CEBD Evidence Update

May 2018





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Welcome to this month’s CEBD Evidence Update, bringing you the latest evidence-based publications in dermatology, with an emphasis on clinical guidelines and systematic reviews.


CEBD Evidence Updates are compiled by the Centre of Evidence Based Dermatology at the University of Nottingham, with funding from Nottingham University Hospitals NHS Trust, as a service to the dermatology community. An archive of these updates is available on the list home page: CEBD-EVIDENCE-UPDATES.


The title of each item provides a link to the abstract in PubMed. If the paper is open-access (indicated in brown text towards the bottom of the PubMed record) or you have an institutional subscription to the journal concerned, you can access it by clicking on the full text link at the top right of the PubMed record. It is important to appraise the quality of systematic reviews before applying to your practice—we recommend the AMSTAR 2 tool, which is very quick and easy to use. See also this open-access article: Research Techniques Made Simple: Assessing Risk of Bias in Systematic Reviews.


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Systematic reviews & evidence summaries

Eczema & dermatitis

Psoriasis & psoriatic arthritis

Acne & rosacea

Skin cancers & sun protection

Infections of the skin

Drug & treatment reactions/safety

Vitiligo & pigmentary disorders

Hair & nail disorders

Oral disorders

Chronic wounds & ulcers

Other disorders affecting the skin

Skin conditions & dermatology in general

Skin surgery & lasers

Service delivery & management

Prescribing and safety alerts

CEBD publications & news

Other key publications that have caught our eye










Scottish Medicines Consortium: brodalumab (Kyntheum)


“Brodalumab (Kyntheum®) is accepted for restricted use within NHSScotland.

Indication under review: for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy.

SMC restriction: for patients who have failed to respond to standard systemic therapies (including ciclosporin, methotrexate and phototherapy), are intolerant to, or have a contra-indication to these treatments.”



Scottish Medicines Consortium: avelumab (Bavencio)


“Avelumab (Bavencio®) is accepted for use within NHSScotland.

Indication under review: As monotherapy for the treatment of adult patients with metastatic Merkel cell carcinoma (mMCC).”



Oral propranolol in the treatment of proliferating infantile haemangiomas: The British Society for Paediatric Dermatology consensus guidelines.

Solman L, Glover M, Beattie PE, Buckley H, Clark S, Gach JE, Giardini A, Helbling I, Hewitt RJ, Laguda B, Langan SM, Martinez AE, Murphy R, Proudfoot L, Ravenscroft J, Shahidullah H, Shaw L, Syed SB, Wells L, Flohr C.

Br J Dermatol. 2018 May 17. doi: 10.1111/bjd.16779. [Epub ahead of print]


“METHODS: This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting.

RESULTS: The expert panel achieved consensus on 47 statements in 8 categories including indications and contraindications for starting propranolol, pre-treatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment.”





S3 Guideline for the treatment of psoriasis vulgaris, update - Short version part 1 - Systemic treatment.

Nast A, Amelunxen L, Augustin M, Boehncke WH, Dressler C, Gaskins M, Härle P, Hoffstadt B, Klaus J, Koza J, Mrowietz U, Ockenfels HM, Philipp S, Reich K, Rosenbach T, Rzany B, Schlaeger M, Schmid-Ott G, Sebastian M, von Kiedrowski R, Weberschock T.

J Dtsch Dermatol Ges. 2018 May;16(5):645-669. doi: 10.1111/ddg.13516.


“The German guideline for the treatment of psoriasis vulgaris was updated using GRADE methodology. The guideline is based on a systematic literature review completed on December 1, 2016, and on a formal consensus and approval process. The first section of this short version of the guideline covers systemic treatment options considered relevant by the expert panel and approved in Germany at the time of the consensus conference (acitretin, adalimumab, apremilast, cyclosporine, etanercept, fumaric acid esters, infliximab, methotrexate, secukinumab and ustekinumab).”



Japanese Dermatological Association Guidelines: Guidelines for the treatment of acne vulgaris 2017.

Hayashi N, Akamatsu H, Iwatsuki K, Shimada-Omori R, Kaminaka C, Kurokawa I, Kono T, Kobayashi M, Tanioka M, Furukawa F, Furumura M, Yamasaki O, Yamasaki K, Yamamoto Y, Miyachi Y, Kawashima M.

J Dermatol. 2018 May 21. doi: 10.1111/1346-8138.14355. [Epub ahead of print]


“The Guidelines for the Treatment of Acne Vulgaris of the Japanese Dermatological Association was first published in Japanese in 2008 and revised in 2016 and 2017. These guidelines (GL) indicate the standard acne treatments in Japan and address pharmaceutical drugs and treatments applicable or in use in Japan.”


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Systematic reviews & evidence summaries



Eczema & dermatitis


Interventions for preventing occupational irritant hand dermatitis.

Bauer A, Rönsch H, Elsner P, Dittmar D, Bennett C, Schuttelaar MLA, Lukács J, John SM, Williams HC.

Cochrane Database Syst Rev. 2018 Apr 30;4:CD004414. doi: 10.1002/14651858.CD004414.pub3


“AUTHORS' CONCLUSIONS: Moisturisers used alone or in combination with barrier creams may result in a clinically important protective effect, either in the long- or short-term, for the primary prevention of OIHD [occupational irritant hand dermatitis]. Barrier creams alone may have slight protective effect, but this does not appear to be clinically important. The results for all of these comparisons were imprecise, and the low quality of the evidence means that our confidence in the effect estimates is limited. For skin protection education, the results varied substantially across the trials, the effect was imprecise, and the pooled risk reduction was not large enough to be clinically important. The very low quality of the evidence means that we are unsure as to whether skin protection education reduces the risk of developing OIHD. The interventions probably cause few or no serious adverse effects. We conclude that at present there is insufficient evidence to confidently assess the effectiveness of interventions used in the primary prevention of OIHD. This does not necessarily mean that current measures are ineffective. Even though the update of this review included larger studies of reasonable quality, there is still a need for trials which apply standardised measures for the detection of OIHD in order to determine the effectiveness of the different prevention strategies.”



A systematic review on the off-label use of montelukast in atopic dermatitis treatment.

Chin WK, Lee SWH.

Int J Clin Pharm. 2018 May 18. doi: 10.1007/s11096-018-0655-3. [Epub ahead of print]


“Results: Among 301 articles screened, 11 studies met the inclusion criteria and were included in the review. The study populations consist of paediatric and adult subjects with moderate-to-severe AD (atopic dermatitis]. Montelukast use was shown to improve symptoms such as pruritus in four studies. Another 2 studies reported that montelukast could improve symptoms similar to the standard regimen of topical steroid and oral antihistamine. However, five studies reported that montelukast had no effects in symptoms alleviation. The use of montelukast was associated with a similar safety profile to placebo and well-tolerated with minimal adverse effects.

Conclusion: There is limited evidence to suggest that the off-label use of montelukast is effective in treating moderate-to-severe AD. Further research with larger study populations employing standardized endpoint measuring instrument is warranted to further investigate the off-label use of montelukast in AD treatment. Until then, the use of conventional treatments including optimal daily skin hydration should remain the mainstay in the management of atopic dermatitis. In fact, for moderate-to-severe condition, steroid sparing immune-suppressants should still be used clinically until more effective and safer alternative is discovered.”


