S3 Guideline Urticaria. Part 1: Classification and diagnosis of urticaria – German-language adaptation of the international S3 Guideline

The lifetime prevalence of urticaria, a severe allergic disease, is almost 20%. It not only limits the quality of life of those affected, but also their general performance at work and in their daily activities. This publication is the first section of the Urticaria Guideline. It covers the classification and diagnosis of urticaria, taking into account the major advances in research into its causes, triggering factors and pathomechanisms. It also addresses strategies for the efficient diagnosis of the different subtypes of urticaria. This is crucial for individual, patient-oriented treatment, which is covered in the second part of the guideline, published separately. This German-language guideline was developed according to the criteria of the AWMF on the basis of the international English-language S3 guideline with special consideration of health system characteristics in the German-speaking countries. This first part of the guideline describes the classification of urticaria, distinguishing spontaneously occurring wheals (hives) and angioedema from forms of urticaria with inducible symptoms. Urticaria is defined as sudden onset of wheals, angioedema, or both, but is to be distinguished from conditions in which wheals occur as a short-term symptom, such as anaphylaxis. The diagnosis is based on (a limited number of) laboratory tests, but especially on medical history. In addition, validated instruments are available to measure the severity, activity and course of the disease.     

S3 Guideline Urticaria. Part 2: Treatment of urticaria – German-language adaptation of the international S3 guideline

This publication is the second part of the German-language S3 guideline on urticaria. It covers the management of urticaria and should be used together with Part 1 of the guideline on classification and diagnosis. This publication was prepared according to the criteria of the AWMF on the basis of the international English-language S3 guideline with special consideration of health system conditions in German-speaking countries. Chronic urticaria has a high impact on the quality of life and daily activities of patients. Therefore, if causal factors cannot be eliminated, effective symptomatic treatment is necessary. The recommended first-line treatment is to administer new generation, non-sedating H1 antihistamines. If the standard dose is not sufficiently effective, the dose should be increased up to fourfold. For patients who do not respond to this treatment, the second-line treatment in addition to antihistamines in the treatment algorithm is omalizumab and, if this treatment fails, ciclosporin. Other low-evidence therapeutic agents should only be used if all treatments in the treatment algorithm agreed upon by the guideline group fail. Both the benefit-risk profile and cost should be considered. Corticosteroids are not recommended for long-term treatment due to their inevitable severe side effects.     

What is the role of field-directed therapy in the treatment of actinic keratosis? Part 1: overview and investigational topical agents

Actinic keratosis (AK) constitutes the initial epidermal lesion in a disease continuum that may progress to invasive squamous cell carcinoma (SCC). A number of treatment options are available to clear lesions, and thus reduce the risk for progression. Field-directed approaches are primarily used to clear multiple AKs and subclinical lesions. Current field-directed approaches still have a number of unmet needs, and a number of investigational agents are being evaluated. Topical therapy can be improved by shortening treatment periods; enhancing tolerability, compliance, and patient satisfaction; reducing recurrence rates; and lowering cost. This 2-part review will explain the role of field-directed therapy in the treatment of AK. Part 1 focuses mainly on investigational agents that are being studied for topical patient-administered, field-directed therapy.     

Latin American Clinical Practice Guidelines on the Systemic Treatment of Psoriasis SOLAPSO – Sociedad Latinoamericana de Psoriasis (Latin American Psoriasis Society)

This Clinical Practice Guideline on the systemic treatment of Psoriasis includes the recommendations elaborated by a panel of experts from the Latin American Psoriasis Society SOLAPSO, who assessed the quality of the available evidence using the GRADE system and the PICO process to guide the literature search. To answer each question, the experts discussed the results of randomized controlled trials, observational studies and metanalysis evaluating the interventions identified (non-biologics, biologics and phototherapy) in different populations of patients with moderate to severe plaque-psoriasis, which was summarized in Tables ad-hoc. The main end-points considered to assess efficacy were PASI 50, 75, 90 and 100, PGA 0-1 and significant improvement of health-related quality of life. Specific adverse events, either severe or leading to treatment interruption, were also evaluated. The 31 recommendations included in this CPG follow the structure proposed by GRADE: direction (for or against) and strength (strong or weak). The goal of this CPG is to improve the management of patients with psoriasis by recommending interventions of proved benefit and providing a reference standard for the treating physician. Adhering to the contents of this CPG does not guarantee therapeutic success. The final decision on the specific treatment is the responsibility of the physician based on the individual circumstances and considering the values, the preferences and the opinions of the patient or caregivers.     

