The Chronicle of Skin & Allergy Oct-Nov. 2015

24
Psoriasis Vaccines should be recommended for patients treated with biologics n Checking a patient’s vaccine status should be standard before treating with a biologic by EMILY INNES, Associate Editor, The Chronicle I t is important that dermatolo- gists routinely check patient’s immunization status before starting them on biologic therapies, according to a Markham, Ont.-based dermatologist who spoke at Dermatology Update in Toronto. “We know that patients with dif- ferent inflammatory diseases may have an increased risk of infection so to consider anything you can do to reduce the risk of those infections would be very important,” said Dr. John Kraft, with the Lynde Centre for Dermatology. “Medications, as well, [such as biologics] that you add on to treat your patient with inflammato- ry conditions will also increase the chances of cer- tain infections. Immunizations have their way of decreasing this infection risk.” Patients on biologics more susceptible to infection Dr. Kraft said when clinicians are screening for cardiovascular comor- bidities, latent tuberculosis or hepati- tis, it it is a good opportunity to also consider immunizations. “We are going to be putting them at a disadvantage in terms of suscep- tibility to getting infections. Therefore we should consider protecting them by offering vaccinations to our patients.” Vaccines should be administered at least two weeks before biologics Please turn to Vaccines page 20 à Canada random telephone survey that occurred between Sept. 2010 and Sept. 2011. Participants included in the investigation were 480 individuals with either self-reported convinc- ing symptoms or a physician’s diagnosis of an allergy to any of nine common food allergens to milk, egg, peanut, tree nut, shell- fish, fish, wheat, soy, or sesame. A total of 4,950 healthy controls also completed the survey, the authors reported. According to investigators, the P RACTICAL T HERAPEUTICS and C LINICAL N EWS from the W ORLD of D ERMATOLOGY n O CT./N OV. 2015 by JOHN EVANS, Associate Editor, The Chronicle E czema in the first two years of life appears to be associ- ated with common food allergies, according to results of a case control study published in the International Archives of Allergy and Immunology (May 2015; 166(3):199–207). This study, referred to as the SPAACE study (Surveying Prevalence of Food Allergy in All Canadian Environments), consisted of a cross- Atopic dermatitis Eczema in first two years of life linked to common food allergies n Early life events crucial to development of food allergy, tolerance of & ALLERGY SKIN SKIN The Chronicle All rights reserved. Chronicle Information Resources Ltd. Canada Post Canadian Publications Mail Sales Product Agreement Number 40016917 questions in the survey asked about environmental factors including day- care attendance, pet ownership, whether the indi- vidual spent time living on a farm, as well as personal and family history of atopy including both eczema and asthma. “We were especially interested in eczema in early life because all [recent] studies suggest that events in the environ- Please turn to Eczema page 21 à NMSC Sunburn art likely to promote new, unusual tanning practices n Disturbing trend amplifies deleterious effects of tanning, dermatologist says by JOHN EVANS, Associate Editor, The Chronicle T he emergence of ‘sunburn art’—creating an image on the skin by applying an adhesive stencil or painting on sun- block before Please turn to Sunburn art page 12 à Dr. Moshe Ben-Shoshan Dr. John Kraft See page 4 See page 4 Image courtesy chris kohut (cc) Creative Commons Psoriasis Patients expecting improved outcomes n The Chronicle is committed to maintaining leadership in envi- ronmentally sustainable poli- cies, and to encouraging the adoption of “green-aware” prac- tices in healthcare. We invite your comments via e-mail, at: [email protected] Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:31 PM Page 1

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Transcript of The Chronicle of Skin & Allergy Oct-Nov. 2015

Page 1: The Chronicle of Skin & Allergy Oct-Nov. 2015

P s o r i a s i s

Vaccines should berecommended forpatients treatedwith biologicsn Checking a patient’svaccine status shouldbe standard beforetreating with a biologic by EMILY INNES,Associate Editor, The Chronicle

It is important that dermatolo-gists routinely check patient’simmunization status before

starting them on biologic therapies,according to a Markham, Ont.-baseddermatologist who spoke atDermatology Update in Toronto.

“We know that patients with dif-ferent inflammatory diseases mayhave an increased risk of infection soto consider anything you can do toreduce the risk of those infectionswould be very important,” said Dr.John Kraft, withthe Lynde Centrefor Dermatology.“Medications, aswell, [such asbiologics] thatyou add on totreat your patientwith inflammato-ry conditions willalso increase thechances of cer-tain infections. Immunizations havetheir way of decreasing this infectionrisk.”

Patients on biologicsmore susceptible to infectionDr. Kraft said when clinicians arescreening for cardiovascular comor-bidities, latent tuberculosis or hepati-tis, it it is a good opportunity to alsoconsider immunizations.

“We are going to be putting themat a disadvantage in terms of suscep-tibility to getting infections. Thereforewe should consider protecting themby offering vaccinations to ourpatients.”

Vaccines should be administeredat least two weeks before biologics

Please turn to Vaccines page 20à

Canada random telephone surveythat occurred between Sept. 2010and Sept. 2011.

Participants included in theinvestigation were 480 individualswith either self-reported convinc-ing symptoms or a physician’sdiagnosis of an allergy to any ofnine common food allergens tomilk, egg, peanut, tree nut, shell-fish, fish, wheat, soy, or sesame.A total of 4,950 healthy controlsalso completed the survey, theauthors reported.

According to investigators, the

PRACTICAL THERAPEUTICS and CLINICAL NEWS from the WORLD of DERMATOLOGY n OCT./NOV. 2015

by JOHN EVANS,Associate Editor, The Chronicle

Eczema in the first two yearsof life appears to be associ-ated with common food

allergies, according to results of acase control study published in theInternational Archives of Allergyand Immunology (May 2015;166(3):199–207).

This study, referred to as theSPAACE study (Surveying Prevalenceof Food Allergy in All CanadianEnvironments), consisted of a cross-

A t o p i c d e r m a t i t i s

Eczema in first two years of lifelinked to common food allergiesn Early life events crucial to development of food allergy, tolerance

o f & A L L E R G YSKINSKINThe Chronicle

All rights reserved. C

hronicle Inform

ation Resources Ltd.Canada Post C

anadian Publications Mail Sales Product Agreem

ent N

umber 40016917

questions in the survey asked aboutenvironmental factors including day-

care attendance,pet ownership,whether the indi-vidual spent timeliving on a farm, aswell as personaland family historyof atopy includingboth eczema andasthma.

“We wereespecially interested in eczema inearly life because all [recent] studiessuggest that events in the environ-

Please turn to Eczema page 21àN M S C

Sunburn artlikely to promotenew, unusual tanning practicesn Disturbing trend amplifies deleteriouseffects of tanning, dermatologist says by JOHN EVANS, Associate Editor, The Chronicle

The emergence of ‘sunburn art’—creating an image on theskin by applying an adhesive stencil or painting on sun-block before Please turn to Sunburn art page 12à

Dr. MosheBen-Shoshan

Dr. John Kraft

See page 4See page 4

Image courtesy chris kohut (cc) Creative Commons

Psoriasis

Patients expecting improved outcomes

n The Chronicle is committed tomaintaining leadership in envi-ronmentally sustainable poli-cies, and to encouraging theadoption of “green-aware” prac-tices in healthcare. We inviteyour comments via e-mail, at:[email protected]

Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:31 PM Page 1

Page 2: The Chronicle of Skin & Allergy Oct-Nov. 2015

For oily skin For dry skin

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Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:31 PM Page 2

Page 3: The Chronicle of Skin & Allergy Oct-Nov. 2015

THE CHRONICLE of SKIN & ALLERGY

Vol. 21, No. 7 Oct./Nov. 2015 · 3

R e s e a r c h

Do JAKs promote hair growth?

TOP ofthe MONTH

Outcomes of continuous suturesequivalent to interrupted suturesfor facial woundsNo significant differences seen incosmetic outcomes between con-tinuous or interrupted suture tech-niques, may save time and materi-als, according to the results of aVancouver study . . . . . . . . . . . . . . . . 8

The latest news in pediatricdermatology: Cancer survivors andsun avoidanceChildhood cancer survivors, in spiteof instruction on sun protectionhabits, do not generally fully followthese instructions, and additionalefforts to improve sun protectionbehaviour will be needed through-out their lives . . . . . . . . . . . . . . . . 12

Clinical erythema assessment tool forintra- and intra-rating of facialerythema determined reliable Evaluated for the first time, theClinician Erythema Assessment(CEA) grading scale has beendetermined to be an effective mea-sure of facial erythema associatedwith rosacea . . . . . . . . . . . . . . . . .18

Chronicle Postgraduate Educational SupplementIn this month’s Chronicle Post -graduate Educational Supplement,Spanish researchers investigatehow adherence to drug treatmentsand adjuvant barrier repair thera-pies play a key role in achievingclinical improvement in patientswith mild to moderate acne . . . 23

“If you don’t achieve a target [with a psoriasistherapy] after three to six months, you have not

hit the bull’s eye.”Dr. Charles Lynde, medical director at the Lynde Institute for

Dermatology in Markham, Ont., and associate professor in theDepartment of Medicine at the University of Toronto

(see page 4)

Janus kinase (JAK) inhibitors, used fortreating auto-immune diseases such asrheumatoid arthritis, appear to stronglypromote hair growth when appliedtopically to the skin, say researchersfrom Columbia University MedicalCenter in New York. The findings werepublished in Science Advances (Oct. 2,2015; 1(9): e1500973).

The researchers were testing JAKinhibitors orally for the treatment ofalopecia areata. They have also beentested for treating plaque psoriasis.

In a press release from theMedical Center on Oct. 23, 2015, studyauthor Angela M. Christiano, PhD,said: “What we’ve found is promising,though we haven’t yet shown it’s acure for pattern baldness.”

Dr. Christiano and her team havebeen investigating the use of JAKinhibitors to impair the auto-immuneresponse associated with alopecia

areata. In the course of those experi-ments, Dr. Christiano found thathealthy mice grew more hair whenthe drugs were applied topically thanwhen they were taken systemically.That suggested JAKs were doingmore than just reducing the immunesystem’s attack on the hair follicles—they may be working on the hair folli-cles directly in some way.

Researchers found that JAKinhibitors applied topically were mak-ing the hair follicles come out of dor-mancy rapidly, with some resting hairfollicles sprouting a new hair in lessthan 10 days.

“There aren’t many compoundsthat can push hair follicles into theirgrowth cycle so quickly,” said Dr.Christiano in the release. “Some topi-cal agents induce tufts of hair hereand there after a few weeks, but veryfew compounds have this potent aneffect so quickly.”

From the News Resources of The Chronicle

Published eight times per year bythe proprietor, ChronicleInformation Resources Ltd., withoffices at 555 Burnham thorpe Road,Ste 306, Toronto, Ont. M9C 2Y3Canada. Telephone: (416) 916-2476; Facs. (416) 352-6199.

E-mail: [email protected]

ISSN No. 1209-0581

Contents © ChronicleInformation Resources Ltd., 2015except where noted. All rights

reserved worldwide.

The Publisher prohibits reproduc-tion in any form, including print,broadcast, and electronic, withoutwritten permissions.

Printed in Canada. The Chronicleof Skin & Allergy is a Canadianpublication. The Publisher certifiesthat advertising placed in this pub-lication meets Revenue Canadarequirements for tax deductibility.

Subscriptions: $85.60 per year inCanada, $129.95 per year in allother countries. Single copies:$10.00 per issue (plus 13% HST).

Canada Post Canadian PublicationsMail Sales Product AgreementNumber 40016917. Please forwardall correspondence on circulationmatters to: The Chronicle of Skin &Allergy, 555 Burnhamthorpe Road,Ste 306, Toronto, Ont. M9C 2Y3

Ideas in the Service of Medicinesm

Affiliated journals of the ChronicleCompanies include The Chronicle ofCosmetic Medicine+ Surgery, TheChronicle ofNeurology &Psychiatry, PediatricChronicle, The

Chronicle of Healthcare Marketing,Drug Rep Chronicle, and Linacre’sBooks/Les Editions Linacre

October/November 2015 • Vol. 21 No. 7

Medical EditorWayne Gulliver, MD, FRCPC

Editor, Cosmetic DermatologySheldon V. Pollack, MD, FRCPC

Publisher Mitchell ShannonEditorial Director R. Allan Ryan

Senior Editor Lynn BradshawAssociate Editors John Evans, Emily Innes

Production and Circulation Cathy Dusome

Sales & Marketing Sandi Leckie, RN

Founding Editor Colin A. Ramsay, MD, FRCPC (1936-2003)

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Richard Langley, MD, FRCPC

Danielle Marcoux, MD, FRCPC

R.A.W. Miller, MD, FRCPC

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Kim Papp, MD, FRCPC

Yves Poulin, MD, FRCPC

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Contacting The Chroniclen READER SERVICE: To change your address, or

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Comptroller Rose Arciero

A Message from theMedical Editor

In this issue of THE CHRONICLE wecover a multitude of topics rang-ing from childhood food allergies

to an update on the treatment of pso-riasis to the best wayto repair a Mohs surgi-cal defect. As in everyissue, there is signifi-cant content related toresearch across thecountry.