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Psoriasis & psoriatic arthritis


Systemic monotherapy treatments for generalized pustular psoriasis: A systematic review.

Zhou LL, Georgakopoulos JR, Ighani A, Yeung J.

J Cutan Med Surg. 2018 Apr 1:1203475418773358. doi: 10.1177/1203475418773358. [Epub ahead of print]


“In total, 31 studies met eligibility criteria. Described treatment modalities included retinoids, cyclosporine, biologics, and dapsone. Despite the lack of high-quality evidence or a well-accepted treatment algorithm for GPP, systemic retinoids, cyclosporine, biologics, and dapsone are all possible first-line agents, with retinoids being one of the best-supported treatment options and biologics as an emerging therapeutic field with great potential requiring additional data. However, the final choice of treatment should be considered within the unique context of each patient.”



Efficacy and safety outcomes for originator TNF inhibitors and biosimilars in rheumatoid arthritis and psoriasis trials: a systematic literature review.

Moots RJ, Curiale C, Petersel D, Rolland C, Jones H, Mysler E.

BioDrugs. 2018 May 22. doi: 10.1007/s40259-018-0283-4. [Epub ahead of print]


“RESULTS: Of 83 publications identified, 16 publications were included for analysis (RA [rheumatoid arthritis]: originators, n = 5; biosimilars, n = 6; PsO [plaque psoriasis]: originators, n = 2; biosimilars, n = 3). American College of Rheumatology 20% response rates were higher among patients with RA receiving originator biologics and biosimilars in biosimilar trials than among patients receiving the originator biologics in pivotal trials. In etanercept studies in PsO, a difference was observed in Psoriasis Area and Severity Index 75% response rates between biosimilar and pivotal trials. Insufficient efficacy data were available from adalimumab and infliximab biosimilar studies in PsO to determine any differences in treatment responses between pivotal and biosimilar studies.

CONCLUSIONS: Observed differences in treatment response rates between pivotal originator trials and trials of originator biologics and their respective biosimilars may be attributable to fundamental differences in study design and/or baseline patient characteristics, which require further analysis.”



Emerging therapies in psoriasis: A systematic review.

Lee EB, Amin M, Bhutani T, Wu JJ.

Cutis. 2018 Mar;101(3S):5-9.


“We reviewed published data from phase 2 and 3 clinical trials of 2 IL-17 inhibitors (ixekizumab and brodalumab); 3 IL-23 inhibitors (guselkumab, tildrakizumab, and risankizumab); and 1 tumor necrosis factor (TNF) inhibitor (certolizumab pegol). Janus kinase inhibitors were not included in our review, as they currently are not approved by the US Food and Drug Administration (FDA) and there are no plans to further develop this class for treatment of psoriasis. Overall, the clinical improvement provided by and the safety profiles of these agents are promising; they may be equal to or more efficacious than available therapeutic options for treating the symptoms of psoriasis. Long-term studies are still needed, however, to further establish safety and efficacy profiles for these biologic agents.”



Systematic review of anti-drug antibodies of IL-17 inhibitors for psoriasis.

Thomas LW, Lee EB, Wu JJ.

J Dermatolog Treat. 2018 May 8:1-25. doi: 10.1080/09546634.2018.1473552. [Epub ahead of print]


“A total of 14 papers were reviewed. Only one secukinumab trial detected treatment-emergent ADA [anti-drug antibodies] in 4 out of 996 (0.41%) patients during the 52-week treatment period. Two of these patients (1 on 150-mg retreatment as needed and 1 on 150-mg fixed interval) were found to have neutralizing antibodies; however, they were not associated with decreased efficacy. One paper reported ADAs against ixekizumab. One out of 1150 (9%) developed titers to ixekizumab after receiving 160-mg-loading dose followed by 80 mg every 2 weeks. Nineteen out of 1150 (1.7%) developed high titer (>1:1280) which impacted clinical outcomes. Three studies did detect ADA against brodalumab; however, none were neutralizing. It is difficult to draw a conclusion from our findings given the variability in ADA development. Most trials did not develop ADA, and if they did, the majority of the time they were not neutralizing. Only ixekizumab showed decreased efficacy, but no increased adverse events in cases with neutralizing ADA.”



Obesity and response to anti-tumor necrosis factor-α agents in patients with select immune-mediated inflammatory diseases: A systematic review and meta-analysis.

Singh S, Facciorusso A, Singh AG, Casteele NV, Zarrinpar A, Prokop LJ, Grunvald EL, Curtis JR, Sandborn WJ.

PLoS One. 2018 May 17;13(5):e0195123. doi: 10.1371/journal.pone.0195123. eCollection 2018.


“RESULTS: Based on 54 cohorts including 19,372 patients (23% obese), patients with obesity had 60% higher odds of failing therapy (OR,1.60; 95% CI,1.39-1.83;I2 = 71%). Dose-response relationship was observed (obese vs. normal BMI: OR,1.87 [1.39-2.52]; overweight vs. normal BMI: OR,1.38 [1.11-1.74],p = 0.11); a 1kg/m2 increase in BMI was associated with 6.5% higher odds of failure (OR,1.065 [1.043-1.087]). These effects were observed across patients with rheumatic diseases, but not observed in patients with IBD. Effect was consistent based on dosing regimen/route, study design, exposure definition, and outcome measures. Less than 10% eligible RCTs reported outcomes stratified by BMI.

CONCLUSIONS: Obesity is an under-reported predictor of inferior response to anti-TNF agents in patients with select immune-mediated inflammatory diseases. A thorough evaluation of obesity as an effect modifier in clinical trials is warranted, and intentional weight loss may serve as adjunctive treatment in patients with obesity failing anti-TNF therapy.”



Tongue psoriasis: Clinical aspects and analysis of epidemiological associations in 313 children, with a systematic literature review.

Pourchot D, Chiaverini C, Bourrat E, Barbarot S, Vabres P, Hubiche T, Droicourt C, Piram M, Kupfer-Bessaguet I, Ferneiny M, Puzenat E, Balguérie X, Beauchet A, Bursztejn AC, Mahé E; Groupe de recherche de la Société française de dermatologie pédiatrique.

Ann Dermatol Venereol. 2018 May 14. pii: S0151-9638(18)30381-8. doi: 10.1016/j.annder.2018.04.003. [Epub ahead of print]


“RESULTS: 7.7% of the 313 children with psoriasis had tongue involvement. The clinical aspects were geographic tongue (4.2%), fissured tongue (2.8%) and both (0.64%). There was no association between tongue involvement and the clinical characteristics of the children. Two hundred and ninety-five articles were referenced and 3 were analysed. Psoriasis is very rare in cases of tongue abnormalities.

CONCLUSION: The prevalence of tongue involvement was 7.7% in children with psoriasis. No clinical or epidemiological association was shown. Tongue involvement does not modify the management of psoriasis. In the literature review it was not possible to evaluate either the prevalence of tongue involvement in psoriasis or the positive predictive value thereof.”



Do psoriasis patients engage in vigorous physical activity?

Amin M, Lee EB, Bhutani T, Wu JJ.

Cutis. 2018 Mar;101(3):198-200.