Psoriasis: what is new in nonbiologic systemic therapy in the era of biologics?

Psoriasis is a common debilitating disease significantly affecting the quality of life of the patients. Majority of the psoriasis patients have mild disease which can be managed by topical therapies. Around 30% of the psoriasis patients require systemic therapy during the course of their disease. There is a vast array of drugs for the treatment. Methotrexate, cyclosporine and retinoids are the most commonly used conventional systemic drugs. Newer studies provide insight into their more effective and safer use and as combination therapy with biologics. In recent times, many new drugs with novel mechanisms of action other than biologics have been tried in psoriasis. In this article, we have reviewed the current developments and new found role of the conventional drugs as well as the newer nonbiologic systemic drugs in the treatment of psoriasis.     

Treatment of inflammatory facial acne vulgaris: Comparison of the 1450‐nm diode laser and conventional physical treatment

The efficacy of the 1450‐nm diode laser in the treatment of inflammatory facial acne was evaluated by comparing it with conventional physical treatment. Seventeen patients received laser treatment on the right side of the face and conventional physical treatment on the other side. The two modalities were compared through photographs, inflammatory acne lesion counts, and a patient questionnaire. Clinical response was evaluated in 16 patients. Evaluation of baseline and follow‐up photographs indicated that more improvement was obtained after laser treatment than by physical treatment in six patients. In two patients, physical treatment yielded better results than laser treatment. Equal effect was obtained in eight patients. All patients had a reduction in the inflammatory acne lesion count on the laser‐treated side, which was statistically significantly greater on the laser‐treated side compared with the side treated physically (p = 0.039, Wilcoxon signed ranks test). By the assessment of patient satisfaction, seven patients preferred laser treatment, two patients preferred physical treatment and three patients found laser treatment equal to physical treatment. Questionnaire details could not be obtained in 4 patients. This study indicates that the 1450‐nm diode laser is a new option for local treatment of acne.     

Update on vasculitis: overview and relevant dermatological aspects for the clinical and histopathological diagnosis – Part II

Vasculitis is a group of several clinical conditions in which the main histopathological finding is fibrinoid necrosis in the walls of blood vessels. This article assesses the main dermatological aspects relevant to the clinical and laboratory diagnosis of small- and medium-vessel cutaneous and systemic vasculitis syndromes. The most important aspects of treatment are also discussed.     

Impact of Psoriasis on Patients’ Work and Productivity

Background: Psoriasis negatively impacts patient quality of life; however, the impact on work and productivity is not well known. Objective: To determine the impact of psoriasis on work and productivity using data from the National Health and Wellness Survey (NHWS). Methods: Data collected from 40 730 adults who completed the NHWS between 1 May and 30 June 2004, of whom 1127 had psoriasis, were analyzed. Psoriasis patients and a matched cohort of non-psoriasis patients were identified to assess the impact of psoriasis on work and productivity. Results: Psoriasis patients were more likely to have missed work for health-related reasons (p < 0.05), had significantly more health-related work productivity impairment (p < 0.001), more overall work impairment (p < 0.001), and more impairment in activity other than work (p < 0.001) than non-psoriasis patients. Conclusions: The results of this large-scale national survey suggest that psoriasis has a significant negative impact on overall work productivity.     

[Translated article] Practical Update of the Guidelines Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis With Biologic Agents: Part 2—Management of Special Populations,Patients With Comorbid Conditions,and Risk