Starting out westDr. David Zloty’s pioneer research onsuture techniques answers an impor-tant question “which method willgive the best cosmetic outcome”?(see page 8). It’s great to see ourCanadian derm surgeons leading theworld in this area of research.

From Ontario, Dr. Jerry Tan pro-vides readers with insight into thenew method for measuring erythemarelated to rosacea (see page 18). Onthe psoriasis front Drs. MelindaGooderham and Julia Carroll weigh-in on the recent development withrespect to brodalumab in suicide risk(page 4). In the same article Dr.Charles Lynde reflects upon the tar-get for treating psoriasis and how wehave gone from a target of PASI 50 in2005 to PASI 90 or 100 in 2015. Withthe treatments we have in our toolkitand the addition of the anti IL-17s wecan help achieve these targets in themajority of our patients. Drs. Lyndeand Gooderham also highlight the

Please turn to Message page 21à

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LESS.Less ingredients. No sulfates* or scents. Our mild, gentle cleansers and benzoyl peroxide wash are there to support your treatment regimen

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TM/® or licensed GlaxoSmithKline Consumer Healthcare Inc. Mississauga, Ontario L5N 6L4 ©2015 The GSK group of companies. All rights reserved.

*Excluding Spectro AcneCare® which is a medicated treatment.

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es* or sctaedients. No sulfe therash arxide w

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Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:31 PM Page 3

Page 4: The Chronicle of Skin & Allergy Oct-Nov. 2015

by LOUISE GAGNON,Correspondent, The Chronicle

4 · Oct./Nov. 2015

Lead article THE CHRONICLE of SKIN & ALLERGY

COSENTYX and SensoReady are registered trademarks.Product Monograph available on request.Printed in Canada 15COS020E© Novartis Pharmaceuticals Canada Inc. 2015

AE: adverse event.† Clinical signi�cance unknown.‡ ERASURE was a randomized, multicenter, double-blind, placebo-controlled phase III trial. Patients were randomized in a 1:1:1 ratio to receive COSENTYX® 300 mg (n=245), COSENTYX® 150 mg (n=245), or placebo (n=248). COSENTYX®

groups received two 150-mg subcutaneous injections (i.e., 300 mg total) or one 150-mg injection plus one placebo injection. Both injections were administered once weekly at weeks 0, 1, 2, 3, then monthly from week 4 to week 48. § FIXTURE was a randomized, multicenter, double-blind, placebo- and active-controlled phase III trial. Patients were randomized in a 1:1:1:1 ratio to receive COSENTYX® 300 mg (n=327), COSENTYX® 150 mg (n=327), etanercept (n=326),

or placebo (n=326). COSENTYX® groups received two 150-mg subcutaneous injections (i.e., 300 mg total) or one 150-mg injection plus one placebo injection. Both injections were administered once weekly at weeks 0, 1, 2, 3, then monthly from week 4 to week 48. Etanercept patients received 50 mg administered subcutaneously twice weekly from baseline until week 12 and then once weekly through week 51, in accordance with the standard dosing regimen.

Indication and clinical use:COSENTYX® (secukinumab) is indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. • Geriatric patients ≥65 years: Although limited data, no differences in safety or ef�cacy

observed between older and younger patients • Safety and effectiveness not established in patients below 18 years of ageContraindications:• Severe hypersensitivity to the active substance or any of its excipientsRelevant warnings and precautions: • Infections: could potentially increase risk of infections; caution in patients with a chronic

infection or recurrent infections; patients should be evaluated for tuberculosis prior to initiation of treatment with COSENTYX®

• Caution in patients with active Crohn’s disease • Caution in latex-sensitive patients: natural latex derivatives in the removable cap of

the pre-�lled syringe/COSENTYX® SensoReady® pen • Should not be used with live vaccinations; can be used with those that are inactivated

or non-live • Pregnancy: should not be used unless expected bene�ts to the mother clearly outweigh

potential risks to fetus • Nursing women: Caution should be exercisedFor more information:Consult the Product Monograph at www.novartis.ca/CosentyxMonograph for important infor-mation relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-363-8883.

References: 1. COSENTYX® Product Monograph. Novartis Pharmaceuticals Inc., February 27, 2015. 2. Langley RG, Elewski BE, Lebwohl M et al. Secukinumab in plaque psoriasis – results of two phase III trials. N Engl J Med 2014;371(4):326–38. 3. Data on �le. Novartis Pharmaceuticals Canada Inc.

NEW

THE FIRST AND ONLY

IL-17A INHIBITOR†

65.0% of patients achieved PASI 90vs. 33.4% etanercept (p<0.0001, secondary endpoint)

The most common AEs were nasopharyngitis (11.4%), diarrhea (4.1%), and upper respiratory tract infection (2.5%)

59.2% of patients achieved PASI 90vs. 1.2% placebo (p<0.0001, secondary endpoint)

81.6% of patients achieved PASI 75vs. 4.5% placebo (p<0.0001, co-primary endpoint)

COSENTYX’SSUSTAINABILITY High ef�cacy sustained at

week 52vs. etanercept§

COSENTYX’SSAFETY PROFILE

Provensafety pro�le

COSENTYX’SSTRENGTHHigh

PASI 90 scoresachieved at week 12 vs. placebo (secondary endpoint)‡

C l i n i c a l p r a c t i c e

n PASI 75 was once the gold standard for treatment outcomes. Now PASI 90 or even 100 are the goals

New psoriasistreatment choic-es that do notrequire monitor-ing and thera-

pies that address patientswith moderate psoriaticdisease are encouraging,developments, accordingto Canadian clinicianswho participated in a tele-phone interview with THECHRONICLE OF SKIN &ALLERGY. They alsoacknowledge that the sus-pension of studies into oneantibody targeting the IL-17 receptor has been a dis-appointment.

The manufacturer of the mono-clonal antibody brodalumab,designed to treat moderate-to-severepsoriasis, made the decision to ceaseparticipating in clinical trial programsafter reports of completed suicidesled to the U.S. Food and DrugAdministration indicating that arestrictive label on the therapy wouldbe required.

“It’s well-established that thispopulation is already at risk for anincreased risk of suicide,” explainedDr. Melinda Gooderham, a dermatol-

ogist and med-ical director ofthe Skin Centrefor Dermatologyin Peterborough,Ont.

“But it isactually a lownumber of cases,and it was not asignificant num-ber [of cases],”said Dr. Gooder-ham. “The deci-sion [by the com-pany] was notdue to safety con-cerns, but was abusiness deci-sion.”

Other agents thattarget the IL-17 pathway—secuk-inumab, which is commercially avail-able, and ixekizumab, which is stillunder investigation, have not pro-duced similar concerns.

Best to discuss with patientsSome clinicians say the news aboutbrodalumab may lead patients tothink twice about initiating therapywith new biologic agents, accordingto Dr. Julia Carroll, a dermatologist,medical director and co-founder atCompass Dermatology in Toronto,and a lecturer at the University ofToronto.

“There is the potential thatpatients will stumble across [news ofreports of suicide], so it’s best that

we address ithead on andexplain they maysee reports ofthis and explainit to them,” saidDr. Carroll. “It isbetter that theydon’t comeacross [the infor-mation] them-selves and thendecide not to use[that category oftreatments].”

Another newdevelopment isthat establishedbiologic agentsare beginning tobe studied in the

pediatric population. Dr. Ian Landells,medical director at Nexus ClinicalResearch in St. John’s, Newfound-land and Labrador, and clinical asso-ciate professor at MemorialUniversity, is encouraged by data pre-sented in the first quarter of 2015,which demonstrated that ustekinum-ab produced a favourable responsein adolescents with severe plaquepsoriasis aged 12 to 17 years and theregular weight-based dose provedmore efficacious and had a pro-longed effect compared to the halfweight-based dose.

“The efficacy was outstanding,and there were no new safety sig-

Dr. MelindaGooderham

Dr. Ian Landells

Dr. Charles LyndeDr. Julia Carroll

Please turn to Psoriasis page 6à

Psoriasis

Patients expectingmore improvement

in disease

Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:32 PM Page 4

Page 5: The Chronicle of Skin & Allergy Oct-Nov. 2015

COSENTYX and SensoReady are registered trademarks.Product Monograph available on request.Printed in Canada 15COS020E© Novartis Pharmaceuticals Canada Inc. 2015

AE: adverse event.† Clinical signi�cance unknown.‡ ERASURE was a randomized, multicenter, double-blind, placebo-controlled phase III trial. Patients were randomized in a 1:1:1 ratio to receive COSENTYX® 300 mg (n=245), COSENTYX® 150 mg (n=245), or placebo (n=248). COSENTYX®

groups received two 150-mg subcutaneous injections (i.e., 300 mg total) or one 150-mg injection plus one placebo injection. Both injections were administered once weekly at weeks 0, 1, 2, 3, then monthly from week 4 to week 48. § FIXTURE was a randomized, multicenter, double-blind, placebo- and active-controlled phase III trial. Patients were randomized in a 1:1:1:1 ratio to receive COSENTYX® 300 mg (n=327), COSENTYX® 150 mg (n=327), etanercept (n=326),

or placebo (n=326). COSENTYX® groups received two 150-mg subcutaneous injections (i.e., 300 mg total) or one 150-mg injection plus one placebo injection. Both injections were administered once weekly at weeks 0, 1, 2, 3, then monthly from week 4 to week 48. Etanercept patients received 50 mg administered subcutaneously twice weekly from baseline until week 12 and then once weekly through week 51, in accordance with the standard dosing regimen.

Indication and clinical use:COSENTYX® (secukinumab) is indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. • Geriatric patients ≥65 years: Although limited data, no differences in safety or ef�cacy

observed between older and younger patients • Safety and effectiveness not established in patients below 18 years of ageContraindications:• Severe hypersensitivity to the active substance or any of its excipientsRelevant warnings and precautions: • Infections: could potentially increase risk of infections; caution in patients with a chronic

infection or recurrent infections; patients should be evaluated for tuberculosis prior to initiation of treatment with COSENTYX®

• Caution in patients with active Crohn’s disease • Caution in latex-sensitive patients: natural latex derivatives in the removable cap of

the pre-�lled syringe/COSENTYX® SensoReady® pen • Should not be used with live vaccinations; can be used with those that are inactivated

or non-live • Pregnancy: should not be used unless expected bene�ts to the mother clearly outweigh

potential risks to fetus • Nursing women: Caution should be exercisedFor more information:Consult the Product Monograph at www.novartis.ca/CosentyxMonograph for important infor-mation relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-363-8883.

References: 1. COSENTYX® Product Monograph. Novartis Pharmaceuticals Inc., February 27, 2015. 2. Langley RG, Elewski BE, Lebwohl M et al. Secukinumab in plaque psoriasis – results of two phase III trials. N Engl J Med 2014;371(4):326–38. 3. Data on �le. Novartis Pharmaceuticals Canada Inc.

NEW

THE FIRST AND ONLY

IL-17A INHIBITOR†

65.0% of patients achieved PASI 90vs. 33.4% etanercept (p<0.0001, secondary endpoint)

The most common AEs were nasopharyngitis (11.4%), diarrhea (4.1%), and upper respiratory tract infection (2.5%)

59.2% of patients achieved PASI 90vs. 1.2% placebo (p<0.0001, secondary endpoint)

81.6% of patients achieved PASI 75vs. 4.5% placebo (p<0.0001, co-primary endpoint)

COSENTYX’SSUSTAINABILITY High ef�cacy sustained at

week 52vs. etanercept§

COSENTYX’SSAFETY PROFILE

Provensafety pro�le

COSENTYX’SSTRENGTHHigh

PASI 90 scoresachieved at week 12 vs. placebo (secondary endpoint)‡

Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:32 PM Page 5

Page 6: The Chronicle of Skin & Allergy Oct-Nov. 2015

NEW ROSIVER™ (ivermectin) Cream, 1% for thetopical treatment of papulopustular rosacea in adults1

ROSIVER™ is a trademark of Galderma Canada Inc.

ROSIVER (ivermectin) Cream, 1% is for the topical treatment of infl ammatory lesions (papules and pustules) of rosacea in adults 18 years of age or older.

Refer to the page in the bottom right icon for additional safety information and for a web link to the Product Monograph discussing:

• Relevant warnings and precautions regarding skin reactions, allergic reactions, and skin irritation; concomitant use of potentially irritating topical products or procedures; use in pregnant women; and serious adverse reactions in nursing infants

• Conditions of clinical use, adverse reactions, drug interactions, and dosing/administration instructions

The additional safety information page contains the reference list and study parameters relating to this advertisement.