“A total of 353 nonduplicate articles were identified, and of 4 relevant studies, one provided sufficient data and was included in our review. Results from our review indicate that individuals with psoriasis are less likely to participate in vigorous physical activity compared to individuals without psoriasis. Further research is necessary to clarify this relationship.”



Association between psoriasis and erectile dysfunction: A meta-analysis.

Wu T, Duan X, Chen S, Chen X, Yu R, Yu X.

J Sex Med. 2018 May 4. pii: S1743-6095(18)30932-9. doi: 10.1016/j.jsxm.2018.04.630. [Epub ahead of print]


“RESULTS: In total, 9 studies with 36,242 psoriasis patients and 1,657,711 controls (participants without psoriasis) met inclusion criteria and showed that there was statistically significant association between psoriasis and ED [erectile dysfunction] risk (OR 1.35; 95% CI 1.29-1.41; P < .00001; I2 = 44%). A significant association for adjusted-for-covariates studies between psoriasis and ED risk was also observed (OR 1.22; 95% CI 1.08-1.37; P = .002; I2 = 43.8%). It revealed the International Index of Erectile Function-5 score was statistically significantly lower in the psoriasis group than controls (SMD -3.09; 95% CI -4.81 to -1.37; P = .0004; I2 = 77%). A subgroup analysis was performed to potentially explain heterogeneity. It examined the main potential sources of inter-study variance including variance sample sizes and different assessment tools for ED.

CLINICAL TRANSLATION: The risk of ED in psoriasis patients should also be assessed by physicians.

CONCLUSIONS: This study is a well-designed and comprehensive meta-analysis to examine the relationship between psoriasis and risk of ED. However, the included studies are mostly cross-sectional or have small sample cohorts, which could bring bias and heterogeneity into the analysis. Our findings support the hypothesis that psoriasis is associated with an increased risk of ED. Furthermore, additional prospective cohort studies are needed to elucidate these relationships and to advance knowledge in this field.”



[Correlation of psoriasis with erectile dysfunction: A meta-analysis].

Zhang FB, Wu BC, Xie LB, Jiang R.

Zhonghua Nan Ke Xue. 2017 Mar;23(3):256-261. Chinese.


“RESULTS: A total of 6 studies were included in this analysis. The analysis with the fixed-effects model revealed a significant correlation between psoriasis and ED [erectile dysfunction] (OR = 1.92, 95% CI: 1.532.40, P <0.01), and that on 3 of the studies with the random-effects model showed that the IIEF-5 scores were significantly lower in psoriasis patients than in non-psoriasis males (MD = 3.11, 95% CI: 4.85--1.37, P <0.01).

CONCLUSIONS: There is a certain correlation between psoriasis and ED. Psoriasis patients may have a higher incidence of ED though it is to be further confirmed by more higher-quality studies.”



The effect of biologic and targeted synthetic drugs on work- and productivity-related outcomes for patients with psoriatic arthritis: A systematic review.

Iragorri N, Hofmeister M, Spackman E, Hazlewood GS.

J Rheumatol. 2018 May 1. pii: jrheum.170874. doi: 10.3899/jrheum.170874. [Epub ahead of print]


“CONCLUSION: Treatment with IFX [infliximab], GOL [golimumab], CZP [certolizumab pegol], ustekinumab, and apremilast resulted in improvements in self-reported work productivity. A pooled analysis was not possible because of the clinical heterogeneity of the trials and variability in outcome reporting.”


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Acne & rosacea


Chemical peels for acne vulgaris: a systematic review of randomised controlled trials.

Chen X, Wang S, Yang M, Li L.

BMJ Open. 2018 Apr 28;8(4):e019607. doi: 10.1136/bmjopen-2017-019607.


“RESULTS: Twelve RCTs (387 participants) were included. Effectiveness was not significantly different: trichloroacetic acid versus salicylic acid (SA) (percentage of total improvement: risk ratio (RR) 0.89; 95% CI 0.73 to 1.10), glycolic acid (GA) versus amino fruit acid (the reduction of inflammatory lesions: mean difference (MD), 0.20; 95% CI -3.03 to 3.43), SA versus pyruvic acid (excellent or good improvement: RR 1.11; 95% CI 0.73 to 1.69), GA versus SA (good or fair improvement: RR 1.00; 95% CI 0.85 to 1.18), GA versus Jessner's solution (JS) (self-reported improvements: RR 1.00; 95% CI 0.44 to 2.26), and lipohydroxy acid versus SA (reduction of non-inflammatory lesions: 55.6%vs48.5%, p=0.878). Combined SA and mandelic acid peeling was superior to GA peeling (percentage of improvement in total acne score: 85.3%vs68.5%, p<0.001). GA peeling was superior to placebo (excellent or good improvement: RR 2.30; 95% CI 1.40 to 3.77). SA peeling may be superior to JS peeling for comedones (reduction of comedones: 53.4%vs26.3%, p=0.001) but less effective than phototherapy for pustules (number of pustules: MD -7.00; 95% CI -10.84 to -3.16).

LIMITATIONS: The methodological quality of the included RCTs was very low to moderate. Meta-analysis was not possible due to the significant clinical heterogeneity across studies.

CONCLUSION: Commonly used chemical peels appear to be similarly effective for mild-to-moderate acne vulgaris and well tolerated. However, based on current limited evidence, a robust conclusion cannot be drawn regarding any definitive superiority or equality among the currently used chemical peels. Well-designed RCTs are needed to identify optimal regimens.”



Acne scarring management: Systematic review and evaluation of the evidence.

Bhargava S, Cunha PR, Lee J, Kroumpouzos G.

Am J Clin Dermatol. 2018 May 9. doi: 10.1007/s40257-018-0358-5. [Epub ahead of print]


“RESULTS: The efficacy of lasers and radiofrequency in atrophic acne scarring is confirmed by many comparative and observational studies. Other modalities can be used as an adjunct, the choice of which depends on the type, severity, and number of atrophic scars. Minimally invasive procedures, such as fractional radiofrequency and needling, provide good outcomes with negligible risks in patients with dark or sensitive skin types.

CONCLUSIONS: There is a lack of high-quality data. Fractional lasers and radiofrequency offer significant improvement in most types of atrophic acne scars with minimal risks and can be combined with all other treatment options. Combination therapies typically provide superior outcomes than solo treatments.”



Acupuncture for acne vulgaris: A systematic review and meta-analysis.

Mansu SSY, Liang H, Parker S, Coyle ME, Wang K, Zhang AL, Guo X, Lu C, Xue CCL.

Evid Based Complement Alternat Med. 2018 Mar 12;2018:4806734. doi: 10.1155/2018/4806734. eCollection 2018.


“Results: Twelve RCTs were included in the qualitative review and 10 RCTs were included in meta-analysis. Methodological quality of trials was generally low. The chance of achieving ≥30% change in lesion count in the acupuncture group was no different to the pharmacotherapy group (RR: 1.07 [95% CI 0.98, 1.17]; I2 = 8%) and ≥50% change in lesion count in the acupuncture group was not statistically different to the pharmacotherapy group (RR: 1.07 [95% CI 0.98, 1.17]; I2 = 50%).

Conclusions: While caution should be exercised due to quality of the included studies, acupuncture and auricular acupressure were not statistically different to guideline recommended treatments but were with fewer side effects and may be a treatment option. Future trials should address the methodological weaknesses and meet standard reporting requirements stipulated in STRICTA.”



