News Forum

GPs with an interest in dermatology review the latest papers of significance from research teams across the world

Psychiatric morbidity in patients with psoriasis
Community-based study of acne vulgaris in adolescents
Oral contraceptives and their effect on the vaginal mucosa
Obesity, psoriasis and links to cardiovascular disease
Hepatitis B and systemic glucocorticosteroid therapy
Combined adapalene and benzoyl peroxide in acne
Nickel allergy, patch tests and repeated open application tests
Tetracyclines in acne and the risk of lupus erythematosus


Psychiatric morbidity in patients with psoriasis
Sampogna F, Tabolli S, Abeni D. Br J Dermatol 2007; 157(3): 508-13
Psoriasis is a chronic, often widespread and, at present, incurable skin condition that can have a significant psychological impact on patients. Over the years, various scoring systems have been devised to assess the level of psychological impact, but this study went one step further. It looked not only at the level of psychological impact, but also at how that level varied as the severity of the underlying disease changed.

All eligible adults admitted to a hospital dermatological department with psoriasis during a two-year period were assessed using three questionnaires, SAPASI (Self Administered Psoriasis Area and Severity Index), the GHQ 12 (12 item General Health Questionnaire) and Skindex 29. The questionnaires were completed again a month after discharge and results compared.
A total of 414 patients were recruited over the two-year period. Of these, 17.6 per cent recorded no change or a worsening of the psoriasis over the month after discharge, and 68.2 per cent reported a clearance of the psoriasis.

Significant determinants in psychological improvement were improved SAPASI score, symptom improvement, no localisation on the face and gender (women were less likely to improve psychologically than men).

A percentage of those who had full clearance of their psoriasis showed no change in their psychological symptoms, possibly related to fear of recurrence. Overall, the study reinforces the fact that psoriasis can have a significant psychological impact and this does not necessarily improve as the condition improves.
- Dr Nigel Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary

Community-based study of acne vulgaris in adolescents
Tan H, Tan AW, Barkham T et al. Br J Dematol 2007; 157(3): 547-51
There is little research looking at the prevalence of acne in Asian teenagers, but this study was undertaken to determine the epidemiology of acne in teenagers in Singapore.
For this, 1,045 teenagers aged between 13 and 19 years were recruited in a community setting; of these, 920 (88 per cent) identified themselves as having acne.

A dermatologist examined 806 of these patients and determined that 51.4 per cent had mild acne, 40 per cent had moderate acne and 8.6 per cent had severe acne. P acnes isolation was attempted in 262 patients. Cultures were positive in 174 patients (66.4 per cent), with antibiotic-resistant strains in 26 (14.9 per cent). Of these, 42 per cent had received antibiotics before, but 58 per cent reported no prior treatment of their acne with topical or oral antibiotics.

More than half had self-medicated with OTC preparations and 31.5 per cent had sought help from a doctor. When questioned about their views regarding the causes of acne, the following opinions were recorded: 31 per cent thought chocolate was the culprit, while 55 per cent thought fried food was the cause. Cosmetics were cited by 54 per cent, heat by 45 per cent, stress by 57 per cent, hormones by 58 per cent and infection by 30 per cent. Many also reported the significant psychological impact the condition had on their life.

This study highlights the need for better education regarding the aetiology and available treatments for acne, as well as serving as a useful reminder to clinicians of the psychological impact of acne on adolescents. NS

Oral contraceptives and their effect on the vaginal mucosa
Johnesson U, Blomgren B, Hilligies M et al. Br J Dermatol 2007; 157(3): 487-93
Oral contraceptives are currently used by more than 200 million women worldwide. It is known that these hormones exert an effect on the endometrium, cervix and vaginal mucosa, but no study has looked at their effect on the vulval mucosa.

That was the aim of this study, which recruited 45 healthy women, 20 of whom were taking the combined oral contraceptive pill and 25 of whom were taking no hormones.
A 6mm punch biopsy was taken from the right posterior vestibule on days seven to 11 of the menstrual cycle, followed by a second punch two weeks later in 16 women without the combined oral contraceptive pill.

Women taking the combined oral contraceptive pill displayed morphology of the mucosa with more shallow and sparser dermal papillae compared with women in the follicular phase. Similar findings of an increased epithelial volume was seen in women during the luteal phase. The results suggest a gestogenic effect on the mucosa but whether this correlates with increased mechanical pain is not clear and requires further study. NS

Obesity, psoriasis and links to cardiovascular disease
Sterry W, Strober B, Menton A. Br J Dermatol 2007; 157(4): 547-51
In these times of the quality and outcomes framework and preventive medicine, we all spend many hours a week targeting cardiovascular risk associated with chronic diseases, such as diabetes, smoking and obesity.

As yet, no skin conditions have been included in the quality and outcomes framework, but it is becoming increasingly apparent that patients with psoriasis, especially those who develop the disease early in life, have an increased risk of not only IHD, but also hypertension, dyslipidaemia and insulin resistance.
In many cases, those with a long history of psoriasis have a higher BMI than the general population, which may be a contributory factor in these conditions.

This paper reported on a recent meeting of experts from dermatology and other specialties to discuss associations between psoriasis, obesity and subsequent cardiovascular comorbidity. From the discussions, many points were highlighted. For example, it is not yet known whether obesity increases the risk of psoriasis, or whether the psoriasis pre-dates the obesity – further studies are required. The role of adipocytokines in both conditions needs to be investigated.