*Mean infl ammatory lesion counts at baseline: ROSIVER 31.0; vehicle 30.5.1 †Mean infl ammatory lesion counts at baseline: ROSIVER 32.9; metronidazole 0.75% cream 32.1.3

• Demonstrated a powerful and rapid reduction in infl ammatory lesions vs. vehicle° Median percent reduction from baseline in infl ammatory lesion counts at

Weeks 2 and 12 was 30.0% and 76.0% vs. 16.5% and 50.0% for once-daily ROSIVER vs. vehicle cream, respectively; both P<0.001 (secondary endpoint)*2

• Provided superior effi cacy vs. metronidazole 0.75% cream ° Percent reduction from baseline in infl ammatory lesion counts at Weeks 3

and 16 were 32.5% and 83.0% vs. 30.5% and 73.7% for once-daily ROSIVER vs. twice-daily metronidazole 0.75% cream, respectively; both P≤0.04 (primary endpoint)†1,3

• Demonstrated an excellent safety and tolerability profi le° Most common adverse reactions were: skin burning sensation, skin irritation, pruritus, and dry skin (1.0% vs. 2.2%, 0.9% vs. 2.4%, 0.8% vs. 1.1%, and 0.5% vs. 0.7% for ROSIVER vs. vehicle cream, respectively)1

° The safety profi le remained stable under conditions of long-term use as observed with treatment for up to one year1

6 · Oct./Nov. 2015

Lead articleTHE CHRONICLE of SKIN & ALLERGY

nals,” said Dr. Landells. “TheEuropean regulatory authority gave afavourable response for the use ofustekinumab in adolescents based onthese data. We are hoping it will leadto a similar decision in NorthAmerica.”

Outcome goals changingDr. Charles Lynde, medical director atthe Lynde Institute for Dermatology inMarkham, Ont. and associate profes-sor in the Department of Medicine atthe University of Toronto, said theother two agents that target IL-17 donot appear to present the same con-cern as brodalumab.

“The other two companies aredistancing themselves and saying[their agents] are different,” said Dr.Lynde.

While brodalumab proved moreeffective than ustekinumab in clinicalstudies, a restrictive warning for itsuse would mean in practical termsthat dermatologists would likely haveto screen patients for psychiatrichealth before initiating them on bro-dalumab, explained Dr. Lynde.

“It would be a roadblock [to pre-scription of brodalumab],” Dr. Lyndesaid.

As with other goals in medicine,practitioners of dermatology areeager to see improved outcomes intheir patients, which has given rise tothe concept of treating to target.

“Ten years ago, we felt the targetwas PASI (Psoriasis Area andSeverity Index) 50,” said Dr. Lynde.“Then the FDA asked for PASI 75 asthe gold standard. Now in clinical tri-als, people are talking about PASI 90or PASI 100 or near clear or essen-tially clear. That is what we are tryingto achieve, and that is what manypatients want.

“If you don’t achieve an [expect-ed] target after three to six months,you have not hit the bull’s eye,” saidDr. Lynde.

“Either you can look at maximiz-ing the dosage of the drug or chang-ing to a different drug with a differ-ent mechanism of action. We havemany more therapies [available tous]. It was not so long ago that wejust had methotrexate and beforethat we only had tar and light. With abigger armamentarium, we can mixand match to achieve good resultsfor our patients.”

Some patients may prefer oralagents such as the phosphodi-esterase-4 inhibitor apremilast, notedDr. Lynde.

“This is for a population that isnot ready for biologics but wantsmore than topical agents,” said Dr.Lynde during an interview.“Apremilast requires no monitoring,and it is very safe.”

Dr. Gooderham agreed thatapremilast is very palatable for manypatients and while she described it asless efficacious than a biologic, it isnot a fair comparison to pit the oralagent against a biologic with respectto its place in the therapeutic arma-mentarium.

“Patients may have five per centbody surface area [affected by psoria-sis], but they may not want to put onointment regularly,” explained Dr.Gooderham.

“A therapy like [apremilast] isgreat for that patient, and it is lessexpensive than a biologic.”

According to Dr. Gooderham,there is a whole “middle ground” ofpatients with psoriasis for whom abiologic is not indicated, but whosecondition remains uncontrolled withtraditional topical therapies or whowould opt not to take methotrexate.Such patients are suitable candi-dates for an oral therapy like apremi-last.

Other oral therapies, such astofacitinib, a Janus kinase inhibitor,have been studied against the bio-logic etanercept, and it was conclud-ed the novel therapy was non-inferi-or to the biologic, noted Dr.Gooderham.

Studying inflammation pathwaysPsoriasis is a condition that is illus-trative of inflammation that is pre-sent in the body. Indeed, researchpresented by Dr. Wayne Gulliver atthe annual meeting of the AmericanAcademy of Dermatology concludedcardiovascular health was compro-mised in psoriatic patients inNewfoundland, particularly whenthey had early onset of disease, andthat exposure to a biologic helpedprotect the cardiovascular health ofthese patients. Specifically, therewas an 83% decreased risk of havinga myocardial infarction in the psori-atic population with exposure to bio-logic therapy lasting at least onemonth.

“Decreasing inflammation in the

skin and the rest of the body givesthese people longer and more fruitfullives,” said Dr. Lynde.

The economic burden of psoria-sis should not be underestimated,noted Dr. Lynde, pointing to a reviewthat placed direct costs at $51.7 bil-lion to $63.2 billion in the U.S. annual-ly, with indirect costs estimated at aprice tag of as high as $35.4 billionannually (JAMA Dermatol 2015;151(6):651–658).

“There are direct costs, and thereare indirect costs,” Dr. Lynde said.“There are the direct costs of drugsand seeing doctors. Absenteeismfrom work, for example, is an indirectcost.”

Adjunctive therapies importantThe use of adjunctive therapies suchas effective moisturizers can ward offexacerbation of psoriasis throughminimizing the potential for theKoebner phenomenon induced byscratching, noted Dr. Carroll.

“For some, psoriasis is veryitchy,” said Dr. Carroll. “It’s importantthat individuals with psoriasis try notto scratch because they can inducepsoriasis due to the trauma of repeat-ed scratching.”

Other new molecules underdevelopment include BI 655066, abiologic which selectively blocks IL-23. Phase II data demonstratedpatients were clear or almost clearafter 12 weeks of therapy and hadmild side effects.

“It is moving into Phase III, and itlooks like a very promising drug,” saidDr. Lynde.

“It gives very high efficacy [PASI90 and 100], and it seems to be veryclean in terms of safety.”

Non-proprietary and brand names oftherapies: brodalumab (not availablein Canada); secukinumab (Cosentyx,Novartis); ustekinumab (Stelara,Janssen); apremilast (Otezla,Celgene); tofacitinib (Xeljanz, PfizerCanada); etanercept (Enbrel,Amgen).

Psoriasis: Patients expect improvementContinued from page 4

Indication and clinical use: ROSIVER (ivermectin) Cream, 1% is for the topical treatment of infl ammatory lesions (papules and pustules) of rosacea in adults 18 years of age or older.

Relevant warnings and precautions:• Risk of local skin reactions,

allergic reactions, and skin irritation

• Avoid concomitant use of potentially irritating topical products or procedures

• Caution in pregnant women• Risk of serious adverse reactions

in nursing infants (nursing women should discontinue nursing or the drug)

For more information:Please consult the Product Monograph at http://galderma.ca/Portals/4/pdf/ROSIVER_product-monograph.pdf for important information relating to adverse reactions, drug interactions, and dosing/administration information which have not been discussed in this advertisement.

The Product Monograph is also available by calling us at 1-800-467-2081.

References:1. ROSIVER™ Product Monograph. Galderma

Canada Inc. April 22, 2015.2. Stein Gold L et al; Effi cacy and safety of

ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol. 2014;13(3):316–323. A phase 3, multicentre, randomized, double-blind, 12-week, vehicle-controlled, parallel-group study assessing the effi cacy and safety of ROSIVER once daily in 683 patients with moderate to severe papulopustular rosacea (IGA score of 3 or 4). The co-primary effi cacy endpoints were the success rate based on the IGA outcome (percentage of patients “clear” and “almost clear” at Week 12 of the study) and absolute change from baseline in infl ammatory lesion counts.

3. Taieb A et al; Ivermectin Phase III Study Group. Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating infl ammatory lesions of rosacea: a randomized, investigator-blinded trial. Br J Dermatol. 2015;172(4):1103–10.An investigator-blinded, multicentre, randomized, parallel-group study comparing the effi cacy and safety of ROSIVER once daily with metronidazole 0.75% cream twice daily in 962 patients with moderate to severe papulopustular rosacea (IGA score of 3 or 4) over a 16-week treatment period. The primary effi cacy endpoint was percent change in infl ammatory lesion counts from baseline to week 16.

IGA: Investigator Global Assessment.

Canadian DermatologyIndustry Association.

. . . . . . . . . . . . 18

Galderma Canada Inc.Rosiver. . . . . . . . . . . . . 7, 6

GlaxoSmithKlineSpectro. . . . . . . . . . . . . 2

LEO Pharma

Picato. . . . . . 9

NovartisCosentyx . . . . . . . . . . . . . 5

PfizerCorporate. . . . . . . . . . . . . 27

Pierre FabreDermo Cosmetique

Avéne XeraCalm AD . . . . 19

Procter & GambleGillette Venus Swirl. . . . . . . . 28

THERAPEUTIC INDEX

Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:32 PM Page 6

Page 7: The Chronicle of Skin & Allergy Oct-Nov. 2015

NEW ROSIVER™ (ivermectin) Cream, 1% for thetopical treatment of papulopustular rosacea in adults1

ROSIVER™ is a trademark of Galderma Canada Inc.

ROSIVER (ivermectin) Cream, 1% is for the topical treatment of infl ammatory lesions (papules and pustules) of rosacea in adults 18 years of age or older.

Refer to the page in the bottom right icon for additional safety information and for a web link to the Product Monograph discussing:

• Relevant warnings and precautions regarding skin reactions, allergic reactions, and skin irritation; concomitant use of potentially irritating topical products or procedures; use in pregnant women; and serious adverse reactions in nursing infants

• Conditions of clinical use, adverse reactions, drug interactions, and dosing/administration instructions

The additional safety information page contains the reference list and study parameters relating to this advertisement.

*Mean infl ammatory lesion counts at baseline: ROSIVER 31.0; vehicle 30.5.1 †Mean infl ammatory lesion counts at baseline: ROSIVER 32.9; metronidazole 0.75% cream 32.1.3

See page XX for additional safety information.

• Demonstrated a powerful and rapid reduction in infl ammatory lesions vs. vehicle° Median percent reduction from baseline in infl ammatory lesion counts at

Weeks 2 and 12 was 30.0% and 76.0% vs. 16.5% and 50.0% for once-daily ROSIVER vs. vehicle cream, respectively; both P<0.001 (secondary endpoint)*2

• Provided superior effi cacy vs. metronidazole 0.75% cream ° Percent reduction from baseline in infl ammatory lesion counts at Weeks 3

and 16 were 32.5% and 83.0% vs. 30.5% and 73.7% for once-daily ROSIVER vs. twice-daily metronidazole 0.75% cream, respectively; both P≤0.04 (primary endpoint)†1,3

• Demonstrated an excellent safety and tolerability profi le° Most common adverse reactions were: skin burning sensation, skin irritation, pruritus, and dry skin (1.0% vs. 2.2%, 0.9% vs. 2.4%, 0.8% vs. 1.1%, and 0.5% vs. 0.7% for ROSIVER vs. vehicle cream, respectively)1

° The safety profi le remained stable under conditions of long-term use as observed with treatment for up to one year1

Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:32 PM Page 7

Page 8: The Chronicle of Skin & Allergy Oct-Nov. 2015

Picato® Gel (ingenol mebutate) is indicated for topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults.

Picato® Gel is about treatment time in actinic keratosis.

C O V E R E DO N M O S TP R I V A T EP L A N S

• Local Skin Responses (LSRs)* are transient and typically occur within 1 day of treatment and peak in intensity up to 1 week following completion of treatment. These e�ects typically resolve within 2 weeks on the face and scalp, and within 4 weeks on the trunk and extremities.

• Short duration dosing: once daily for 3 days on face/scalp or 2 days on trunk/extremities

*LSRs included erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration

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by JOHN EVANS,Associate Editor, The Chronicle

Both interrupted and continuous 5–0 nylonsutures used to close facial wounds fromMohs micrographic surgery (MMS) pro-

duced equivalent cosmetic outcomes at all exam-ined time points in a large, randomized trial pub-lished in Dermatologic Surgery (Aug. 2015;41(8):919–928).

A total of 105 individuals with facial defectsfrom MMS surgery were enrolled, and 101 of themcompleted assessment at all time points. All stud-ied scars were at least 4 cm inlength. Participants who wererandomly selected had half oftheir scar sutured with inter-rupted 5–0 nylon stitches, andthe other half sutured with run-ning 5–0 nylon stitches.Unblinded scar evaluation wasdone at one week, eightweeks, and six months by theprincipal investigator. Blindedphotographic assessmentswere done at one week and six months by both aplastic surgeon and a general dermatologist usingthree different scar assessment scales.

First of a series of studiesThe study was the first of a series of studies under-taken by senior author Dr. David Zloty, clinical asso-ciate professor, Department of Dermatology andSkin Science, University of British Columbia,

Vancouver, and his colleagues in order to test com-monly-accepted ideas about skin surgery that maybe insufficiently supported. “There are conceptsthat everybody believes to be true, but when youlook at the evidence itis either non-existent,weak, or of poor quali-ty,” said Dr. Zloty. “Oneof the biggest ones wasthe idea that interrupt-ed sutures were goingto give a better long-term final cosmeticresult compared to arunning suture, espe-cially on a facial site.”