Dairy intake and acne development: A meta-analysis of observational studies.

Aghasi M, Golzarand M, Shab-Bidar S, Aminianfar A, Omidian M, Taheri F.

Clin Nutr. 2018 May 8. pii: S0261-5614(18)30166-3. doi: 10.1016/j.clnu.2018.04.015. [Epub ahead of print]


“RESULTS: Highest compared with lowest category of dairy (OR: 2.61, 95% CI: 1.20 to 5.67), total milk (OR: 1.48, 95% CI: 1.31 to 1.66), low-fat milk (OR: 1.25, 95% CI: 1.10 to 1.43) and skim milk (OR: 1.82, 95% CI: 1.34 to 2.47) intake significantly was associated with the presence of acne. Results of dose-response analysis revealed a significant linear relationship between dairy, whole milk and skim milk and risk of acne and nonlinear association between dairy, milk, low-fat milk and skim milk intake and acne.

CONCLUSION: In this meta-analysis we found a positive relationship between dairy, total milk, whole milk, low-fat and skim milk consumption and acne occurrence. In contrary, no significant association between yogurt/cheese and acne development was observed.”


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Skin cancers & sun protection


The clinical significance of KIT mutations in melanoma: a meta-analysis.

Gong HZ, Zheng HY, Li J.

Melanoma Res. 2018 May 9. doi: 10.1097/CMR.0000000000000454. [Epub ahead of print]


“KIT mutations were reported in 497 (9.5%) of 5224 patients with melanomas, and were associated significantly with age, clinical melanoma subtype, anatomic location, and chronic sun-damage (CSD), but not with sex, histological type, Breslow thickness, ulceration, mitotic rate, or tumor stage. The incidence of KIT mutation was significantly higher in older individuals (OR=1.296, 95% CI: 1.025-1.641; P=0.031), and showed a positive association with mucosal melanoma (OR=1.363, 95% CI: 1.094-1.697; P=0.006), acral melanoma (OR=1.374, 95% CI: 1.123-1.682; P=0.02), and CSD (OR=1.880, 95% CI: 1.127-3.136; P=0.016), but a negative relationship with melanomas arising in non-CSD skin (OR=0.562, 95% CI: 0.392-0.805; P=0.002). The frequency of KIT mutations was associated negatively with melanomas located on the extremities. KIT mutations, which are critical in the genetic pathogenesis of melanomas, define a unique subtype of melanoma associated closely with older age, and acral, mucosal, or CSD sites, but not associated with any histological features or tumor stage. Although the KIT mutation rate is higher in White than Asian populations, no significant difference in clinical association with KIT mutations was detected between the two groups.”



Systematic review of advanced practice nurses' skin cancer detection knowledge and attitudes, clinical skin examination, lesion detection, and training.

Loescher LJ, Stratton D, Slebodnik M, Goodman H.

J Am Assoc Nurse Pract. 2018 Jan;30(1):43-58. doi: 10.1097/JXX.0000000000000004.


“CONCLUSIONS: The studies mainly targeted or included nurse practitioners. Collectively, participants had variable, suboptimal skin cancer knowledge, even after an intervention. A slight majority performed CSE [clinical skin examination] during annual visits but agreed that CSE was important and within their scope of practice. Major CSE barriers were lack of time, training, and confidence. Participants who received training were more proficient in identifying suspicious versus benign lesions. Few skin cancer detection training opportunities for nurses exist.

IMPLICATIONS: The level of certainty of the evidence for skin cancer detection by advanced practice nurses and their impact on the skin cancer problem remain low. These nurses would benefit from accessible and efficacious CSE and lesion training.”



Radiotherapy for inoperable Merkel cell carcinoma: a systematic review and pooled analysis.

Patel P, Modi C, McLellan B, Ohri N.

Dermatol Pract Concept. 2018 Apr 30;8(2):149-157. doi: 10.5826/dpc.0802a15. eCollection 2018 Apr.


“Results: Eight case reports, 4 case series, and 6 retrospective studies, yielding 68 patients, were included in our analysis. Of the 24 stage I/II patients treated with local irradiation, 6 (25%) relapsed and 1 (4%) died from MCC [Merkel cell carcinoma]. Of the 24 stage I/II patients treated with local and regional nodal irradiation, 5 (21%) relapsed and 2 (8%) died from MCC. Of the 20 stage III patients treated with local and regional nodal irradiation, 12 (60%) relapsed and 7 (35%) died from MCC.

Conclusions: Radiation monotherapy appears to be a reasonable treatment modality for patients with inoperable stage I-III MCC. Further investigation with prospective studies is needed to draw definitive conclusions.”


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Infections of the skin


None found this month.


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Drug & treatment reactions/safety


Cutaneous toxicity as a predictive biomarker for clinical outcome in patients receiving anticancer therapy.

Rzepecki AK, Cheng H, McLellan BN.

J Am Acad Dermatol. 2018 May 4. pii: S0190-9622(18)30654-6. doi: 10.1016/j.jaad.2018.04.046. [Epub ahead of print]


“Although preliminary studies are promising about the potential role of cutaneous toxicities as a surrogate biomarker of treatment efficacy, larger prospective studies are needed to confirm this relationship. Dermatologists have a unique opportunity to collaborate with oncologists in the multidisciplinary treatment paradigm by helping to identify and manage these dermatologic events of cancer patients. A heightened awareness of these toxicities is critical as it can potentially allow recognition of the efficacy of anticancer therapy and may influence treatment decisions and patient outcomes.”



Use of trolamine to prevent and treat acute radiation dermatitis: a systematic review and meta-analysis.

Menêses AG, Reis PEDD, Guerra ENS, Canto GL, Ferreira EB.

Rev Lat Am Enfermagem. 2018;26:e2929. doi: 10.1590/1518-8345.2035.2929. Epub 2018 May 7. Portuguese, Spanish, English.


“RESULTS: Seven controlled clinical trials were identified. The controls used were calendula, placebo, institutional preference / usual care, Aquaphor®, RadiaCare™, and Lipiderm™. The studies were pooled using frequency of events and risk ratio with 95% confidence intervals, in subgroups according to radiation dermatitis graduation.

CONCLUSION: Based on the studies included in this review, trolamine cannot be considered as a standardized product to prevent or treat radiation dermatitis in patients with breast and head and neck cancer.”


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Vitiligo & pigmentary disorders


Risk of skin cancer in people with vitiligo: a systematic review and meta-analysis.

Ban L, Labbouz S, Grindlay D, Batchelor J, Ratib S.

Br J Dermatol. 2018 Apr 28. doi: 10.1111/bjd.16703. [Epub ahead of print]


“This review supports the current view that vitiligo may be protective of skin cancer. This could be due to the genetic and autoimmune profile of vitiligo, or the fact that patients with vitiligo are more careful regarding sun protection than those without vitiligo. This is the first review in this clinical area which has searched the literature comprehensively and synthesised data in a systematic way. However, our review is limited by the small number of included studies and high heterogeneity due to methodological and clinical differences between the included studies. Furthermore, the lack of studies has prohibited subgroup analysis and assessment of publication bias.”



The role of interleukins in vitiligo: A systematic review.

