Plain Language Summaries

Epidemiology and extra-cutaneous comorbidities of severe acne in adolescence: a US population-based study

J.I. Silverberg, N.B. Silverberg

This summary relates to DOI: 10.1111/bjd.12912

British Journal of Dermatology, 170, 1136–1142, May 2014


Acne is a common skin disorder but little is known about its epidemiology (patterns, prevalence and causes). This study therefore used data from the 2007 National Health Interview Survey, a questionnaire study of 9417 children aged 0–17 years, to examine acne's epidemiology as well as comorbidities, meaning other disorders that occur at the same time as the acne and that may be linked. In particular, the US-based researchers looked for comorbidities that were sinopulmonary (affecting the ear, sinus or lungs), gastrointestinal (digestive system) and psychological (mental and emotional well-being). The overall prevalence rose from 1.7% at age 11 years to 12.1% at age 17. There were no significant differences of the prevalence of severe acne across different racial groups at age 11–13 and 16–17 years, however it was significantly higher in Whites compared with other racial groups at age 14–15 years. The prevalence was higher in girls than boys at age 11–13 but not at age 14 and above. There were no significant associations between severe acne and household income. Severe acne was associated with increased odds of several, but not all, sinopulmonary disorders. It was also associated with increased odds of some gastrointestinal comorbidities, including heartburn and food allergy. With regards to psychological comorbidities, there was a link between severe acne and increased odds of depression, anxiety, attention deficit disorder and insomnia, but not phobias. These associations are likely not specific to acne, as such psychological disorders have also been observed in childhood eczema and can occur in any chronic disease of childhood. Future studies are needed to confirm the association between acne, gastrointestinal and sinopulmonary disease and to determine whether P. acne (the acne causing bacterium) may play a harmful role.

The dermatology outpatient discharge decision: understanding a critical but neglected process

N.A. Harun, S. Salek, V. Piguet, A.Y. Finlay

This summary relates to DOI: 10.1111/bjd.12826

British Journal of Dermatology, 170, 1029–1038, May 2014


One of the most frequent decisions a clinician has to make is whether or not to discharge a patient. This review of 17 studies, seven of which related to dermatology, aimed to identify the influences on deciding when to discharge outpatients (patients attending daytime clinics in hospitals). The study found that diagnosis and severity of skin disease were the main influences on whether or not a patient was discharged. However, most dermatologists felt pressured to discharge patients due to long waiting lists to be seen in their clinics. Sixty-eight percent of dermatologists in the UK considered clinical experience as an influence on discharge decision taking. Confidence levels and clinical judgement in discharging patients improved with experience. The discharge rates were generally higher among senior clinicians than juniors, however this was not the case in all studies. The clinician's perceptions of the circumstances surrounding a discharge were also found to influence discharge decision-making. This includes the clinician's view on whether the disease can be managed as well at a primary care level (e.g. by the GP) as in the hospital. According to one study, 52% of dermatologists would discharge rude or demanding patients earlier than expected or refer them for a second opinion. The patient's age, employment status and home accessibility may influence discharge decisions. The authors conclude that outpatient discharge decision taking is complex. Beyond diagnosis and disease severity, there is a wide array of non-clinical factors. New studies are needed to develop training methods to improve the quality of discharge decision making.

Burden of disease during quiescent periods in patients with pemphigus

S. Tabolli, C. Pagliarello, A. Paradisi, G. Cianchini, P. Giannantoni, D. Abeni

This summary relates to DOI: 10.1111/bjd.12836

British Journal of Dermatology, 170, 1087–1091, May 2014


Pemphigus vulgaris is a rare disease that causes severe blistering of the skin and of the ‘mucous membranes’ lining the mouth, nose, throat and genitals. It is an autoimmune disease, meaning the body's immune system, which usually fights off infection, wrongly fights healthy cells – those in the skin and mucous membranes in the case of pemphigus. With appropriate treatment, long periods of ‘quiescent’ disease (where there are no physical symptom) are possible. The disease can have a significant impact on the patient's quality of life and emotional wellbeing. This study, by researchers in Italy, involved 203 patients, of whom 47 did not currently have any lesions (blisters or sores), to see whether patients’ wellbeing is negatively affected at all times or just when lesions or blisters are present. They measured quality of life using the Skindex-17 questionnaire and psychological wellbeing using the 12-item General Health Questionnaire (GHQ12). They found that patients without lesions had a better quality of life than patients with active lesions, shown by a 30% reduction of the Skindex-17 scores in the lesion-free group (the lower the score, the better the quality of life). However, despite this reduction, their Skindex scores still remained high. The proportion of patients at risk of anxiety or depression, as indicated by their GHQ12 results, was 44% lower in patients without lesions compared to patients with lesions. However this still exceeds the levels found in the general population. The authors conclude that while patients without lesions reported a better quality of life than patients with lesions, their Skindex-17 scores did however remain elevated. Dermatologists should be aware that a clearing of the skin symptoms does not mean “perfect health” for the patient.