In contrast to thiscommon wisdom, thetrial found no statistical difference in cosmetic out-comes between the two suturing techniques at anytime point, by any assessor, on any of three differ-ent scar assessment scales.

“We were very happy with the findingsbecause we enrolled a large number of patientswhich allowed for a very high degree of statisticalpower,” said Dr. Zloty. A statistician from theUniversity of British Columbia was employed tolook at the data and to ensure enough patientswere enrolled so that the study had the statisticalpower to answer the questions the investigatorswere asking, he said.

The data also showed no difference in outcomefrom different types of reconstruction, whether side-

to-side closure, rotation flap, or transposition flap.“We also looked at sites,” said Dr. Zloty. “Were

there different sites where you are better off usinginterrupted versus running?” Again, because of the

numbers and the powerof the analysis, there wasno perceived differencein cosmetic outcome—forehead, cheek, lip, ornose. “That was alsoquite exciting for us,” Dr.Zloty said, “becausesome people were sayingthat you could use run-ning [sutures], maybe, onthe lateral cheek but youcertainly would not wantto use them on the nose.

Findings a boon to surgeonsDr. Zloty there has long been debate about experi-ence and how those with more experience mighthave better use and handling of instruments andbetter suture handling to deal with the limitationsof running sutures and still obtain great results.Conversely, an inexperienced practitioner usingrunning sutures may get a compromised cosmeticresult. However, that did not seem to be case. “Wewere able actually to separate my repairs—and Ihad 18 years of experience at that time—vs. my fel-low’s repairs. She just had one year. And again, wedid not find any difference,” said Dr. Zloty.

“This is the largest, randomized clinical triallooking to answer this question. There is nothingelse in the literature that we were aware of that wasthis large, this well powered, this robust statisticallyin a randomized, prospective, blinded fashion,” Dr.Zloty said. “I think our results as we have outlinedare very strong and I think the results are very valid.”

Finding no difference in cosmetic outcomesbetween the two suturing techniques is a boon tosurgeons, said Dr. Zloty, who noted that there are anumber of advantages to using running suturescompared to interrupted. “One, you probably useless suture material. With interrupted you may gothrough more suture, and if you are paying forthese sutures there can be a cost saving using therunning suture compared to interrupted.”

Potentially more important though, he said, isthe saving of time. The additional motions neededto tie and cut the additional knots, as well as re-load the suture material can add significant time toa procedure.

However, Dr. Zloty cautions that this studyfocused entirely on facial scars of at least 4 cm, sothe findings cannot be generalized to other sites onthe body or to short scars.

“I personally use running [sutures]” even whenoperating on patients with benign nevi who areconcerned about the cosmetic effects, said Dr.Zloty. “Those cosmetic results have been excellent.So my own bias has been that even for shorterscars, or shorter wounds on the face, running willstill give you at least equivalent if not better resultsthan interrupted. But that is my own personal bias,not supported by the data from our study.”

R e s e a r c h

Outcomes of continuous sutures equivalentto interrupted sutures for facial woundsn No significant differences seen in cosmetic outcomes between techniques, Vancouver study reports

8 · Oct./Nov. 2015

V THE CHRONICLE of SKIN & ALLERGY

Dr. David Zloty

The International League of Dermatological Societies (ILDS) recognized the International AlbinismAwareness Day on June 13, during the World Congress of Dermatology in Vancouver. This marked the firstInternational Albinism Awareness Day, which was adopted by the United Nations' General Assembly in Nov.2014. The ILDS initiative was launched at a press conference during the WCD, featuring speakers whodescribed the disease and new research into its physical and social effects. (l-r) Dr. Margot Whitfield(Australia), Dr. Jerry Shapiro (Canada), Prof. Roderick Hay (U.K.), Dr. Henning Grossman (former head of theRegional Dermatology Training Centre [RDTC] in Moshi, Tanzania), Paul Ash (founder, with his brotherPeter, of Vancouver-based Under the Same Sun, an albinism awareness group), Dr. Claire Fuller (U.K.) andDr. Harvey Lui (Canada).

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Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:33 PM Page 8

Page 9: The Chronicle of Skin & Allergy Oct-Nov. 2015

Picato® Gel (ingenol mebutate) is indicated for topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults.

Picato® Gel is about treatment time in actinic keratosis.

C O V E R E DO N M O S TP R I V A T EP L A N S

• Local Skin Responses (LSRs)* are transient and typically occur within 1 day of treatment and peak in intensity up to 1 week following completion of treatment. These e�ects typically resolve within 2 weeks on the face and scalp, and within 4 weeks on the trunk and extremities.

• Short duration dosing: once daily for 3 days on face/scalp or 2 days on trunk/extremities

*LSRs included erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration

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Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:33 PM Page 9

Page 10: The Chronicle of Skin & Allergy Oct-Nov. 2015

10 · Oct./Nov. 2015

Pediatric dermatology THE CHRONICLE of SKIN & ALLERGY

R e s e a r c h

Cancer survivors, sunn Sun avoidance drops off soon after diagnosis

Childhood cancer survivors, in spite of instruction on sun protection habits,do not fully follow these instructions, and additional efforts to improve sunprotection behaviour is needed throughout their lives, according toresearch published in PLoS One (Sept. 8, 2015).

The authors conducted a case-control study of 143 pediatric patients(average age 11.2±4.6 years) who had histories of malignancy, as well as150 healthy controls (average age 10.4±4.8 years). The mean interval fromdiagnosis in the patients was 4.4±3.8 years. Validated questionnaires wereused to assess sun exposure and protection habits. Both groups reportedsimilar weekday sun exposure time—94±82 minutes a day for patients and81±65 minutes a day for controls (p=0.83). Only on weekends did patientsspend significantly less time outside—103±85 minutes per day compared to124±87 minutes a day for controls (p=0.02). The longer it had been sincepatient diagnosis also correlated with time spent outdoors during weekdaysand weekends (r=0.194, p=0.02; r=0.217, p=0.01, respectively). Sun expo-sure also increased noticeably three years after diagnosis, and age positivelycorrelated with sunburns per year and tanning-specific sun exposure, andnegatively with use of sun protection. No significant difference in compositesun protection score was seen between the two groups.

From the News Resources of The Chronicle

R e s e a r c h

Recalcitrant psoriasisn Fumaric acid esters trialled as alternate TxFrom the News Resources of The Chronicle

Fumaric acid esters (FAE) produced an improvement in both diseaseseverity and quality of life (QoL) in pediatric patients with recalcitrant pso-riasis, with generally mild, transient side effects, suggesting the treatmentmay be a viable alternative systemic treatment in these patients, accordingto a paper published online in the Journal of Dermatological Treatment(Oct. 9, 2015; 1-7).

To investigate the efficacy, impact on QoL, and safety of FAE in thesepatients, investigators examined 14 patients (mean age 13.7 years, rangingfrom eight to 17 years) with recalcitrant plaque psoriasis. The patientswere treated for a mean duration of 48.6 weeks (ranging from 12 to 124weeks), and a mean dosage of 564 mg per day (ranging from 180 to 1200mg maximum daily dose).

At baseline, their mean Psoriasis Area and Severity Index (PASI) scoreswere 10.5 (±1.0 SEM). These compared to 8.6 (±1.1) at week 12, 6.2(±1.6) at week 24, and 4.9 (±1.5) at week 36. A total of nine (64.3%)patients saw an improvement in their PASI scores. Mean CDLQI at weekszero, 12, 24, and 36 were 8.9 (±1.4), 6.8 (±1.2), 3.7 (±1.4), and 3.1 (±2.0).Gastrointestinal complaints occurred in 13 patients, flushes in 10, lympho-cytopenia in five, and eosinophillia in four.

Pediatric dermatology updateURTICARIA, SYSTEMIC LUPUSERYTHEMATOSUS LINKChronic spontaneous urticaria (CSU)may be linked to childhood-onsetsystemic lupus erythematosus(cSLE), occurring primarily at diseaseonset and associated with moderateto high lupus activity without majororgan involvement, according toresearch published in InternationalArchives of Allergy and Immunology(2015; 167(3):186-192).

The study involved 852 cSLEpatients. Guidelines from theEuropean Academy of Allergy andClinical Immunology, the GlobalAllergy and Asthma EuropeanNetwork, the European DermatologyForum, and the World AllergyOrganization were used to diagnoseCSU. Patients with CSU—determinedat urticaria diagnosis—and those with-out—evaluated at last visit—wereassessed for the clinical and laboratoryfeatures of lupus, as well as treatment.CSU was seen in 10 cSLE patients(1.17%), with the mean duration ofcSLE at diagnosis of urticaria beingzero years (-3 to 5 years). Patients withCSU vs. those without had a greaterfrequency of constitutional symptoms(40% vs. 8%, p=0.006), involvement ofthe reticuloendothelial system (30 vs..3%, p=0.003, mucocutaneous andmusculoskeletal manifestations (90%vs 28%; 50% vs. 6%, respectively, bothp<0.0001), and use of methylpred-nisolone pulse therapy (60% vs. 9%,p<0.0001). Those patients with CSUalso had higher median SLE DiseaseActivity Index 2000 (12 vs. 2,p<0.0001), and erythrocyte sedimen-tation rate (40 vs 19 mm/1st hour,p=0.024).

MALIGNANT VS. NON-MALIGNANTNON-MELANOMA SKIN CANCERSIn pediatric patients with non-mela-nomic skin tumours, the ratio ofmalignant to benign skin tumours issmall, with the most common suchlesions being pilomatricoma, pyo-genic granuloma, and nevus seba-ceous, researchers report in theJournal of Clinical MedicineResearch (Oct. 2015; 7(10):770-774).

All skin punch and excisionalbiopsies done in children up to 16years of age at a single dermatologydepartment between Jan. 2007 andJan. 2012 were investigated, exclud-ing melanocytic tumours and cysticand infectious lesions. Patient age,sex, location, and histopathologicdiagnosis were recorded and theirtumours were categorized. Of the203 lesions in children up to age 16,97 lesions in 91 patients were non-melanocytic tumours. Of those 91,47 (51.64%) were male and 44 were(48.36%) female, and the mean agewas 10.55±4.31 years. One (1.03%)of the tumours was malignant whilethe remaining 96 (98.97%) werebenign. Of the non-melanocytictumours, the most common typeswere pilomatricoma (22 lesions,22.68%), pyogenic granuloma (18,18.54%), and nevus sebaceous (10,10.3%). The malignant lesion wascutaneous leukemic infiltrate.Children over age 13 were most fre-quently affected, up to and including16 years, with 38 (41.7%) patients inthat range. Most of the lesions werefound on the head or scalp (32lesions, 32.96%), the trunk (28,28.84%), and the upper limbs (22,22.75%).

SURGICAL EXCISION BEST TXFOR HOBNAIL HEMANGIOMAWhile hobnail hemangioma—alsoknown as targetoid hemosiderotichemangioma—is typically benignand does not require treatment,complete surgical excision appearsto be the most effective approachin cases where intervention is indi-cated, researchers report onlineahead of print in the Journal ofCutaneous Medicine + Surgery(Oct. 16, 2015).

The authors conducted a retro-spective chart review of allhistopathologically confirmed casesof hobnail hemangioma at TheHospital for Sick Children in Torontobetween May 2000 and Dec. 2014.Demographic data, as well as clini-cal characteristics and immunohis-tochemical staining results were col-lected. A total of six patients wereidentified—four male and twofemale—three of whom had con-genital lesions.

The lesions were most com-monly found on the extremities,and treatment options employedincluded observation and surgicalexcision.

ELEVATED RISK OF ARTERIALPLAQUES SEEN IN PEDIATRICPSORIASIS PATIENTSPediatric patients with psoriasisappear to have a higher athero-genic cardiometabolic risk profile,findings which may support theobserved link later in life betweenpsoriasis and cardiovascular dis-ease as well as demonstrating aneed for screening and educationof young patients to minimize latercomplications, investigators reportonline in the Journal ofInvestigational Dermatology (Sept.30, 2015).

Researchers measured lipopro-tein composition and function in 44pediatric patients (mean age 13.0years) with psoriasis, as well as 44age- and sex-matched controls,using NMR spectroscopy to mea-sure high density lipoprotein (HDL)cholesterol efflux capacity (CEC).Individuals with psoriasis had high-er waist-hip ratios (0.85 vs. 0.80;p<0.002) than controls, as well ashigher insulin resistance measures(log transformed HOMA-IR 0.65 vs.0.41; p=0.07). Both groups hadsimilar traditional lipid values, buthaving psoriasis was associatedwith higher concentrations ofapolipoprotein B (72.4 vs. 64.6;p=0.02), a decrease in large HDLparticles (5.3 vs. 6.7; p<0.01), and areduced CED after adjusting forage, sex, fasting glucose, HOMA-IR,systolic blood pressure, body massindex, apolipoprotein A-1, and HDLcholesterol concentration (beta -0.22, p=0.02).

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tanning—is a disturbingtrend, says Vancouver clini-cal and cosmetic dermatolo-gist Dr. David Zloty. Thepractice, he feels, couldencourage people to engagein indoor tanning who mightnot otherwise, as a form ofpersonal artistic expression.