Alcântara Gomes I, Oliveira de Carvalho F, Freire de Menezes A, Menezes Almeida F, Shanmugam S, de Souza Siqueira Quintans J, Quintans-Júnior LJ, Rodrigues de Moura T, Oliveira PD, de Souza Araújo AA.

J Eur Acad Dermatol Venereol. 2018 Apr 28. doi: 10.1111/jdv.15016. [Epub ahead of print]


“The interleukins mainly involved were IL-2, IL-4, IL-6, IL-10 and IL-17. The studies highlight the crucial role of IL-17 in the onset and progression of the disease, and its synergistic action with IL-2, IL-6 and IL-33. Dysregulated levels of the interleukins were also correlated with the stage of disease, the affected skin surface area and indicated as the main factor for lymphocyte infiltration found in depigmented regions. These findings illustrate the growing need for new therapies targeting vitiligo and further research into the role of interleukins as an area of particular interest.”



Evaluation instruments for quality of life related to melasma: An integrative review.

Pollo CF, Meneguin S, Miot HA.

Clinics (Sao Paulo). 2018 May 21;73:e65. doi: 10.6061/clinics/2018/e65.


“Eight articles were identified, of which only one (12.5%) referred to the development and validation of a specific instrument for evaluation of the quality of life of melasma patients. An additional six articles (75%) referred to transcultural adjustment and validation of the same instrument in other languages, and another (12.5%) article reported the development of a generic instrument for evaluation of quality of life in patients with pigment disorders. This review revealed only one specific instrument developed and validated in different cultures. Despite being widely used, this instrument did not follow the classic construction steps for psychometric instruments, which paves the way for future studies to develop novel instruments.”


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Hair & nail disorders


Systematic review of platelet-rich plasma (PRP) preparation and composition for the treatment of androgenetic alopecia.

Kramer ME, Keaney TC.

J Cosmet Dermatol. 2018 May 22. doi: 10.1111/jocd.12679. [Epub ahead of print]


“RESULTS: Nineteen studies (in 15 articles) met the inclusion criteria for analysis. Only 21% of these studies reported all PRP [platelet-rich plasma] preparation factors analyzed, and only 32% of the protocols reported the platelet count for both the initial whole blood and final PRP product.

CONCLUSION: The current reporting of PRP preparation methodology and final composition is inconsistent and insufficient to enable comparison between studies and determination of efficacy for particular treatment applications.”


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Oral disorders


Rate of malignant transformation of oral lichen planus: A systematic review.

Giuliani M, Troiano G, Cordaro M, Corsalini M, Gioco G, Lo Muzio L, Pignatelli P, Lajolo C.

Oral Dis. 2018 May 8. doi: 10.1111/odi.12885. [Epub ahead of print]


“RESULTS: Among 7429 records screened, only 21 were included in this review. Ninety-two out of 6559 patients developed Oral Squamous Cell Carcinoma (OSCC), with an overall TR [malignant transformation rate] of 1.40% (1.37% for OLP [oral lichen planus] and 2.43% for OLL [oral lichenoid lesions]), an annual TR of 0.20%. Female gender, red clinical forms and tongue site seem to slightly increase the transformation risk.

CONCLUSIONS: This systematic review confirms that both OLP and OLL, the latter with a slightly higher TR, may be considered Potentially Malignant Disorders (PMDs) and suggests that erosive type, female gender and tongue site should be considered as risk factors for OLP transformation. Major efforts should be done to establish strict clinical and histological criteria to diagnose OLP and to perform sounder methodological observational studies.”



Prevalence of oral potentially malignant disorders: a systematic review and meta-analysis.

Mello FW, Miguel AFP, Dutra KL, Porporatti AL, Warnakulasuriya S, Guerra ENS, Rivero ERC.

J Oral Pathol Med. 2018 May 8. doi: 10.1111/jop.12726. [Epub ahead of print]


“The meta-analysis showed that the prevalence of OPMD [oral potentially malignant disorders] was 4.47% (95%CI=2.43-7.08). The most prevalent OPMDs were oral submucous fibrosis (4.96%; 95%CI=2.28-8.62) and leukoplakia (4.11%; 95%CI=1.98-6.97). OPMDs were identified more commonly in males (59.99%; 95%CI=41.27-77.30). Asian and South American/Caribbean populations had the highest prevalence rates of 10.54% (95%CI=4.60-18.55) and 3.93% (95%CI=2.43-5.77), respectively. The overall prevalence of oral potentially malignant disorders worldwide was 4.47%, and males were more frequently affected by these disorders. The prevalence of oral potentially malignant disorders differs between populations; therefore, further population-based studies may contribute to the better understanding of these differences.”



An update on drug-induced oral reactions.

Yousefi H, Abdollahi M.

J Pharm Pharm Sci. 2018;21(1):171-183. doi: 10.18433/jpps29893.


“The most frequent oral ADR [adverse drug reaction] was xerostomia, and the most reported cause was antihypertensive medications. Cardiovascular drugs were the most reported culprit agents for induction of oral ulcerative and vesiculo-bullous lesions, followed by methotrexate. Nonsteroidal anti-inflammatory drugs (NSAIDs) and β-blockers were found the most common responsible drugs for induction of oral lichen planus.”


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Chronic wounds & ulcers


Adipose-derived stem cells for treatment of chronic ulcers: current status.

Holm JS, Toyserkani NM, Sorensen JA.

Stem Cell Res Ther. 2018 May 15;9(1):142. doi: 10.1186/s13287-018-0887-0.


“A total of nine clinical trials and fourteen registered trials were included. The studies were significantly different in terms of study design and patient population, and the overall quality of the studies was low to moderate. Despite the overall low study quality and the significant differences between the studies, some conclusions were consistent: ADSCs [adipose-derived stem cells] are safe, improve the healing of chronic ulcers, and reduce pain. As these results are consistent despite the shortcomings of the studies, they appear to highlight the efficacy of ADSCs in the treatment of chronic ulcers. Larger numbers of higher quality studies are needed to determine the precise role of ADSCs in treating chronic leg ulcers.”


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Other disorders affecting the skin


Underlying systemic diseases in pyoderma gangrenosum: A systematic review and meta-analysis.

Kridin K, Cohen AD, Amber KT.

Am J Clin Dermatol. 2018 May 2. doi: 10.1007/s40257-018-0356-7. [Epub ahead of print]


“RESULTS: Twenty-one eligible studies comprising 2611 patients with pyoderma gangrenosum were included in the quantitative synthesis. The overall random-effects pooled prevalence of associated systemic diseases was 56.8% (95% confidence interval 45.5-67.4). The leading underlying disease was inflammatory bowel disease (17.6%; 95% confidence interval 13.0-22.7), followed by arthritis (12.8%; 95% confidence interval 9.2-16.9), hematological malignancies (8.9%; 95% confidence interval 6.5-11.6), and solid malignancies (7.4%; 95% confidence interval 5.8-9.1). In 16.3% (95% confidence interval 7.7-27.1) of cases, the onset of pyoderma gangrenosum was attributed to the pathergy phenomenon.

CONCLUSIONS: More than half of patients with pyoderma gangrenosum present with a relevant underlying disease. Inflammatory bowel disease and arthritis are the most frequently associated diseases. Relative to the reported literature, the pooled prevalence of arthritis and hematological malignancies is lower, while the pooled prevalence of solid malignancies is higher. Owing to the high level of heterogeneity among most of the comparisons, results should be interpreted with caution.”



