An overview of skin scores used for quantifying hand eczema: a critical update according to the criteria of evidence‐based medicine

The present review gives an overview of the enormous variety of skin scores used for assessing severity in patients suffering from hand eczema. In order to evaluate the validity and practical relevance of different scoring systems according to the criteria of evidence‐based medicine, in May 2009 we performed a systematic search of the literature using PubMed and the Cochrane Library. A total of 69 articles reporting on 45 different methods for quantifying hand eczema were identified. The panel of methods varied from pure subjective categories to more or less quantitative scoring systems. Furthermore, by focusing on skin scores used in clinical trials in which the results led to the licensing of a systemic or topical drug for treatment of hand eczema, a panel of different scoring systems was identified. In addition to morphological pattern, some scoring systems included subjective complaints, which might cause an individual bias by overestimation of self‐reports. Inter‐ and intraobserver reliability was rarely reported except for three scores. Among these validated scores interobserver reliability was reported for three scores, but only one of the three included reliability within observers (repeatability). Advantages and disadvantages of the different scoring systems are critically discussed. Depending on different indications and particular settings (e.g. occupational screening vs. clinical examinations, evaluating progress of treatment in everyday clinical practice or for research purposes) scoring systems have to fulfil diverging demands. We draw the conclusion that a standardized diagnostic procedure for assessing the severity of hand eczema would facilitate the comparability of outcome of clinical trials. However, scoring systems used for occupational screening have to fulfil different demands compared with scoring systems used for licensing of drugs. This striking difference might be explained by the skin condition, which is generally supposed to be much better in subjects at medical check‐ups at the workplace.     

Evaluating statistics in clinical trials: making the unintelligible intelligible

Medical practitioners should be familiar with the basic principles of statistical testing and analysis, as the critical evaluation of clinical trials is an essential component to the effective practise of evidence-based medicine. Practitioners also need to be able to identify unethical trial design. The aim of this review is to facilitate an understanding of inferential methodology by introducing some of the basic principles involved in the critical analysis of trial design and interpretation.     

Nonclinical influences,beyond diagnosis and severity,on clinical decision making in dermatology: understanding the gap between guidelines and practice

Background Clinical decision making in dermatology is a complex process and might be influenced by a wide range of nonclinical factors. Objectives The aim of this study was to explore the role of nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology. Methods Semi‐structured qualitative interviews were conducted with 46 clinicians working in departments of dermatology of nine different hospitals in Wales. Interviews were audio‐recorded and later transcribed and their contents analysed. Results Nonclinical factors influencing patient management decisions in dermatology that were identified related to patients, clinicians and practice characteristics. Patient‐related factors included place of residence, socioeconomic circumstances, education and intelligence, ethnicity, age, treatment adherence, expectations from treatment, quality of life, concerns and worries, difficult patients, and family members or friends. Clinician‐related factors included time constraints in clinic, clinicians’ personal circumstances, relationship with colleagues, and relationship with pharmaceutical companies. Practice‐related factors included working in private practice, cost of treatment to the National Health Service (NHS), prescribing bureaucracy, and availability of treatment service in the work place. There was a difference between the consultants’ views and those of the other clinicians over the impact of pharmaceutical companies on clinicians’ prescribing and the awareness of treatment costs to the NHS. Most of the factors identified could potentially influence the clinicians’ decision‐making process subconsciously. Some clinicians highlighted that these factors are untaught in the medical curriculum, and are usually ignored in clinical guidelines, and therefore represent a challenge to the practice of evidence‐based medicine. Conclusions This study has described one aspect of the reality of medical decision making beyond the conventional evidence‐based guidelines approach. Proper understanding of nonclinical influences on decision making is of paramount importance for the best patient‐centred treatment outcomes.     

Improvement in skin wrinkles from the use of photostable retinyl retinoate: a randomized controlled trial

Background Photoaged skin can be treated with retinoids, which are natural and synthetic vitamin A derivatives. However, these are photounstable and can cause skin irritation, which is a major limitation in their use in general cosmetics. Retinyl retinoate, which is an ester of all‐trans retinoic acid (RA) and all‐trans retinol, has reduced toxicity due to blocking of the carboxyl end group of RA and higher skin regeneration activity than retinol. Objectives To assess the efficacy of a photostable retinyl retinoate in treating women over 30 years old with periorbital wrinkles. Methods We conducted two clinical studies with a total of 46 Korean women with periorbital wrinkles, who were not pregnant, nursing or undergoing any concurrent therapy. In the first clinical study, the efficacy of retinyl retinoate was compared with placebo. Twenty‐four patients completed a 12‐week trial of 0·06% retinyl retinoate applied twice daily to one side of the face and a placebo applied to the other side. In the second clinical study, the efficacy of retinyl retinoate was compared with retinol. Twenty‐two patients completed an 8‐week trial of 0·06% retinyl retinoate applied twice daily to one side of the face and 0·075% retinol applied to the other side. Efficacy was based on a global photodamage score, photographs, and image analysis using replicas and visiometer analysis (Skin‐Visiometer SV 600; Courage & Khazaka, Cologne, Germany) every 4 weeks. The standard wrinkle and roughness parameters used in assessing skin by visiometer were calculated and statistically analysed. Results The retinyl retinoate‐treated wrinkles improved compared with wrinkles treated with placebo or retinol, as assessed by both the investigators and the subjects. Also, skin replica analysis indicated significant improvements in retinyl retinoate‐treated skin in both studies, especially in average roughness. Conclusions Retinyl retinoate applied twice daily was significantly more effective than a placebo or retinol in treating periorbital wrinkles. Importantly, no severe side‐effects were observed.