Tanning salon as art studio Dr. Zloty, the medical directorof The Dermatologic SurgeryCentre in Vancouver, saidthat while he has not seenpatients in his own clinicsporting these ‘artistic’ tanpatterns since his patientstend to comprise an olderdemographic, his staff have

spoken with individuals whohave developed suntan ‘tat-toos’ at indoor tanningsalons.

“In fact, [the tanners whowere questioned] said it issometimes standard practicewhen you go to a tanningsalon now,” Dr. Zloty says.“[The salon] will give you

stickers of your choice so thatyou can decorate your bodyin whatever way you choose.So I think [the practice ofsunburn art] is quite com-mon now.”

To date, Dr. Zloty has notobserved the practice amongoutdoor tanners onVancouver’s popular beach-

es. “I think right now it isprobably primarily with hometanners with sun lamps orsun beds in a salon.

“But I think that if thetrend becomes more visible,and there is more mediaexposure, I would not be sur-prised if this translates topeople putting [stickers] onwhile they are doing theiroutdoor tanning,” Dr. Zlotyadded.

Tanning in non-tannersEveryone he is aware of whoreported engaging in this dec-orative behaviour has alreadybeen a chronic tanner, saysDr. Zloty, but he is concernedthat media attention maydraw new tanners.

“If the decorative lookbecomes more accepted inyouth culture, will that enticeothers to specifically go to asalon to get this decorativelook? Not so much that theyare interested in the appear-ance of their skin in terms ofgetting a tan, but in terms ofthe appearance of this so-called art on their skin,” hesays.

“That would be my con-cern long-term, but I do notthink we have any evidencethat is happening now, notyet.”

Regarding the utilizationof public education aboutsun safety in response to thistrend, Dr. Zloty suggests theremay not be much that can bedone to dissuade individualswho are already chronic tan-ners. The best approach, hethinks, might be to targetindividuals who are lookingat this practice first as amethod of self-expressionrather than as a way to add aflourish to existing tanningbehaviour.

“For a certain percentageof the population, I think ourmessages are falling on deafears.

“Most of them are awareof the risks but they still feelthey look healthier, and theyfeel better with the tan,” hesays.

“If they are looking fordecorative options, I wouldrather have them dye theirhair and have nice jewelleryand do their nails, becausethose are all solutions thatstill draw decorative attentionto them but carry no long-term consequences to theiroverall health and the healthof their skin.”

12 · Oct./Nov. 2015

V THE CHRONICLE of SKIN & ALLERGY

Sunburn art not a harmless practice, dermatologist saysContinued from page 1

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Topical liposomaltranexamic acid haspotential in Tx ofmelasma

TOPICALLY APPLIED LIPOSOMAL TRANEXAMIC ACID (TA) appears to be a safe, promising new agent forthe treatment of melasma, according to research published in the Journal of CosmeticDermatology (Sept. 2015; 14(3):174–177).

The authors note that although there are several existing treatment approaches for the common skin darkeningdisorder, none are satisfactory in the management of melasma. As the plasmin inhibitor TA has been reported toimprove melasma when either injected locally, or used orally or topically, they set out to compare topical liposomalTA to conventional hydroquinone therapy in the treatment of melasma.

A split-face, 12-week trial was conducted with 30 women who had bilateral melasma. Participants blindly applied5% topical liposomal TA and 4% hydroquinone cream to the assigned sides of their faces, twice daily. Patients also usedan assigned sun screen once daily in the morning. Melasma area and severity index (MASI) scores were taken to mea-sure skin pigmentation at baseline and at each visit, separately for each side of the face. MASI scores were also record-ed at a follow-up visit one month after end of the treatment period. Of the initial 30 enrollees, 23 completed the study.Mean MASI scores had significantly reduced on both treated sides of the face by the 12 week mark (p<p=0.001). Aslightly larger decrease was seen on the sides treated with 5% liposomal TA, but the difference was not significant.Three patients experienced irritation with hydroquinone, and there were no serious adverse events with TA.

—For more information visit http://tinyurl.com/nud4g6t

PDT investigated forpossible treatment ofabnormal skinscarring

USING AN EX VIVO MODEL, investigators have shown morphological and cellular effects from theapplication of photodynamic therapy (PDT) in the treatment of skin fibrosis correlating withthe degree and severity of the fibrosis, which they suggest indicates that PDT may be ideal for

the treatment of abnormal skin scarring, according to research published in Photodermatology,Photoimmunology & Photomedicine (Sept. 2015; 31(5):239–251).

The authors used PDT combining either 5-aminolevulinic acid (5ALA) or methyl ALA (MALA) with red light illumi-nation at 40 J/cm2 to treat striae alba, fine line, hypertrophic and keloid scars ex vivo. In total, 18 scars were treated.Both H&E and Herovici’s and Weigert’s differential staining methods were used to assess general morphology, whileapoptosis, proliferation, metalloproteinase 3, and tropoelastin expression immunohistochemically quantified. Real-time quantitative reverse transcription polymerase chain reaction was used to assess differential gene expression ofproliferating cell nuclear antigen (PCNA), types I and III collagen (COL), matrix metalloproteinase 3 (MMP3), andtropoelastin (ELN). They found that apoptosis increased, correlating with decreased proliferation and expression ofthe PCNA gene. After PDT, matrix components were observed to be re-organized both in hypertrophic and keloidscars. Expression of COL I and COL III genes decreased, but expression of both MMP3 and ELN increased significantlycompared to both normal skin and untreated controls (p<0.05). No significant differences were seen between PDTtreatments using 5ALA and MALA.

—For more information visit http://tinyurl.com/npr9a4n

Index may helpcaregivers assesshealing time ofchronic and acutewounds

RESEARCHERS HAVE DEVELOPED A MODEL OF FIVE FACTORS that can contribute to prolonged healing of com-plex acute wounds, potentially helping caregivers to predict wound healing time and increasingtheir ability to detect, refer, and focus on patients who have wounds that require higher levels of

care, according to findings published in International Wound Journal (Oct. 2015, 12(5):531–536).Noting that while knowing which wounds are at elevated risk of prolonged healing times is important to enable

timely treatment and communication with medical specialists, the authors point out that existing wound healing prog-nostic models are for chronic ulcers and not acute wounds such as those from trauma or surgery. To address thismissing element, the authors developed a model to attempt to detect which factors could impact the duration of heal-ing in complex acute wounds, and trialed it in a large wound expertise centre (WEC). Some 563 patients with acutewounds were included in the study, who were documented in the WEC registry between 2007 and 2012. Patients’wounds had existed for a median of 19 days (ranging from six to 46 days). Most of the wounds (52%) were located onthe leg. The authors identified five significant, independent predictors of prolonged wound healing. These includedthe wound being located on the trunk (hazard ratio (HR) 0.565, 95% confidence interval (CI) 0.405–0.788, p=0.001),wound infection (HR 0.728, 95% CI 0.534–0.991, p=0.044), wound size (HR 0.993, 95% CI 0.988–0.997, p=0.001),wound duration (HR 0.998, 95% CI 0.996–0.999, p=0.005), and patient age (HR 1.009, 95% CI 1.001–1.018, p=0.020).However, diabetes was not a significant predictive factor.

—For more information visit http://tinyurl.com/pfoyrch

Surveying the current

Dermatologic literature

Recently come across something from the peer-review literature that you consider to be interesting orimpactful? Share it with your colleagues. E-mail your clippings, along with your comments, to:

[email protected]

THE CHRONICLE of SKIN & ALLERGY

Vol. 20, No. 5 Oct./Nov. 2015 · 17

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by EMILY INNES,Associate Editor, The Chronicle

The Clinician ErythemaAssessment (CEA) gradingscale has been deemed an

effective way to assess facial erythe-ma of rosacea by Canadian andAmerican dermatologists, accordingto a study published in The Journal ofthe American Academy ofDermatology (Oct. 2014; 71(4):760–763).

The reliability of the assessmentscale has never been evaluated previ-ously. The objective of this study wasto evaluate the inter-rater and intra-rater reliability of the CEA.

“Currently, there is only one Foodand Drug Administration-approvedpharmacologic treatment that directlytargets erythema of rosacea, leaving apotential unmet need among patientswith rosacea,” stated the authors inthe study. “The development of clini-cal therapies necessitates reliable,responsive, discriminatory, and vali-dated outcome measure to standard-ize diagnosis, evaluation, and treat-

ment.” Twelve U.S. board-certified der-

matologists participated in the studyto rate 28 patientswith facial erythe-ma. Of these,three were maleand 25 female,between the agesof 18 and 61 yearsand were allCaucasian withFitzpatrick skinphototype ranging from I to III.

The dermatologists all underwenta consensus training program beforeevaluating the patients. They wereprovided with reference photographson the use of the CEA and discussedthe results of the evaluations toachieve consensus.

During the rating process, eachdermatologist evaluated each subjecttwice with at least a two-hour intervalbetween evaluation sessions.

The inter-rater reliability for ses-sion one was a weighted 6 of 0.74and for session one and session twowas 0.673. This, according to the

Landis and Koch score, is considereda fair to good reproducibility whereperfect is 1.0. For intra-rater reliability,the overall weighted 6 statisticbetween session one and session twowas 0.692, reported the investigatorsin their study.

High level of reliability reassuring“The level of intra-rater reliability waspreviously unknown. This is an impor-tant concept of any measurementscale as it determines how well otherraters achieve the same outcome,”stated Dr. Jerry Tan, a Windsor, Ont.-

based dermatologist and the study’slead author, in an e-mail to THECHRONICLE OF SKIN & ALLERGY.

“The high inter-rater reliabilityfound in this study for the CEA wasreassuring—demonstrating that differ-ent raters could consistently gradeseverity of redness.”

Dr. Tan said the scale is simple touse with its five grades—clear, almostclear, mild, moderate, and severe—that have a descriptive text to matcheach grade. The clinician needs tomatch the grade of erythema thatmost closely resembles that of thepatient. He said the scale is also easyto teach because of the descriptions

and the visualguides.

“Accurate andreliable means toevaluate skin red-ness is critical indetermining theeffect of medica-tions and/or pro-cedures on red-ness of variousskin conditions,”

said Dr. Tan regarding the clinicalimportance of an effective gradingscale.

A limitation of the study noted bythe researchers was that all the raterswere all experienced dermatologistswho were trained. Dr. Tan said otherdermatologists and general physi-cians would likely yield the same reli-ability if they have been trained to usethe tool.

Another limitation of the studywas the short time interval of twohours between ratings, whichaccording to the authors could leadto recall bias because clinicians mayhave been able to remember previ-ous scores.

As well, using photographs for thetraining can be problematic becausephotos can distort light reflection,colour and depth. However, theinvestigators added that it was neces-sary to use them for convenience inthe training module.

One more severity level neededWhile the authors concluded thatthey support the CEA as a tool forevaluating facial erythema in rosacea,Dr. Tan noted that he might proposetwo changes to the scale and training:“An added grade of very severe mayhave been useful to ensure that theentire spectrum of redness was repre-sented. More images of redness inpeople with different skin colour maybe useful in the future.”

More information is available at:http://ow.ly/FdN17

R o s a c e a

Clinical erythema assessment tool forfacial erythema determined to be reliablen Study evaluates inter- and intra-rater effectiveness of scale for erythema associated with rosacea

18 · Oct./Nov. 2015

V THE CHRONICLE of SKIN & ALLERGY

Dr. Jerry Tan

“The high inter-raterreliability found inthis study for the CEAwas reassuring—

demonstrating that different raters couldconsistently grade severity of redness.”

—Dr. Jerry Tanq

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Page 15: The Chronicle of Skin & Allergy Oct-Nov. 2015

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Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:34 PM Page 15

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are started, but for a live vac-cine ideally four weeks shouldbe allotted before starting thetherapy (J Rheumatol 2012:39:1583–1602).

Immunocompromisedindividuals who are underim-munized are vulnerable toserious infections and even

death; however, healthcareproviders should also consid-er that inappropriate adminis-tration of live vaccines canlead to serious adverse eventsin the immunocompromisedhost,” stated Dr. ClaireBombardier, professor ofmedicine at the University ofToronto, et al in the Journal of

Rheumatology paper. Vaccines can be either in

a live or killed/inactive formand Dr. Kraft said it is criticalto find out which vaccine apatient is receiving andwhich brand. Another consid-eration is live virus shedding,noted Dr. Kraft. The probabili-ty of acquiring a vaccine virus

after close contact with a sin-gle live attenuated influenzavirus recipient is estimated at0.58% to 2.4%.

Even though the risk isgenerally low, he said, “it is stillworthwhile to consider isolat-ing your immunosuppressedpatient from the patient whoreceived the live vaccine, or at

least holding off on the livevaccine in the household con-text of someone who isimmunosuppressed.”

Tx should be stopped beforeadminstering live vaccineTreatment can continue if apatient requires an inactivevaccine while on a biologic.However, Dr. Kraft said if apatient requires a live vaccinethen the therapy should bestopped for two to five half-lives of the biologic before thevaccine is administered.

This ranges anywherefrom eight to 21 days for etan-ercept (4.3 mean half-life,days) to 92 to 230 days forustekinumab (46 mean half-life, days) (J Rheumatol;2012:39:1583–1602).