Pyoderma gangrenosum after breast surgery: A systematic review.

Ehrl DC, Heidekrueger PI, Broer PN.

J Plast Reconstr Aesthet Surg. 2018 Mar 28. pii: S1748-6815(18)30103-7. doi: 10.1016/j.bjps.2018.03.013. [Epub ahead of print]


“A total of 68 articles describing 87 cases of PSPG [post-surgical pyoderma gangrenosum] following aesthetic and reconstructive breast surgery were found. The majority of PSPG (44%) occurred after breast reduction surgery and microsurgical breast reconstruction (16%). The most common associated conditions were malignancies in 37% and autoimmune deficiencies in 17%. Microbiological examinations were found to have a negative result in 90%. The median time from initial presentation with symptoms to correct diagnosis of PG was on average 12.5 days, with unsuccessful first-line therapy on average for 20.0 days. After the diagnosis of PG, medical therapy most commonly involved steroids in 84% and/or Cyclosporine A in 22% of the cases. On average, the duration of this therapy was 4.7 months.”



Comorbidity of viral hepatitis and chronic spontaneous urticaria: A systematic review.

Kolkhir P, Pereverzina N, Olisova O, Maurer M.

Allergy. 2018 May 22. doi: 10.1111/all.13482. [Epub ahead of print]


“The prevalence of CHB [chronic hepatitis B] and CHC [chronic hepatitis C] in CSU [chronic spontaneous urticarial] does not appear to be increased. Less than 5% and less than 2% of CSU patients have markers of CHB and CHC, respectively, according to most of the 32 studies reviewed. Urticarial rash including CSU occurs in ≤3% of patients with CHC as reported by most of 20 studies analysed. Very few patients have been assessed for the effects of antiviral hepatitis treatment on their CSU, and two but not all reportedly showed improvement. Hepatitis B/C infections appear unlikely to be linked to CSU. We suggest that routine screening for these infections in CSU patients is not relevant or cost-effective and should not be performed unless liver function tests are abnormal, risk factors or symptoms of viral hepatitis are present, or urticarial vasculitis is suspected.”



Relapse of porphyria cutanea tarda after treatment with phlebotomy or 4-aminoquinoline antimalarial: A Meta-analysis.

Salameh H, Sarairah H, Rizwan M, Kuo YF, Anderson KE, Singal AK.

Br J Dermatol. 2018 May 11. doi: 10.1111/bjd.16741. [Epub ahead of print]


“RESULTS: Of 375 articles identified as pertaining to PCT [porphyria cutanea tarda] treatment, 12 were eligible for analysis, and of these 5 used high dose 4-aminoquinoline regimens (2 combined with phlebotomy and 3 without phlebotomy), 5 used low dose 4-aminoquinoline regimens and 3 used phlebotomy. Relapse rates during the year after treatment were similar for the high and low dose 4-aminoquinoline groups (35-36%) and lower in the phlebotomy group (20%). Pooled relapse rates (RR) with their 95% confidence intervals (CI) were 8.6 (3.9-13.3) per 100 person-years in the high dose 4-aminoquinoline group, 17.1 (8.9-25.3) per 100 person-years in the low dose 4-aminoquinoline group, and 5.1 (0.5-10.6) per 100 person-years in the phlebotomy group. Subgroup and sensitivity analyses showed similar results.

CONCLUSION: Clinical or biochemical relapse rates ranged 5-17 per 100 person years after remission of PCT. Relapses were somewhat more frequent after remission with 4-aminoquinoline regimens as compared to remission after phlebotomy. Prospective studies are needed to better define how often relapses occur with these treatments after documenting both clinical and biochemical remission of PCT.”



Practical suggestions on intravenous iloprost in Raynaud's phenomenon and digital ulcer secondary to systemic sclerosis: Systematic literature review and expert consensus.

Ingegnoli F, Schioppo T, Allanore Y, Caporali R, Colaci M, Distler O, Furst DE, Hunzelmann N, Iannone F, Khanna D, Matucci-Cerinic M.

Semin Arthritis Rheum. 2018 Apr 4. pii: S0049-0172(18)30013-1. doi: 10.1016/j.semarthrit.2018.03.019. [Epub ahead of print]


“RESULTS: Three major indications were identified for IV ILO [intravenous iloprost] usage in SSc [systemic sclerosis]: RP [Raynaud's phenomenon] non-responsive to oral therapy, DU [digital ulcers] healing, and DU prevention. IV ILO should be administered between 0.5 and 2.0ng/kg/min according to patient tolerability with a frequency depending on the indication.

CONCLUSIONS: Although these suggestions are supported by this expert group to be used in clinical setting, it will be necessary to formally validate the present suggestions in future clinical trials.”



Ultrasonography for the assessment of skin in systemic sclerosis: a systematic review.

Santiago T, Santiago M, Ruaro B, Salvador MJ, Cutolo M, da Silva JAP.

Arthritis Care Res (Hoboken). 2018 May 21. doi: 10.1002/acr.23597. [Epub ahead of print]


“RESULTS: A total of 30 studies were identified, enrolling 1171 SSc [systemic sclerosis] patients, predominantly middle-aged (mean age 55.5 years) females (88,8%). The ultrasound skin measurements reported included thickness, in 28 studies, and/or echogenicity (7 studies) and/or stiffness (6 studies) and/or vascularity (1 study). The main comparator was global and site specific modified Rodnan Skin Score. Reported inter and intra-rater reproducibility appears to be excellent, but this was assessed by a small number of studies. Moreover, there are no published evaluations of construct or criterion validity of skin ultrasound. The responsiveness to change of ultrasound elastography has not been assessed.

CONCLUSIONS: Published reports have strong limitations and are highly heterogeneous, hindering the evidence to support the use of skin ultrasound in clinical practice. Further studies, with modern devices and appropriate methodology, are needed to establish the real value of skin ultrasound assessment in the early diagnosis and monitoring of SSc patients.”



The significance of scalp involvement in pemphigus: A literature review.

Sar-Pomian M, Rudnicka L, Olszewska M.

Biomed Res Int. 2018 Mar 25;2018:6154397. doi: 10.1155/2018/6154397. eCollection 2018.


“This review summarizes the most recent data concerning scalp involvement in pemphigus vulgaris and pemphigus foliaceus. A systematic literature search was conducted in three medical databases: PubMed, Embase, and Web of Science. The analysis included literature data about desmoglein distribution in hair follicles, as well as information about clinical manifestations, histopathology, immunopathology, and trichoscopy of scalp lesions in pemphigus and their response to treatment.”



A review of scoring systems for ocular involvement in chronic cutaneous bullous diseases.

Lee BWH, Tan JCK, Radjenovic M, Coroneo MT, Murrell DF.

Orphanet J Rare Dis. 2018 May 22;13(1):83. doi: 10.1186/s13023-018-0823-5.