Another queston under discussion was whether treatment such as etanercept has any effect on other comorbidities and metabolic syndrome, as well as the psoriasis. Or does obesity have any effect on treatment for psoriasis? Does lifestyle modification, such as smoking, alcohol, weight, lipids, glucose and BP control have any effect on psoriasis severity? These, along with a number of other questions, should form the basis of future studies which will help in our understanding of this chronic condition. NS

Hepatitis B and systemic glucocorticosteroid therapy
Yang C, Swu T, Chiu C. Br J Dermatol 2007; 157: 587-90
Reactivation of hepatitis B virus (HBV) is a known complication of long-term steroid chemotherapy regimens for lymphoma, autoimmune and rheumatic disease. However, this phenomenon has not been widely recognised in dermatology.

This retrospective study looked at 98 patients with pemphigus and dermatomyositis who had received systemic glucocorticosteroids (GC) for at least six months.

Only 21 of 98 (21.4 per cent) were screened or recorded for HBV markers and 36 of 98 (36.7 per cent) did not have LFTs before and after treatment with GCs (despite current guidelines recommending LFTs as a baseline test before long-term GC treatment). Four cases of HBV carriers with viral hepatitis were identified. Two patients developed fulminant hepatitis and died. The other two patients experienced recurrent hepatitis flare following antiviral medication.

HBV is an important global issue. Fatal reactivation with long-term GC therapy is a recognised problem. Most HBV patients are healthy carriers and have normal LFTs.

The authors recommend that all dermatology patients who need long-term GC therapy should have baseline HBV serology in addition to LFTs. They also suggest similar screening in patients receiving new biological immunomodulators. They recommend that chronic HBV carriers should have concurrent antiviral therapy when long-term immunosuppressive therapy is to be used.
-Dr Waseem Chaudhry is a GPSI in dermatology in Caerphilly

Combined adapalene and benzoyl peroxide in acne
Thibautot D, Weiss J, Bucko A et al. J Am Acad Dermatol 2007; 57: 791-9
Acne vulgaris is a complicated disorder of the pilosebaceous unit. Pathogenesis involves hyperkeritinisation, increased sebum production, bacterial proliferation and inflammation. No existing therapy has an effect on all four of these factors. Combination therapies, with complementary effects, are often used in the management of acne, for example, topical retinoid and a systemic antimicrobial.

Adapalene is a synthetic retinoid with anti-inflammatory, comedolytic and anticomedogenic properties. It is commonly used in combination with systemic antibiotics, such as lymecycline. Benzoyl peroxide (BP) is an effective antimicrobial agent with no evidence for development of bacterial resistance. There are several BP-topical antibiotic combinations.

Recently, a new combination of BP with adapalene has been formulated. This study evaluated its efficacy. A total of 517 patients were randomised in a double-blind controlled study to receive adapalene-BP, adapalene, BP or vehicle for 12 weeks. Subjects were evaluated for success rate, lesion count, tolerability and adverse events.

Results showed the adapalene-BP combination was significantly more effective than either agent alone. Beneficial effects were reported as early as one week. Adverse events and tolerability were similar to adapalene alone. This study suggests that a once daily fixed-dose combination of adapalene with BP is a significantly more effective treatment for acne vulgaris, which has rapid onset of action and is well tolerated, compared with adapalene and BP monotherapy. WC

Nickel allergy, patch tests and repeated open application tests
Fischer LA, Johnson JD, Menne T. Br J Dermatol 2007; 157(4): 723-9
This study from Denmark investigated the elicitation threshold in nickel-allergic patients in patch test and repeated open application test (ROAT) methodologies; the thresholds from these two test methods were compared.

It is already known that the frequency of nickel allergy varies between population groups, with exposure correlated to frequency. Experimental studies with other allergens have shown a significant relationship between patch test reactivity and ROAT reactivity.

The study examined 20 nickel-allergic patients over 21 days. A control group of 18 individuals with no nickel allergy was also included. The predicted dose (0.78 microgram nickel per cm2) elicited a reaction in 10 per cent of allergic patients. The threshold for ROAT was significantly lower than that for the patch test, while the dose-response for the accumulated ROAT dose at one, two and three weeks was very similar to the patch test dose-response.

The study concluded that for elicitation of nickel allergy, the elicitation threshold for the patch test is higher than that (per application) for ROAT, but is approximately the same as the accumulated elicitation threshold for ROAT. This study’s findings should be borne in mind when considering risk assessment based on dose-response results from allergic patients. Results from other experimental studies indicate that these findings may apply to other allergens; however, further investigation would be required.WC

Tetracyclines in acne and the risk of lupus erythematosus
Margolis D, Hoffstad O, Bilken W. Br J Dermatol 2007; 157: 540-6
Oral antibiotics, including tetracyclines, are often used to treat acne vulgaris and courses can last many months. Previous studies have associated tetracylines, in particular minocycline, with the risk of developing drug-induced lupus erythematosus (LE). Generally, drug-induced LE resolves with cessation of the causative agent and without additional therapy. This study attempted to determine the frequency of LE in patients with acne vulgaris using antibiotics from the tetracycline group.

The authors used a population-based database, The Health Improvement Network (THIN), from the UK. This was established in 1987 (initially as the General Practice Research Database and then as THIN in 2002) and includes medical information compiled by GPs about more than five million patients.

Using this extensive database, the authors identified 97,694 patients with acne vulgaris. Minocycline was used in 24.8 per cent, doxycycline in 15.6 per cent and other tetracylines in 42.3 per cent, while 17.3 per cent had no tetracycline.

A small increased risk of LE was found with minocycline but not with other tetracylines. The authors expressed this increased risk as 8.8 cases per 100,000 person-years, or as a number needed to harm of 11,364 (number of patients who need to be treated with minocycline for one year to cause one case of LE) . They noted the risk was greater with longer treatment but still present with courses of less than six months.

The authors concluded that there is an association of drug-induced LE with minocycline but not other tetracylines. Although this risk is small, acne is a common condition and many patients are exposed to antibiotics. It would, therefore, be prudent to use other tetracylines in favour of minocycline. WC

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