“It seems like a long timeto stop the drug, but I think itis worthwhile to considerbecause you want to makethe [live] vaccine as safe aspossible when it is adminis-tered,” said Dr. Kraft. Afterthe vaccine is administered itis recommended to wait twoto four weeks before restart-ing the biologic.

Dr. Kraft said some routinevaccinations to considerbefore starting on biologicsinclude the influenza vaccine(yearly); pneumococcal vac-cine (every three to five years);hepatitis B vaccine (vaccine ifserology test is negative); diph-theria, pertussis, and tetanus(Tdap) vaccine (every 10years); measles, mumps, andrubella (MMR) vaccine (adultdose is live so preferablybefore biologic is started); andzoster vaccine (live).

Dr. Kraft said inflammato-ry disease patients have beenfound to have an increasedrisk of developing herpeszoster from the general popu-lation. While the risk does notusually increase until after theage of 60 years, for somepatients, such as rheumatoidarthritis or lupus patients,their risk is increased over theage of 50 years.

Other vaccines to considerinclude the human papillo-mavirus vaccine in youngfemales and males, and vac-cines for travelling patients. Dr.Kraft said the U.S. Centers forDisease Control andPrevention’s website (cdc.gov)is a good resource tool for trav-ellers. It provides recommend-ed vaccines based on the riskof those diseases in the coun-try the patient is visiting.

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V THE CHRONICLE of SKIN & ALLERGY

Vaccines recommended for patients on biologic therapyContinued from page 1

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ment that occur in early lifeare crucial to the develop-ment of food allergy and tol-erance,” says study leadauthor Dr. Moshe Ben-Shoshan, assistant professor,Division of Pediatric Allergyand Clinical Immunology,Department of Pediatrics,McGill University HealthCenter in Montreal. The studywas supported by AllerGenand Health Canada.

Data showed that for allof the included allergens,there was an increased risk ofprobable allergy associatedwith three factors: a personalhistory of eczema in the firsttwo years of life, asthma, orhay fever (odds ratio (OR)2.3, 95% CI 1.6–3.5; OR 2.8,95% CI 2.2–3.6, OR 2.3, 95% CI1.8–3.0 respectively); foodallergy in parents or siblings(OR 3.7, 95% CI 2.5–5.6 formother, OR 3.0, 95% CI 1.8–5.1 for father, and OR 3.1, 95%CI 2.2–4.2 for siblings), andhigh household income (top20%, OR 1.5, 95% CI 1.2–2.0).

It is not surprising to findatopy and generalizedeczema associated with foodallergy, says Dr. Ben-Shoshan,“but the interesting part is thatwe showed that eczema inthe first two years of life is cru-cial for the development of

food allergy and is associatedwith higher risk of food aller-gy, especially peanut and treenuts, but less likely to milk.”

This supports the dualallergen exposure hypothe-sis, he says. “So if you haveearly onset of eczema thenyou are more likely to beintroduced to food allergensin an undesirable way—away that will lead more toallergy rather than toler-ance.”

Dual allergen exposureThe dual allergen exposurehypothesis was proposed byDr. Gideon Lack in 2008 in areport published in TheJournal of Allergy and ClinicalImmunology (June 2008;121(6):1331–1336).

“When you introducesomething early in life in

large amounts through themouth, you are more likely toinduce tolerance. But whenthe skin is impaired and thefirst introduction is throughthe impaired skin barrier, youdo not have the same toler-ance-inducing mechanismand you might induce aller-gy,” says Dr. Ben-Shoshanregarding the hypothesis.

Previous research pub-lished in The Journal ofAllergy and ClinicalImmunology (Jan. 2013;131(1):135–143.e1–12) fromU.K. investigators showedthat in children at higher riskof food allergy—and childrenwith eczema are at higherrisk of developing food aller-gy—early introduction ofpeanut is better for inducingtolerance instead of allergy,

says Dr. Ben-Shoshan. “Our study supports that

and extends it to most foodallergens, except milk,because I think milk is intro-duced early in life even beforeeczema starts to appear,” hesays. “[The findings] showthat you probably need to pro-tect the skin at the same timeyou introduce food throughthe mouth. I think it has prac-tical implications.”

Eczema on the riseThe findings of the study areparticularly importantbecause other research hasshown that the rate of eczemain the world is increasing, par-ticularly in North America,says Dr. Ben-Shoshan.

“So the question is nowwhy is eczema rising inprevalence?” Colder, drier

environments are known tobe associated with increasedloss of moisture from theskin, he says.

Dr. Ben-Shoshan ques-tions whether the increase ineczema prevalence could berelated to environmental fac-tors such as more peoplestaying indoors beingexposed to air-drying centralheating and air-conditioningor immigrants having skinthat is not used to theCanadian climate.

More research is needed,said Dr. Ben-Shoshan, whoadded that in the future hewould like follow up thisresearch with a study intwins to investigate howgenetic factors interplay withenvironmental factors in thedevelopment of food allergy.

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THE CHRONICLE of SKIN & ALLERGY Oct./Nov. 2015 · 21

Eczema in first two years linked to common food allergensContinued from page 1

role of the phosphodiesterase-4 inhibitors and how it is pref-erential treatment for some of our patients.

Comments from the Rock include Dr. Ian Landells’update on the importance of treating pediatric psoriasis andDr. Lynde and others on the importance of targeting inflam-mation to decrease cardiovascular risk in moderate-to-severe psoriasis patients. As well they introduce you tosome of the newer biologic agents under development,including IL-23, which in phase 2 has excellent efficacy.Soon patients may be offered treatment which is one injec-tion per year.

In Montreal, Dr. Moshe Ben-Shoshan studies the role ofskin barrier function in atopic dermatitis with respect to thedevelopment of food allergies (see page 1).

Dr. Craig Elmets and others have pointed out that whilewe are making progress in the treatment of melanoma withthe molecules that target MEK and BRAF, the use of sun-screen still needs some advocacy. Case in point: Dr. Zlotyhighlights the ways our patients continue to devise new andinnovative ways to increase their risk of melanoma, mostrecently that of decorative tanning (see page 1).

Many of us, including Drs. Elmets and Zloty, are soundinga little discouraged by this behaviour. Who can blame them?

—Wayne P. Gulliver, MD, FRCPCMedical Editor

Continued from page 3

Message from the Editor

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TO HEALTHE SKINTO HEALTHE SKIN

�e Heroes Behind Discoveries inDermatologyDermatology

W. STUART MADDIN, MD, FRCPC

H. EILEEN MUR"Y, MD, FRCPC

Editors

W. Stuart Maddin is Clinical Professor Emeritus at the Departmentof Dermatology and Skin Science (Active), Faculty of Medicine, University of British Columbia, Vancouver, Canada

H. Eileen Murray is Professor, University of Manitoba, Canada, andAdjunct Professor, University of British Columbia, Department of Dermatology and Skin Science

Linacre’s BooksA Chronicle Company

is Honoured to present

Preview the contents of “To Heal the Skin” at

www.tohealtheskin.comOrder “To Heal the Skin” online from Amazon.com athttp://ow.ly/V9KTlOrder to “Heal the Skin” directly from the publisher via toll-free telephone:

call 866-63-CHRON (866-632-4766)

The long-awaited hardcover compendium edited byDr. Eileen Murray and the late Dr. Stuart Maddincontains more than 50 chapters which describethe genesis of today’s most-prescribed dermatologic therapies. Chapter contributorsform a “Who’s Who” of dermatology researchersand clinicians. This 400-page textbook is finallyavailable to physicians and lay readers throughamazon.com, from the publisher, and selected north american book retailers.

to-heal-the-skin-ad_Layout 1 11/27/2015 12:20 PM Page 1Skin_OctoberNovember_2015,rar11_ms_rar1_Skin_March_2014,rar1.qxd 27/11/2015 4:34 PM Page 18

Page 19: The Chronicle of Skin & Allergy Oct-Nov. 2015

Linacre’s BooksA Chronicle Company

is Honoured to present

Preview the contents of “To Heal the Skin” at

www.tohealtheskin.comOrder “To Heal the Skin” online from Amazon.com athttp://ow.ly/V9KTlOrder to “Heal the Skin” directly from the publisher via toll-free telephone:

call 866-63-CHRON (866-632-4766)

The long-awaited hardcover compendium edited byDr. Eileen Murray and the late Dr. Stuart Maddincontains more than 50 chapters which describethe genesis of today’s most-prescribed dermatologic therapies. Chapter contributorsform a “Who’s Who” of dermatology researchersand clinicians. This 400-page textbook is finallyavailable to physicians and lay readers throughamazon.com, from the publisher, and selected north american book retailers.

to-heal-the-skin-ad_Layout 1 11/27/2015 12:20 PM Page 1

BACKGROUND

Acne is a common chronicskin disease that very oftenrequires prolonged treat-ments.1 With a chroniccourse2 and an episodic pat-tern of presentation,3 acne

vulgaris lesions occur mainly in exposedareas like the face and the presternalregion. The effect of the scarring may be

notable and the functional, social andemotional impact on the patient’s quali-ty of life may be significant.4,5

Adherence to doctor prescriptions has amajor impact on treatment outcome.6

Several studies conducted over the pastfew years suggest that adherence toacne medications is particularly low3,7

and has been associated with inade-quate response to therapy,8 especially

when both topical and systemic treat-ments are prescribed to the samepatient.9 The treatment plan and thechoice of specific active ingredientsshould take into account not only theindividual characteristics of the patientand/or the disease but also their prefer-ences and expectations with treatmentas well as questions of convenience.10

The adverse effects of the various thera-pies available should also be borne inmind in order to increase adherence tothe physician’s instructions and recom-mendations, thus promoting what areknown as health-related behaviours.7

Specific systemic and topical acnetreatments are often associated withlocal side effects such as dry, burningand itching sensations,7 hence poor tol-erability that further worsens compli-ance.11 Based on the evidence and clin-ical experience obtained with topicaltreatments and their possible irritanteffects,12 adjuvant skin barrier repairtherapies such as specific emulsion anddetergent products, hydrating andemollients are often prescribed in orderto reduce these side effects, all insearch of improving adherence to ther-apeutic strategies.13,14 Other factorssuch as a good and efficient physician-patient relationship are also crucial forimproving adherence to therapeuticstrategy15 since this interactionincludes specific roles and motiva-tions16 that might be essential to thehealing of many patients, particularlyso for patients with chronic disease ordisease having a negative impact onquality of life and self-esteem such asacne.17 Adherence to acne therapieshas been evaluated mainly in subjectsirrespective to grading severity of thecondition (from mild to severe forms)8,18 but, so far, few data are availableregarding this conduct in patients withmild to moderate forms.

In a real-life setting, we evaluatedthe impact of adherence to dermatologistinstructions and recommendations andadherence to the treatments (specific antiacne treatments and adjuvant therapies)on the clinical outcome in patients withmild to moderate acne. The participatingphysicians of the ACTUO trial werepracticing, experienced Spanish derma-tologists working in hospital outpatientdermatology services.

METHODS ACTUO was a multicentre, prospective,observational, epidemiological study ofpatients with mild to moderate acnetreated at 72 dermatology servicesthroughout Spain between Oct. 2011and Nov. 2012. All study materials wereevaluated and approved by a ClinicalResearch Ethics Committee before thestudy start. Approval (Ethics Committeeof “Centro Medico Teknon” Barcelona,Spain) was obtained Aug. 1, 2011.

Subjects

A total of 643 subjects with mild tomoderate acne, after they provided

written informed consent, wereenrolled in the study. Eligibility criteriawere men and women with mild tomoderate acne vulgaris eligible for aspecific acne treatment (topical retinoidagents or antiseptics and/or systemicantibiotics) willing to participate in thestudy. The study was conducted atthree visits carried out in a period ofthree months (V1: baseline, and twofollow-up visits: V2 and V3). In allthree visits, data on acne severity wasrecorded on the Case Report Form(CRF) by the dermatologist using theglobal ranking system of the U.S.FDA19 (0: no lesions, 4: severe) and thetotal number of acne lesions. Acneseverity was also evaluated by thepatient. In addition, adherence to anti-acne treatments and adjuvant thera-pies was also assessed trough study.

Primary outcome

The main objective of this analysis wasto evaluate the impact of adherence tothe treatments on the clinical outcomein patients with mild to moderate acne.A secondary outcome was to evaluatethe impact of the use of specific adju-vant treatments (facial cleansing prod-ucts, emollient moisturizing and leni-tive specific topical cream productscontaining mainly rhamnosoft as emol-lient and antinflammatory agent) onadherence level and entity of the clini-cal outcome obtained. Acne severitywas assessed at each visit with a 5-point score system (from 0 to 4),absolute count of lesions and percent-age of patient reaching a =>50%reduction in lesion numbers.Adherence to treatment was evaluatedat visit 2 and visit 3 by means of vali-dated four-item questionnaire (ECOB)with a dichotomous classification: goodadherence (ECOB score=4) and pooradherence (ECOB <4). Poor adherenceto treatment was defined as a differentto expected answer on the ECOB ques-tionnaire. The four questions of ECOBwere according to Pawin, et al.20

The degree of adherence to theadjuvant measures prescribed by thedoctor (application of cleansers andmoisturizers for facial skin care) wasassessed using the data provided by thepatients attending all three study visits.It was considered that patients who fol-lowed all their doctor’s instructions andrecommendations in at least three of thefour assessments showed compliancewith the medical advice. The effects ofadherence to adjuvant treatment on thedoctor’s and patient’s final assessmentsof acne severity was compared inpatients “without/practically withoutlesions” (FDA scores=0–1) and patients“with lesions” (FDA scores=>2–4). TheACTUO study has evaluated also theimpact of acne and acne treatments onquality of life evaluated by means ofCardiff Acne Disability Index21 (CADI)and Dermatology Life Quality Index(DLQI).22 However these data would bepresented elsewhere.