“Descriptions of ocular involvement in EB/AIBD [epidermolysis bullosa and autoimmune blistering diseases] were identified in 88 peer-reviewed journal articles. Findings reported include but are not limited to: cicatrising conjunctivitis, meibomian gland dysfunction, dry eye disease, trichiasis, symblepharon, fornix fibrosis, keratopathy, ectropion/entropion, ankyloblepharon, corneal ulceration, visual impairment and blindness. Although scoring systems exist for assessment of OSD in mucous membrane pemphigoid, no such tools exist for the other AIBD subtypes or for EB. Several systemic scoring systems exist in the dermatological literature that are efficacious in grading overall EB/AIBD severity, but have limited inclusion of ocular features. To the best of our knowledge, there is no recognised or validated scoring systems which comprehensively stages or grades the spectrum of ocular manifestations in EB/AIBD.”



Biologics in SAPHO syndrome: A systematic review.

Daoussis D, Konstantopoulou G, Kraniotis P, Sakkas L, Liossis SN.

Semin Arthritis Rheum. 2018 Apr 17. pii: S0049-0172(18)30058-1. doi: 10.1016/j.semarthrit.2018.04.003. [Epub ahead of print]


“RESULTS: We identified 66 cases treated with biologics (45 with TNF blockers, 7 with IL-1 blockers, 13 with biologics targeting the IL-23/IL-17 axis, and 1 with tocilizumab). Data support a positive effect of anti-TNF treatment in SAPHO with a response rate in bone and joint manifestations of 93.3%. Skin disease also improved in 21/29 cases (72.4%). Data related to IL-1 inhibition in SAPHO are encouraging with most patients exhibiting a significant response in musculoskeletal manifestations (6/7, 85.7%). However, IL-1 inhibition is not effective in skin manifestations. Ustekinumab seems to have some efficacy with 2/4 patients responding in skin and 3/5 in bone/joint manifestations. Data related to IL-17 blockade indicate efficacy in skin disease with 4/7 patients responding (57.1%). Joint/bone manifestations improved in 3/8 patients (37.5%).

CONCLUSIONS: In SAPHO patients not responding to conventional treatment, TNF blockers appear to be the first choice. In patients failing TNF blockers, IL-1 inhibitors and biologics targeting the IL-17/IL-23 axis could be used.”



A systematic review of the literature of the three related disease entities cheilitis granulomatosa, orofacial granulomatosis and Melkersson - Rosenthal syndrome.

Wehl G, Rauchenzauner M.

Curr Pediatr Rev. 2018 May 14. doi: 10.2174/1573396314666180515113941. [Epub ahead of print]


“RESULTS: Etiology remains unclear for all three disease entities. Etiological relatedness to chronic inflammatory bowel disease is under discussion and effectiveness was found for different treatments, e.g. local triamcinolone injections, antibiotics, surgical interventions, TNF alpha blockers or exclusive enteral nutrition. No randomized controlled trial concerning the therapy of orofacial granulomatosis was found. As a consequence, therapeutic conclusions are drawn mainly from small case series, thus limiting the evidence of therapeutic interventions.

CONCLUSIONS: OFG [orofacial granulomatosis] with the sub-entities MRS [Melkersson Rosenthal syndrome] and cheilitis granulomatosa is an etiological obscure disease process with various possible therapeutic interventions potentially alleviating the disease course but to broaden treatment knowledge further study in randomized controlled trials are needed.”


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Skin conditions & dermatology in general


None found this month.


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Skin surgery and lasers


Effectiveness and safety of hyaluronic acid gel with lidocaine for the treatment of nasolabial folds: A systematic review and meta-analysis.

Wang C, Luan S, Panayi AC, Xin M, Mi B, Luan J.

Aesthetic Plast Surg. 2018 May 8. doi: 10.1007/s00266-018-1149-3. [Epub ahead of print]


“RESULTS: A total of 908 patients from 12 RCTs were included in the meta-analysis. VAS score within 30 min after injection in the HAL [hyaluronic acid with lidocaine] group was much lower than that with just HA [hyaluronic acid] group (MD = - 28.83, 95% CI - 36.38 to - 21.28). There was no significant difference in effectiveness between the two products 24 months post-injection (MD = 0.13, 95% CI - 0.15 to 0.41). The main adverse events, such as swelling, erythema, bruising, itching and induration, also showed no significant difference.

CONCLUSIONS: HAL is more effective for pain relief than HA alone, but both display similar effectiveness and safety for the correction of NLFs [nasolabial folds].”


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Service delivery & management


None found this month.


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Prescribing and safety alerts



We acknowledge the NICE Medicines Awareness Service and MHRA Drug Safety Update as sources in compiling this section.



Revised SmPC (Summary of Product Characteristics): Humira (adalimumab) 40 mg solution for injection in pre-filled pen


An additional dosing scheme has been added in Section 4.2—80mg every other week, as an alternative option to the current approved 40mg weekly for psoriasis, hidradenitis suppurativa and certain other conditions.



Revised SmPC (Summary of Product Characteristics): Imnovid hard capsules (pomalidomide) – all strengths


Sections 4.2, 4.4 and 4.8 now include advice/warnings about the management of patients who develop adverse skin reactions to pomalidomide. Section 4.2 states:
“Pomalidomide interruption or discontinuation should be considered for Grade 2-3 skin rash. Pomalidomide must be discontinued for angioedema, Grade 4 rash, exfoliative or bullous rash, or if Stevens-Johnson syndrome (SJS), Toxic Epidermal Necrolysis (TEN) or Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is suspected, and should not be resumed following discontinuation from these reactions.”



Revised SmPC (Summary of Product Characteristics): Lasilactone (furosemide and spironolactone) capsules


Lichenoid reactions has been added as an undesirable effect.



Revised SmPC (Summary of Product Characteristics): Firazyr (Icatibant) injection


Urticaria has been added as a potential adverse effect of treatment (frequency unknown).



Revised SmPC (Summary of Product Characteristics): Epiduo (0.1%adapalene/2.5% benzoyl peroxide) Gel


Anaphylactic reaction, skin discolouration (hyperpigmentation and hypopigmentation) and urticaria have been added as adverse effects.



Revised SmPC (Summary of Product Characteristics): Glivec (imatinib) 100 and 400 mg film-coated tablets


Pseudoporhyria has been added as an adverse effect (unknown frequency), plus a warning to avoid/ minimise direct sunlight due to the risk of phototoxicity associated with imatinib treatment.


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CEBD publications & news



Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness.

Santer M, Ridd MJ, Francis NA, Stuart B, Rumsby K, Chorozoglou M, Becque T, Roberts A, Liddiard L, Nollett C, Hooper J, Prude M, Wood W, Thomas KS, Thomas-Jones E, Williams HC, Little P.

BMJ. 2018 May 3;361:k1332. doi: 10.1136/bmj.k1332.


“RESULTS: 483 children were randomised and one child was withdrawn, leaving 482 children in the trial: 51% were girls (244/482), 84% were of white ethnicity (447/470), and the mean age was 5 years. 96% (461/482) of participants completed at least one post-baseline POEM, so were included in the analysis, and 77% (370/482) completed questionnaires for more than 80% of the time points for the primary outcome (12/16 weekly questionnaires to 16 weeks). The mean baseline POEM score was 9.5 (SD 5.7) in the bath additives group and 10.1 (SD 5.8) in the no bath additives group. The mean POEM score over the 16 week period was 7.5 (SD. 6.0) in the bath additives group and 8.4 (SD 6.0) in the no bath additives group. No statistically significant difference was found in weekly POEM scores between groups over 16 weeks. After controlling for baseline severity and confounders (ethnicity, topical corticosteroid use, soap substitute use) and allowing for clustering of participants within centres and responses within participants over time, POEM scores in the no bath additives group were 0.41 points higher than in the bath additives group (95% confidence interval -0.27 to 1.10), below the published minimal clinically important difference for POEM of 3 points. The groups did not differ in secondary outcomes, economic outcomes, or adverse effects.