A randomized clinical trial of photodynamic therapy with methylaminolevulinate versus 3% diclofenac plus hyaluronic acid gel for the treatment of multiple actinic keratoses of the face and scalp

C. Zane, E. Facchinetti, M.T. Rossi, C. Specchia, P.G. Calzavara-Pinton

This summary relates to DOI: 10.1111/bjd.12844

British Journal of Dermatology, 170, 1143–1150, May 2014


Actinic keratoses (AKs) are areas of sun-damaged skin found predominantly on sun-exposed parts of the body. They are usually harmless but there is a very small risk of some actinic keratoses progressing to a form of skin cancer called squamous cell carcinoma. The aim of this Italian study was to compare the efficacy and cost-effectiveness of two treatment options: a gel called DHA containing Diclofenac and hyaluronic acid, and photodynamic therapy (PDT, a treatment using a type of light) combined with methylaminolevulinate cream (known as MAL-PDT). Two-hundred patients with a total of 1674 AKs were randomly selected to receive either DHA or MAL-PDT. Each patient had multiple AKs, and after 90 days, the researchers measured the overall response rate of the patient (i.e. looking at all of that person's AKs) as well as of the individual lesion. ‘Complete remission’ was used to describe the removal of the actinic keratoses, and referred either to the removal of all AKs on the patient (‘per patient’) or to the removal of an individual patch of AK (‘per lesion’). After 90 days, the complete remission rates of individual lesions were 85.9% with MAL-PDT and 51.8% with DHA. AKs of all thicknesses were significantly more responsive to MAL-PDT. The ‘per patient’ complete remission rates were 68.4% with MAL-PDT and 27.0% with DHA. Rating of cosmetic outcome was very good or excellent with both treatments, in the vast majority of complete remission patients. The authors conclude that efficacy, cosmetic outcome and patients’ overall satisfaction of MAL-PDT are superior in comparison to DHA. MAL-PDT is more expensive but it is more cost-effective.

Cryotherapy is preferable to ablative CO2 laser for the treatment of isolated actinic keratoses of the face and scalp: a randomised clinical trial

C. Zane, E. Facchinetti, M.T. Rossi, C. Specchia, B. Ortel, P. Calzavara-Pinton

This summary relates to DOI: 10.1111/bjd.12847

British Journal of Dermatology, 170, 1114–1121, May 2014


Actinic keratoses (AKs) are rough, dry areas (lesions) of skin caused by excessive sun exposure over many years. They which are usually harmless but can develop into squamous cell carcinoma, a type of skin cancer. There are several different ways of treating them. This study compared two options commonly used when there are fewer than five lesions and when the surrounding skin has mild or no sun damage. These options are ‘cryotherapy’ (freezing the lesion with liquid nitrogen) and a type of laser treatment called ‘CO2 laser ablation’. Two-hundred patients with a total of 543 AKs received either cryotherapy or CO2 laser ablation. After 90 days, the ‘complete remission’ rate was measured and compared with the thickness of the original lesion. Complete remission means that the symptoms have been removed, and refers either to the removal of all AKs on the patient (‘per patient’) or to the removal of an individual patch of AK (‘per lesion’). Complete remission is different from cure because it cannot be guaranteed that the symptoms will not return. The researchers, from Italy, found that after 90 days the complete remission rates ‘per patient’ and ‘per lesion’ were similar for both treatments. The rate of patients with complete remission for all of their lesions was 71.6% for cryotherapy and 65.3% for laser. The complete remission rates for an individual lesion were 78.2% for cryotherapy and 72.4% for laser. Patients with complete remission of all of their lesions were checked again after 12 months and at this point, the ‘per patient’ complete remission rate was 72.6% for cryotherapy but only 21.9% for laser. Furthermore, cryotherapy was found to be more effective for treating thicker lesions.

A population-based study of the incidence of delusional infestation in Olmsted County, Minnesota, 1976–2010

C.H. Bailey, L.K. Andersen, G.C. Lowe, M.R. Pittelkow, J.M. Bostwick, M.D.P. Davis