POSTGRADUATEEDUCATIONAL SUPPLEMENTAdherence to

drug treatments andadjuvant barrier repairtherapies are key factorsfor clinical improvement

in mild to moderateacne: the ACTUO obser-vational prospectivemulticenter cohorttrial in 643 patients

Raúl de Lucas,1 Gerardo Moreno-Arias,2 MontserratPerez-López,3 Ángel Vera-Casaño,4 Sonia Aladren,5Massimo Milani,5,* and on behalf of ACTUO

Investigators study groupfrom 1Hospital Universitario La Paz, Madrid, Spain, 2Hospital Quirón Teknon, Barcelona,

Spain, 3Clínica Dermatológica de Moragas, Barcelona, Spain, 5Isdin S.A. MedicalDepartment, Provençals 33, Barcelona, Spain, *Corresponding author.

ABSTRACTBackground: In acne, several studies report a poor adherence to treatment. We eval-uate, in a real-life setting and conditions, the impact of compliance to physician’sinstructions, recommendations and adherence to treatments on clinical outcome inpatients with mild to moderate acne in an observational, non-interventionalprospective study carried out in 72 dermatologic services in Spain (ACTUO Trial). Methods: Six-hundred-forty-three subjects were enrolled and 566 patients (88%) com-pleted the three study visits. The study aimed to evaluate the impact of adherence(assessed with ECOB scale) on clinical outcome, as well as how the use of specificadjuvant treatments (facial cleansing, emollient, moisturizing and lenitive specific topi-cal products) influences treatment adherence and acne severity (0–5 points score).Recommendation of specific adjuvant skin barrier repair products was made in 85.2%.Results: Overall, clinical improvement was observed throughout follow-up visitswith an increased proportion of patients who reported reductions of =>50% onthe total number of lesions (two months: 25.2%; three months: 57.6%) and reduc-tions of severity scores (2.5, 2.0 and 1.3 at one, two and three months after treat-ment, respectively). Adherence to treatment was associated with a significantreduction on severity grading, a lower number of lesions and a higher proportionof patients with =>50% improvement.Conclusion: Good adherence to medication plus adherence to adjuvants was signifi-cantly associated with a higher clinical improvement unlike those that despite adher-ence with medication had a low adherence to adjuvants. A good adherence to adju-vant treatment was associated with improved adherence and better treatment out-comes in mild to moderate acne patients. (ISRCTN Registry: ISRCTN14257026).

Reprinted with permission from: de Lucas, et al: BMC Dermatology 2015; 15:17. © 2015 deLucas, et al; licensee BioMed Central Ltd. http://www.biomedcentral.com/1471-5945/15/17

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Statistical methods

The FDA ratings made by the physicianand patient after three months weregrouped into two categories: presenceof lesions (FDA=>2-4), or absence ornear absence of lesions (FDA=0–1).Using the parameters severity and totalnumber of lesions, improvement wasassessed by classifying patients into twogroups based on the reduction of acneseverity (=>50% improvement vs.improvement <50%) and the percent-ages of reduction of comedones andpapules/pustules. Statistical analysis wasperformed using the statistical softwareSPSS ver.19. Continuous variables wereexpressed as mean (SD). Categoricalbinary variables were expressed as pro-portions (%). The Mann–Whitney,Wilcoxon and the chi-square tests wereused for inference statistical analysistests. A multivariate logistics regressionanalysis was performed in order toassess the correlation between improve-ment of acne severity score, percentageof patients with 50% or more in acnelesion number reduction, and the fol-lowing variable: demographic data,adherence to specific treatments and toadjuvant treatments.

RESULTS Table 1 gives information aboutpatients’ characteristics at the time ofenrollment. A total of 643 cases wereenrolled. A total of 566 patients (88%)completed the three-visit study. Dataare presented as per protocol analysis.At baseline, adjuvant products wereprescribed in 83.8% of the patients. Theapplication frequency was 1.3/day.Prescription for specific adjuvant prod-ucts was made for 85.2% of the patients.Severity of acne assessed by the physi-cian was 2.5±0.6 and mean number ofcomedones was 18.9±2. Severity acnescore was significantly (p<0.001)reduced in comparison with baselineafter one month (2.0±0.8) and afterthree months (1.3±0.9). At the end ofthe study period patients scoring 0(complete cure of acne) were 17%. Ingeneral, significant reductions in theseverity scores vis-à-vis the baseline visitwere observed in both doctor's andpatients’ assessment (2.1±0.9 at onemonth and 1.4±0.9 at three months;p<0.001). Figure 1 shows the evolutionof acne severity score in the populationas a whole. Percentage of patientsshowing at least 50% of lesion reductionwas 25.2% at visit 2 and 57.6% at visit 3.

According to the ECOB scores,good adherence to treatment was doc-umented in 50.0% of the patients atvisit 2 and in 66.3% at visit 3. Goodadherence to treatment was associatedwith a significant (p<0.05) acneimprovement in comparison withpoor adherence group at both controlvisits. At visit 3 acne severity scorewas 1.19±0.8 in patients with goodadherence to adjuvants vs. 1.4±0.9 inpoor adherence group. Good adher-ence to specific acne treatments (facialcleansers) was documented in 83.6%at visit 2 and in 89.9% at visit 3. At theend of study, patients with good

adherence to treatment presented asignificant improvement of acne bothin term of acne severity score (1.2 vs.1.7; p=0.001) and regarding the pro-portion of patients whom reduction oflesions was =>50% (60.9% vs. 32.8%;p<0.001) when compared to thosewith poor adherence (Fig. 2). Inpatients for whom the dermatologisthad prescribed adjuvant therapies, agood adherence to this treatment wasdocumented in 36.2%. Adherence toadjuvant treatment improves acnethus it was associated with a signifi-cant reduction of score grading severi-ty at visit 3 (1.2 vs. 1.4; p=0.002), witha higher percentage of reduction ofaverage lesions number vs. baseline(50.8% vs. 43.7%; p=0.015) and withmore patients obtaining a =>50%reduction in acne lesions’ number(65.9% vs. 51.5%; p=0.003) in compari-son with the low adherence group(Fig. 2). Adherence to adjuvant treat-ments was associated with a greaterproportion of patients with a completecure of acne (defined as no or veryfew acne lesions) at the final visit incomparison with poor-adherers(66.5% vs. 52.6%; p=0.004). In particu-lar, good adherence to adjuvant treat-ments improved the adherence to top-ical retinoid therapy therefore influ-encing clinical improvement of acneshowing a higher proportion patientswith adherence to treatment in adher-ers to adjuvants when compared tonon-adherers (85.5% vs. 70.7%;p<0.001). In addition, in patients witha good adherence toadjuvants weresignificantly more frequently consid-ered with an =>50% improvementon clinical outcome in comparisonwith those that did not adhere toadjuvants (65.9% vs. 51.5%; p=0.003).

Multiple logistic regression analy-sis was performed to identify factorsinfluencing clinical improvement ofacne. Adherence to specific treatments,adherence to adjuvant treatments andgood adherence to treatment are signif-icantly (p=0.001) correlated with clini-cal improvement of acne. In accordancewith previous studies, sex (women vs.men) and the fact of being accompa-nied (by parents/tutor or relative) or notat the medical visit are also indepen-dent factors affecting improvementclinical outcome of acne. Other analysisallowed observing an associationbetween the patient’s assessment ofquality of life based on the DLQI scaleand the adherence to adjuvant treat-ment since rates of improvement onQoL were lower in non-compliers (43%vs. 56.1%, p=0.007).

DISCUSSIONLow adherence to treatments is still arelevant problem in the treatment ofmild to moderate acne.23 The definitionof strategies to improve adherence withboth pharmacological and behaviouraltreatment remains a major challenge.Suboptimal medication adherence isone of the major reasons for treatmentfailure in subject with acne vulgaris.24

Our findings reveal that dermatologists

in Spain frequently prescribe specificadjuvant treatment for acne. They rec-ommend the use of specific productsincluding non-comedogenic soaps andmoisturizers in over 80% of acnepatients. The synergy between theeffects of drug treatment and adjuvantproducts can improve comfort duringthe various stages of treatment and canencourage patients to continue theapplication of the products. Adherence

to adjuvant treatment was associatednot only with a 2.4-fold increase in theprobability of adherence to pharmaco-logical treatment, but also with a signif-icant reduction in acne severity, in thenumber of lesions as assessed by boththe treating physician and the patient,and a higher percentage of patientswhose severity improved by 50% ormore. In the ACTUO study low adher-ence to treatment was found in 50% of

POSTGRADUATE EDUCATIONAL SUPPLEMENTTable 1: Sociodemographic data and acne severity at baseline visit

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the patients (at one month) and thisresult is in line with previous publisheddata. Low adherence to adjuvant treat-ments was observed in up to 63.8% ofsubjects after three months. In additionwe have to consider that these dataderived from a per protocol analysis,not including 12.4% of patients notattending to control visits which there-fore could be considered as “non-com-plier” by definition. In line with previ-ous experiences,3 we have observedthat adherence to pharmacologicaltreatment is a key factor for theimprovement of acne both in terms ofreduction of severity grading, numberof lesions and percentage of patientsobtaining at least a 50% acne improve-ment. Good adherence to adjuvanttreatments also improves clinical evolu-tion of acne with a greater reduction ofseverity of grading and number oflesions and with a significant greaterpercentage of patients obtaining a 50%or more improvement of acne in com-parison with patients with poor adher-ence to adjuvant treatments.Furthermore, patients with good adher-ence with drug and those with adher-ence to adjuvant treatments presentedthe highest percentage of patients withimprovement of acne lesions =>50%.In addition, in the present study it wasshown that adherence to adjuvantproducts is the second most importantfactor (just after adherence to drugtreatment) influencing the degree ofacne improvement. A good adherenceto adjuvant treatment is associated withan improved adherence to acne treat-ments and with a better treatment out-come in mild to moderate acne

patients. Some limitations should betaken in account in evaluating theresults of our study. In particular theevaluation of compliance was based onself-reporting questionnaire. Thisapproach however was used in otherstudies assessing the same outcomeand the ECOB questionnaire is consid-ered a validated tool.3,18 On the otherhand, we believe that the sample sizeand the study design adopted, quiteclose to “real life” conditions of acnetreatment strategies, could be consid-ered as aspects increasing the externalvalidity and the generalization of theobserved results of the ACTUO.

CONCLUSIONS The ACTUO observational studyresults confirm that adherence to phar-macological treatment and adjuvanttherapies are both key factors of acneimprovement in terms of reduction ofseverity, number of lesions and per-centage of patients with at least a 50%acne improvement. In addition, adher-ence to adjuvant treatment with specif-ic cleansers and moisturizers forpatients with acne is the second mostimportant factor in achieving symptomimprovement, after completion of drugtreatment. Good adherence to adjuvanttreatment is associated with a 2.2-foldincrease in the probability of adherenceto topical pharmacological treatmentand with significant reductions in theseverity and number of acne lesions.

ABBREVIATIONS ECOB: Elaboration de un outil deevaluación de l’observance des traita-

ments medicamenteuxCRF: Case report formFDA: Food and Drug Administration

COMPETING INTERESTS Sonia Aladren and Massimo Milaniare ISDIN employees. The ACTUOstudy was supported by an unrestrict-ed grant of ISDIN SA.

AUTHORS’ CONTRIBUTIONSRDL, GMA, MPL, AVC participated inthe study design, coordination andpatients enrollment. MM and SA par-ticipated in the design of study proto-col and data analysis. All authors readand approved the final manuscript.

