesions were still hypopigmented after 1 year, the 5‐ALA patch‐PDT groups showed hypopigmentation in 0% (superiority trial) and 3% (noninferiority trial) of the treated lesions. Conclusion Twelve months after a single 5‐ALA patch‐PDT the majority of lesions were still cleared with an excellent cosmetic outcome. 5‐ALA patch‐PDT proved to be superior to cryosurgery in the noninferiority study setting.