This summary relates to DOI: 10.1111/bjd.12848

British Journal of Dermatology, 170, 1130–1135, May 2014


‘Delusional infestation’ is a disorder in which patients falsely believe that they are infested with parasites, insects, or inanimate objects, despite evidence to the contrary. Most frequently, the perceived infestation is in, on, or under the skin. ‘Epidemiology’ is the study of the patterns, incidence and causes of a specific disease or health issue within a population. It is important in shaping decisions such as healthcare budgets allocated to a particular disease, as well as understanding who is affected and why. Little is known about the epidemiology of delusional infestation, and this study sought to establish the incidence of the disease within a specific area in the US over a 34-year period. This was done using the resources of the Rochester Epidemiology Project, a system under which almost all of the 144 000 people living in Olmsted County, Minnesota, have permitted for their medical records to be shared with researchers wishing to conduct ‘population based studies’. The study found that, while still rare, the disease is more common than earlier estimated. The annual incidence was 1.9 per 100 000 person-years (‘person-years’ means the total number of years that all the study's participants were monitored for – this takes into account both the number of people in the study and the amount of time each person spends in the study). Incidence was found to increase with age, with the mean age at diagnosis being 61.4 years, and it was more common in women than men. The incidence increased over the four decades included in the study, from 1.6 per 100 000 person-years in 1976–1985, to 2.6 per 100 000 person-years in 2006–2010.

Alcohol drinking and cutaneous melanoma risk – A systematic review and dose-risk meta-analysis

M. Rota, E. Pasquali, R. Bellocco, V. Bagnardi, L. Scotti, F. Islami, E. Negri, P. Boffetta, C. Pelucchi, G. Corrao, C. La Vecchia

This summary relates to DOI: 10.1111/bjd.12856

British Journal of Dermatology, 170, 1021–1028, May 2014


Melanoma is a form of skin cancer, and this review of 16 previous studies, providing a combined total of 6251 cases of melanoma, looked at the link between alcohol and the disease. The study focused on the effect of what the researchers classify as moderate to heavy drinking (more than one drink, or 12.5 g of ethanol a day), and found that this increases melanoma risk by 20 per cent. There has been very little research into the effect of heavy drinking (more than 50 g of ethanol a day) in this area, however it was noted that risk increased proportionately with alcohol intake, allowing the researchers to estimate an increased risk of 55 per cent for heavy drinkers. It has been previously reported that alcohol drinking increases the severity of sunburn, which is one of the major risk factors for melanoma, however, this study, by researchers from Italy, Sweden, USA, Iran and France, has made the link between alcohol consumption and skin cancer. The researches explain that ethanol is converted to a chemical compound called acetaldehyde soon after it is ingested. It is thought that acetaldehyde may act as a ‘photosensitizer’ (making skin more sensitive to light), which in turn generates molecules called ‘reactive oxygen species’ that damage cells (known as ‘oxidative stress’) in a way that can cause skin cancers. The authors do, however, add a note of caution to interpreting the results, as it is not possible to quantify the impact of UV in isolation on each individual and retrospectively adjust the results accordingly if this wasn't factored into the original study.

Satisfaction with medication is high for biologics in psoriasis. Results from the BioCAPTURE network

J.M.P.A. van den Reek, P.P.M. van L€umig, M.E. Otero, J. Zweegers, P.C.M. van de Kerkhof, P.M. Ossenkoppele, M.D. Njoo, J.M. Mommers, M.I.A. Koetsier, W.P. Arnold, B.A.M. Sybrandy-Fleuren, A.L.A. Kuijpers, M.P.M. Andriessen, M.M.B. Seyger, W. Kievit, E.M.G.J. de Jong

This summary relates to DOI: 10.1111/bjd.12862

British Journal of Dermatology, 170, 1158–1165, May 2014


Psoriasis is a common skin disease affecting about 2% of the population. In about 90% of cases it requires long-term treatment. Such treatments for patients with severe psoriasis include biologics (biological drugs – so named because they mimic normal human molecules). There are many studies into the effectiveness of different biologics but this study looked specifically at patients’ own satisfaction with three biologics treatments: etanercept, adalimumab and ustekinumab. Satisfaction with medication is important because it is believed to encourage people to adhere to their treatment as well as improving their health-related quality of life. The researchers, from the Netherlands, measured patient satisfaction in 106 volunteers during their first 6 months of treatment, using the Treatment Satisfaction Questionnaire for Medication (TSQM), which includes patients’ views on the medication's effectiveness, side-effects and convenience. Patients completed a TSQM at the start of treatment and again after three and then 6 months (or at the end of treatment if it lasted less than 6 months). After 3 months and 6 months, median scores relating to satisfaction in the different areas measured by TSQM significantly improved compared to the start of treatment: 66.7% for effectiveness and 100% for side-effects after both three and 6 months, 66.7% for convenience after 3 months rising to 77.8% after 6 months, and 75.0% for global satisfaction (overall level of satisfaction) rising to 83.3%. As can be read from these scores, the domains ‘effectiveness’ and ‘convenience’ showed most room for improvement at month six. Patients who had never previously been treated with biologics scored significantly better regarding ‘global satisfaction’ after 6 months compared to those with prior biologics treatment.