CONCLUSIONS: This trial found no evidence of clinical benefit from including emollient bath additives in the standard management of eczema in children. Further research is needed into optimal regimens for leave-on emollient and soap substitutes.”



Standardized Reporting of the Eczema Area and Severity Index (EASI) and the Patient-Oriented Eczema Measure (POEM): A Recommendation by the Harmonising Outcome Measures for Eczema (HOME) Initiative.

Grinich E, Schmitt J, Küster D, Spuls PI, Williams HC, Chalmers JR, Thomas KS, Apfelbacher C, Prinsen CAC, Furue M, Stuart B, Carter B, Simpson E.

Br J Dermatol. 2018 May 10. doi: 10.1111/bjd.16732. [Epub ahead of print]


“The objective of this letter is to provide recommendations for the minimum reporting of EASI and POEM scores in AD clinical trials with the goal of minimizing bias, improving the quality of data synthesis, and facilitating study interpretation by patients, clinicians, and other stakeholders.”



Is methotrexate an effective and safe treatment for maintaining hair regrowth in people with alopecia totalis? A critically appraised topic.

Browne R, Stewart L, Williams HC.

Br J Dermatol. 2018 May 19. doi: 10.1111/bjd.16796. [Epub ahead of print]


“DISCUSSION: We found insufficient evidence to conclude whether methotrexate is useful for maintaining regrowth in extensive alopecia areata. We found some evidence to suggest that hair regrowth may be induced by methotrexate when used in combination with systemic corticosteroids, but it was difficult to attribute responses to any one treatment or spontaneous regrowth. Included case series were at a high risk of bias.

CLINICAL MESSAGE: Randomised controlled trials are needed to evaluate whether methotrexate alone, or in combination with corticosteroids, versus placebo is useful for inducing and/or maintaining remission of hair regrowth. In the meantime, methotrexate may occasionally be considered in people with severe disease that significantly impacts on their quality of life.”



Risk of skin cancer in people with vitiligo: a systematic review and meta-analysis.

Ban L, Labbouz S, Grindlay D, Batchelor J, Ratib S.

Br J Dermatol. 2018 Apr 28. doi: 10.1111/bjd.16703. [Epub ahead of print]

See above under Vitiligo & pigmentary disorders



Interventions for preventing occupational irritant hand dermatitis.

Bauer A, Rönsch H, Elsner P, Dittmar D, Bennett C, Schuttelaar MLA, Lukács J, John SM, Williams HC.

Cochrane Database Syst Rev. 2018 Apr 30;4:CD004414. doi: 10.1002/14651858.CD004414.pub3

See above under Eczema & dermatitis


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Other key publications that have caught our eye



TREatment of ATopic eczema (TREAT) Registry Taskforce: An international Delphi exercise to identify a core set of domains and domain items for national atopic eczema photo- and systemic therapy registries.

Gerbens LAA, Apfelbacher CJ, Irvine AD, Barbarot S, de Booij RJ, Boyce AE, Deleuran M, Eichenfield LF, Hof MH, Middelkamp-Hup MA, Roberts A, Schmitt J, Vestergaard C, Wall D, Weidinger S, Williamson PR, Flohr C, Spuls PI; international TREAT Registry Taskforce.

Br J Dermatol. 2018 May 15. doi: 10.1111/bjd.16714. [Epub ahead of print


“This core set of domains and items to be captured by national AE [atopic eczema] systemic therapy registries will standardise data collection and thereby allow direct comparability across registries and facilitate data pooling between countries. Ultimately, it will provide greater insight into the effectiveness, safety and cost-effectiveness of photo- and systemic immunomodulatory therapies.”



Severe and predominantly active atopic eczema in adulthood and long term risk of cardiovascular disease: population based cohort study.

Silverwood RJ, Forbes HJ, Abuabara K, Ascott A, Schmidt M, Schmidt SAJ, Smeeth L, Langan SM.

BMJ. 2018 May 23;361:k1786. doi: 10.1136/bmj.k1786.


“RESULTS: 387 439 patients with atopic eczema were matched to 1 528 477 patients without atopic eczema. The median age was 43 at cohort entry and 66% were female. Median follow-up was 5.1 years. Evidence of a 10% to 20% increased hazard for the non-fatal primary outcomes for patients with atopic eczema was found by using Cox regression stratified by matched set. There was a strong dose-response relation with severity of atopic eczema. Patients with severe atopic eczema had a 20% increase in the risk of stroke (hazard ratio 1.22, 99% confidence interval 1.01 to 1.48), 40% to 50% increase in the risk of myocardial infarction, unstable angina, atrial fibrillation, and cardiovascular death, and 70% increase in the risk of heart failure (hazard ratio 1.69, 99% confidence interval 1.38 to 2.06). Patients with the most active atopic eczema (active >50% of follow-up) were also at a greater risk of cardiovascular outcomes. Additional adjustment for cardiovascular risk factors as potential mediators partially attenuated the point estimates, though associations persisted for severe atopic eczema.

CONCLUSIONS: Severe and predominantly active atopic eczema are associated with an increased risk of cardiovascular outcomes. Targeting cardiovascular disease prevention strategies among these patients should be considered.”



How data can deliver for dermatology.

Abuabara K, Asgari MM, Chen SC, Dellavalle RP, Kalia S, Secrest AM, Silverberg JI, Solomon JA, Weinstock MA, Wu JJ, Chren MM; Epidemiology Expert Research Group.

J Am Acad Dermatol. 2018 Mar 21. pii: S0190-9622(18)30470-5. doi: 10.1016/j.jaad.2018.03.020. [Epub ahead of print] No abstract available.


“Much has been written about ‘big data’ in medicine, but few articles have focused on the potential for better data to transform dermatology. We provide a conceptual framework for how technological advances could enable standardized data collection and analysis from patient-provider encounters and improve patient care, advance our understanding of dermatologic diseases, and streamline billing and reimbursement. We also briefly address some of the challenges unique to dermatology, though our primary goal is to describe the rationale for supporting improvements in routine clinical data collection.”



Dressings for venous leg ulcers.

Tate S, Price A, Harding K.

BMJ. 2018 May 2;361:k1604. doi: 10.1136/bmj.k1604. No abstract available.


“What you need to know

•The cornerstone of treatment for venous leg ulcers is compression therapy, but dressings can aid with symptom control and optimise the local wound environment, promoting healing

•There is no evidence to support the superiority of one dressing type over another when applied under appropriate multilayer compression bandaging

•When selecting a dressing, look at the wound bed, edge and surrounding skin and decide on the goal of the dressing: for example, if there are signs of localised infection consider an antimicrobial dressing, if there is heavy exudate consider an absorbent dressing”


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Dr Douglas Grindlay
Information Specialist

Centre of Evidence Based Dermatology
University of Nottingham

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+44 (0) 115 8468624



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