Background and objectivesSince its inception, the Psoriasis Group (GPs) of the Spanish Academy of Dermatology and Venereology (AEDV) has worked to continuously update recommendations for the treatment of psoriasis based on the best available evidence and incorporating proposals arising from and aimed at clinical practice. An updated GPs consensus document on the treatment of moderate to severe psoriasis was needed because of changes in the treatment paradigm and the approval in recent years of a large number of new biologic agents.MethodologyThe consensus document was developed using the nominal group technique complemented by a scoping review. First, a designated coordinator selected a group of GPs members for the panel based on their experience and knowledge of psoriasis. The coordinator defined the objectives and key points for the document and, with the help of a documentalist, conducted a scoping review of articles in Medline, Embase, and the Cochrane Library up to January 2021. The review included systematic reviews and meta-analyses as well as clinical trials not included in those studies and high-quality real-world studies. National and international clinical practice guidelines and consensus documents on the management of moderate to severe psoriasis were also reviewed. The coordinator then drew up a set of proposed recommendations, which were discussed and modified in a nominal group meeting. After several review processes, including external review by other GPs members, the final document was drafted.ResultsThe present guidelines include updated recommendations on assessing the severity of psoriasis and criteria for the indication of systemic treatment. They also include general principles for the treatment of patients with moderate to severe psoriasis and define treatment goals for these patients as well as criteria for the indication and selection of initial and subsequent therapies Practical issues, such as treatment failure and maintenance of response, are also addressed.     

High-frequency devices effect in vitro: promissing approach in the treatment of acne vulgaris?

BackgroundAcne vulgaris is an inflammatory skin disorder leading to an impairment of quality of life and is therefore not only a cosmetic issue. Its pathogenesis is multifactorial – of particular importance is the colonization with the bacterium Propionibacterium acnes. A wide range of different treatment options exists including topical and systemic treatments depending on severity. High Frequency (HF) therapy, historically developed in the 19^th century, claims antimicrobial effects on acne skin, but solid data on its efficacy and mechanism of action is lacking.ObjectivesThe main objective of this study was to determine the efficacy of HF therapy on skin flora and P. acnes in vitro using a commercial device as well as to review studies on the mechanism of action.MethodsThe plasma source was investigated regarding electrical settings, heat, and ozone development. Bacterial skin flora, fungal isolates, and P. acnes were exposed to HF in vitro and compared to unexposed controls by evaluating the number of colonies on agar plates. To further analyze bacterial species from normal skin flora, 16S-sequencing was performed. Statistical analyses were carried out using row analysis and unpaired t-test.ResultsHF treatment led to a significant reduction of almost every bacterial and fungal species investigated in this study. Moreover, the number of colonies forming units was significantly decreased in P. acnes after HF treatment compared to controls in vitro.Study limitationsThe experiments were performed in vitro only. To assess clinical effects further in vivo experiments are necessary.ConclusionsThe results collected in this study, although in vitro, provide a mechanistic basis for HF as a complementary treatment option for patients with acne. It might also have a beneficial effect on patients with superficial infectious skin of the skin.     

Psoriasis: is it the tip of the iceberg for the quality of life of patients and their families?

Objective To evaluate the impact of psoriasis on patients’ and their relatives’ quality of life (QoL). Methods Eighty patients with their accompanying family members were included in the study. For measuring health related QoL (HRQoL) of patients with psoriasis, two questionnaires were used: Short Form 36 Health Survey (SF‐36) and EuroQol (EQ‐5D). Disease‐specific HRQoL was assessed by the Dermatology Life Quality Index. For measuring the quality of life of patients’ relatives, a specific questionnaire for dermatological diseases was used (Family Dermatology Life Quality Index, FDLQI). Results Of our patients, 88.3% reported that their disease affects in many and different ways their QoL whereas only 11.2% reported that psoriasis does not influence at all their life. Regarding FDLQI, 90% of the participating family members, responded that their relative’s psoriasis affected their own QoL. Conclusions Psoriasis is a chronic disease that affects in a cumulative way the quality of life of both patients and their close relatives.     

What is the role of field-directed therapy in the treatment of actinic keratosis? Part 2: Commonly used field-directed and lesion-directed therapies

Actinic keratosis (AK) constitutes the initial epidermal lesion in a disease continuum that may potentially progress to invasive squamous cell carcinoma (SCC). A number of treatment options are available to clear lesions and thus reduce the risk for progression to SCC. Field-directed therapies are primarily used to clear multiple AKs and subclinical lesions. Part 1 of this review explaining the role of field-directed therapy for the treatment of AK discussed the unmet needs with current therapies and the investigational agents that are being developed to fill treatment gaps. Part 2 will mainly focus on field-directed therapies that currently are available for AK, such as resurfacing procedures, patient-administered topical therapy, and photodynamic therapy (PDT), as well as lesion-directed therapy, which is used to clear discrete lesions in relatively small numbers.