ACKNOWLEDGEMENTS Actuo Study Group Investigators:Abellaneda Fernández, Cristina;Aguayo Leyva, Ingrid Rocío; AlcarazLeón, Inmaculada; Alonso García,Ignacio; Arechalde Pérez, Ana; BalbínCarrero, Eva; Ballestero Corominas,Alejandro; Bilbao Badiola, Ibon; BoadaGarcía, Aram; Ciudad Blanco, Cristina;De Lucas, Raúl; Del Pozo Hernando,Luis Javier; Del Rio Reyes, Rosa;Eguino Gorrochategui, Patricia; EscalasTaberner, Juan; Espelt Otero, JorgeLuis; Fernández Angel,Isabel;Fernández Casado, Alex; FernándezTorres, Rosa Mª; Gallego Álvarez,Silvia; Galvany Rosell, Loida; GamoVillegas, Reyes; Ginarte Val, Manuel;Gómez Fernández, Cristina; GómezVázquez, Mercedes; Gutiérrez De LaPeña, Javier; Hernandez Cano, Natalia;Houmani Houmani, Manmoud;Ibargoyen Esnal, Jesús; Iglesias Sancho,Maribel; Izquierdo Herce, Noelia;Jeremías Torruella, Javier; LatorreFuentes, José Mª; Llambrich Mañes,Alex; López Ferrer, Ana; Mariscal Polo,Amaia; Márquez Balbas, Gemma;Martin Ezquerra, Gemma; Martin Urda,Maria Teresa; Martinez Escala, MariaEstela; Martinez Fernández, Matilde;Mieras Barceló, Caterina; Molina Ruiz,Ana; Montero Pérez, Iria; MorenoArias, Gerardo A.; Nadal Llado,Cristina; Naranjo Díaz, Maria José;Nasarre Calvo,Jaume; Navajas Pinedo,Belén; Oleaga Morante, José Manuel;Perelló Llinas, Guillermo; Pérez Losada,Mª Eugenia; Pérez-López, Montserrat;Pérez-Beato De Cos, Mª Paz; PestoniPorven, Carmela; Poza Magdalena,Olga; Rocamora Duran, Vicenc;Rodriguez Caruncho, Clara; RodriguezGranados, Mª Teresa; Roe Crespo,Esther; Ruiz Carrascosa, José Carlos;Salgado Boquete, Laura; SanchezMuros, Virginia; Sanz De GaldeanoPalacio,Carmen; Taberner Ferrer, Rosa;Trasobares Marugan, Lidia; Uria García,Mª Carmen Valle Martin, Mª Del Mar;Valle Santana, Pilar; Vázquez García,Juan; Velasco Pastor, Manuel; VeraCasaño, Angel; Vilarrasa Rull, Eva;Waadad Waadad, Tamim.

REFERENCES1. Kligman AM: An overview of acne. J

Invest Derm 1974; 62:268-287.2. Bhate K, Williams HC: Epidemiology of

acne vulgaris. Br J Dermatol 2013;168:474-485.

3. Thiboutot D, Gollnick H, Bettoli V,Dréno B, et al: New insights into themanagement of acne: an update fromthe Global Alliance to ImproveOutcomes in Acne group. J Am AcadDermatol 2009; 60:S1-S50.

4. Lasek RJ, Chren MM: Acne vulgarisand the quality of life of adult derma-tology patients. Arch Dermatol 1998;134:454-458.

5. Goulden V: Guidelines for the manage-ment of acne vulgaris in adolescents.Pediatr Drugs 2003; 5:301-313.

6. Weiden PJ, Rao N: Teaching medicationcompliance to psychiatric residents:placing an orphan topic into a train-ing curriculum. Acad Psychiatry 2005;29:203-210.

7. Haider A, Shaw JC: Treatment of acnevulgaris. JAMA 2004; 292:726-735.

8. McDonald HP, Garg AX, Haynes RB:Interventions to enhance patientadherence to medication prescrip-tions: scientific review. JAMA 2002;288:2868-2879.

9. Dréno B, Layton A, Zouboulis CC, et al:Adult female acne: a new paradigm. JEur Acad Dermatol Venereol 2013;27:1063-1070.

10. Russell JJ: Topical therapy for acne. AmFam Physician 2000; 61:357-365.

11. Snyder S: Medical adherence to acnetherapy: a systematic review. Am JClin Dermatol 2014; 15:87.

12. Weiss JS: Current options for the topicaltreatment of acne vulgaris. PediatrDermatol 1997; 14:480-488.

13. Herane MI, Fuenzalida H, Zegpi E, et al:Specific gel-cream as adjuvant to oralinsotretinoin improved hydration andprevented TEWL increase—a doubleblind, randomized, placebo-controlledstudy. J Cosmet Dermatol 2009; 8:181-185.

14. Del Rosso JQ: Clinical relevance of skinbarrier changes associated with theuse of oral isotretinoin: the impor-tance of barrier repair therapy inpatient management. J Drugs Dermatol2013; 12:626-631.

15. Renzi C, Picardi A, Abeni D, et al:Association of dissatisfaction with careand psychiatric morbidity with poortreatment compliance. Arch Dermatol2002; 138:337-342.

16. Tsou AY, Creutzfeldt CJ, Gordon JM:The good doctor: professionalism inthe 21st century. Handb Clin Neurol2013; 118:119-132.

17. Farin E, Gramm L, Schmidt E: Predictorsof communication preferences inpatients with chronic low back pain.Patient Prefer Adherence 2013; 7:1117-1127.

18. Zaghloul SS, Cunliffe WJ, Goodfield MJ:Objective assessment of compliancewith treatments in acne. Br J Dermatol2005; 152:1015-1021.

19. US Department of Health and HumanServices Food and DrugAdministration Center for DrugEvaluation and Research (CDER).Guidance for Industry; AcneVulgaris:Developing Drugs for Treatment.2005.

20. Pawin H, Beylot C, Chivot M, et al:Creation of a tool to assess adherenceto treatments for acne. Dermatology2009; 218:26-32.

21. Motley RJ, Finlay AY: Practical use of adisability index in the routine man-agement of acne. Clin Exp Dermatol1992; 17:1-3.

22. De Tiedra AG, Mercadal J, Badía X, etal: Adaptación transcultural al españoldel cuestionario Dermatology LifeQuality Index (DLQI): El índice decalidad de vida en dermatología. ActasDermatosifilogr 1998; 89:692-700.

23. Jones-Caballero M, Pedrosa E, PeñasPF: Self-reported adherence to treat-ment and quality of life in mild tomoderate acne. Dermatology 2008;217:309-314.

24. Miyachi Y, Hayashi N, Furukawa F, etal: Acne management in Japan: studyof patient adherence. Dermatology2011; 223:174-181.

Figure 1: Acne severity score

Figure 2

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Pfi zer is committed to help advance innovation in Dermatology

ANTIOXIDANTS FUEL MELANOMA?An antioxidant commonly used innutritional supplements doubled thespread of melanoma in a mousemodel, adding evidence to the ideathat antioxidants may fuel thegrowth of cancer cells, reports TheWall Street Journal (Oct. 8, 2015).

Researchers from theSahlgrenska Academy in Gothen-burg, Sweden, found that the antiox-idant N-acetylcysteine (NAC) dou-bled the rate at which malignantmelanoma spread to the animals’lymph nodes. As well, when theinvestigators repeated the experi-ment with human cells cultured inthe lab, the cancerous cells becamebetter at invading adjacent tissue,the news outlet reports.

The study’s lead author, profes-sor Martin Bergö of the SahlgrenskaCancer Center, noted the study onlylooked at antioxidants from nutri-tional supplements, according to theJournal, so the findings can not beextrapolated to antioxidants fromfood. Professor Bergö was quotedsaying that the findings are part of agrowing body of evidence that sug-gests antioxidant supplements arenot helpful for the prevention of can-cer, and may be harmful, so thatindividuals who have cancer or areat risk of developing cancer shouldavoid using them.

PHARMACISTS ASSESSING ANDTREATING SKIN AILMENTS INNEWFOUNDLAND AND LABRADORPharmacists in Newfoundland andLabrador are now allowed to bothprescribe for and treat minor ail-ments, including many skin condi-tions, reports CBC News (Sept. 22,2015).

At a news conference, theprovince’s health minister, SteveKent, introduced new regulationsthat would expand pharmacists’scope of practice. “You don’t needto go to the emergency room or yourdoctor anymore to treat acne orheart burn or a minor headache orjoint pain,” Kent was quoted saying.According to the CBC, skin condi-tions included in the regulationsinclude acne, mild to moderateatopic dermatitis, callouses andcorns, cold sores, contact dermati-tis, and fungal infections of the skin.Pharmacists will need to be autho-rized with the provincial pharmacyboard in order to be able to treatpatients under the new rules,according to the news outlet.

“It’s about patient choice andaccess because access has been areal problem, especially in ruralareas,” Richard Coombs, past presi-dent of the provincial pharmacists’association said.

CONFIRMED: PSORIATICS ATHIGHER RISK OF DEPRESSIONPatients with psoriasis, regardless ofits severity, are at elevated risk fordepression, reports U.S. News &World Report (Oct. 1, 2015).

A study published online inJAMA Dermatology (Sept. 30, 2015),that examined disease data on morethan 12,000 men and women, col-lected between 2009 and 2012 bythe U.S. National Health andNutrition Examination Survey. Theinvestigators identifyed psoriasisamong nearly 3% of respondentsand major depression among nearly8%, and almost 17% of psoriasispatients also had depression. Studyauthor Dr. Roger Ho, assistant pro-fessor in the department of derma-tology at New York University Schoolof Medicine, said the risk of depres-sion in psoriasis patients may be dri-ven more by worry about appear-ance than skin status. However, Dr.Gary Goldenberg, assistant professorof dermatology at the Icahn Schoolof Medicine at Mount Sinai in NewYork City, said it is possible thatdepression and psoriasis may sharephysiological pathways, and that thenext step in research into the linkmay be to see if treatment with pso-riasis medications have an impacton depressive symptoms.

NUMBER OF MOLES ON RIGHT ARMMAY INDICATE MELANOMA RISKHaving 11 or more moles on yourright arm may be a simple indicatorof being at high risk of melanoma,reports CTV News (Oct. 20, 2015).

Reporting on research publishedin the British Journal of Dermatologyon Oct. 19, the news outlet noted thatthe investigators found that the num-ber of moles on a person’s right armwas a good predictor of that person’stotal mole count, and that the higherthe total mole count the higher theperson’s risk of skin cancer. The studylooked at 3,594 sets of femaleCaucasian twins who had the moleson 17 body areas counted, reportedCTV. Similar counts were done on agroup of approximately 400 men andwomen with melanoma. The newoutlet quoted the study’s lead author,Simone Ribero of the department oftwin research and genetic epidemiolo-gy at King’s College, London, U.K., say-ing that the findings could have a “sig-nificant impact”, and allow doctors toquickly and accurately estimate apatient’s total number of moles via aneasily accessible body part.

Research of NoteNEW SEVERITY SCORE FOR HIDRADENITIS SUPPURATIVA

Researchers have developed a new composite, dynamic disease severity score tailoredfor hidradenitis suppurativa (HS) called the Acne Inversa Severity Index (AISI). Thescale includes a physician-rated assessment of the types of lesions appearing as well

as what body sites are involved. A zero to 10 visual analogue scale (illness-VAS) is also includedto assess pain, discomfort, and disability arising from HS.

To assess the validity of the new scale, it was compared to Hurley staging classification,modified Sartorius score, and the Dermatology Life Quality Index (DLQI). In 46 patients with HS,the authors demonstrated a significant correlation between AISI and Hurley staging (r: 0.70856,p=0.0021), modified Sartorius score (r: 0.9730, p<0.00001), and DLQI (r: 0.8257, p=0.221). Inthe new scale, HS may be categorized as mild, moderate, or severe (AISI <10, 10>18, or >18,respectively). AISI was also faster to administer than the Sartorius score, taking an average of46.44±19.24 seconds vs. 83.2±19.04 seconds, p=1.31x10-6.Chiricozzi A, Faleri S, Franceschini C, Caro RD, Chimenti S, Bianchi L: AISI A new disease severity

assessment tool for hidradenitis suppurativa, in Wounds (Oct. 2015; 27(10):258-264).

HDR PLESIOTHERAPY FOR NON-MELANOMA SKIN CANCER

Aretrospective institutional study of non-melanoma skin cancer (NMSC) treated usingtwo hypofractionated high-dose-rate (HDR) plesiotherapy techniques looked at 134basal cell or squamous cell skin carcinomas treated in the same radiation oncology

department between Nov. 2006 and Dec. 2011. Lesions were treated with the HDR plesiother-apy using either a fixed (Leipzig) applicator or a customized mold. The median follow up was33 months, with overall disease-free survival 95.12% at three years, and 93.36% at five. Withthe applicator, disease-free survival was 94.9% at both three and five years, while with thecustom mold it was 93.1% at three years and 88% at five. 98% of lesions completelyregressed, two persisted after treatment (both Leipzig), and six had local recurrence (fiveLeipzig and three molds, p=0.404). Acute toxicity below Grade 2 was seen in 57.3% ofpatients, and only 2.2% of lesions had Grade 4. Custom molds were borderline significantlyassociated with elevated toxicity (p=0.067). Larger tumours were associated with greaterskin toxicity. Cosmeisis outcomes were excellent or good in 82% of patients, fair in 13%, andwere not available in 5%.

Arenas M, Arguis M, Diez-Presa L, et al: Hypofractionated high-dose-rate plesiotherapy in non-melanoma skin cancer treatment, in Brachytherapy (Oct. 17, 2015 online edition).

What THE LAY PRESS is saying about . . .

Department Editor: John Evans

Diagnostic Quiz

A. Epidermolysis bullosaB. Urticaria pigmentosa

C. LentigoD. Linear IgA dermatosis

THE EDITORS invite your participation in thisregular feature of the journal.Please send all images and

correspondence to:Medical Editor,

The Chronicle of Skin & Allergy555 Burnhamthorpe Road, Suite 306,

Toronto, Ont. M9C 2Y3.Telephone: (416) 916-2476

E-mail: [email protected]

Correct answer: Urticaria pigmentosa

26 · Oct./Nov. 2015

Journal Club THE CHRONICLE of SKIN & ALLERGY

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