Andrew G Affleck

Cost effectiveness of the two-compound formulation calcipotriol and betamethasone dipropionate gel in the treatment of scalp psoriasis in Scotland

Abstract Objectives: To compare the cost effectiveness of the two-compound formulation (TCF) calcipotriol plus betamethasone dipropionate gel used first-, second- or third-line to standard topical treatments for moderately severe scalp psoriasis from a Scottish NHS perspective. Research design and methods: Treatment pathways for scalp psoriasis patients in primary care were defined by Scottish prescribing statistics, an interview programme and published sources. The extensive 1-year Markov model included 12 different topical treatment pathways, each simulating three lines of therapy. Seven pathways contained the TCF gel in first-, second- or third-line. The remaining five pathways were included as comparators, reflecting the heterogeneity across clinical practice. The cost effectiveness of TCF gel was compared to the average of five non-TCF gel pathways. The clinical effectiveness measure was the ability of topical treatments to control disease at 4 weeks. Response rates were derived from indirect comparisons of ten randomised controlled trials. Utilities were elicited from SF-36 (v2) scores in one TCF gel trial. The main outcome was the incremental cost per quality-adjusted life-year (QALY). Extensive sensitivity analyses were performed to assess the robustness of the results. Results: TCF gel used first-, second- or third-line was projected to increase QALYs (around 0.0025) with cost savings per patient (£20–30) over 1 year. The study analysis acknowledged a number of limitations including lack of quality comparator data, the need to make assumptions in the absence of evidence and lack of model validation. However the results showed that TCF gel was the dominant treatment strategy across a broad range of credible scenarios. Conclusions: Scalp psoriasis is difficult to treat. Many different topical preparations can be used but several factors such as greasiness, irritation, time needed to apply, and lack of efficacy often result in reduced adherence to treatment regimens. Where cosmetic properties are important for patient acceptability and compliance is a major issue contributing to treatment failure, the once-daily TCF gel offers patients with scalp psoriasis an attractive, cost-saving treatment option.

Predicting pain during and after Mohs micrographic surgery: The need to consider psychological factors

2. McArdle F, Rhodes LE, Parslew RA, Close GL, Jack CI, Friedman PS, et al. Effects of oral Vitamin E and s carotene supplementation on ultraviolet radiation-induced oxidative stress in human akin. Am J Nutr 2004;80:1270-5. 3. Vivekananthan DP, Penn MS, Sapp SK, Hsu A, Topol EJ. Use of antioxidant vitamins for the prevention of cardiovascular disease: metaanalysis of randomized trials. Lancet 2003;361 (9374):2017-23. 4. Redlich CA, Chung JS, Cullen MR, Blaner WS, Van Bennekum AM, Berglund L. Effect of long-term beta-carotene and vitamin A on serum cholesterol and triglyceride levels among participants in the Carotene and Retinol Efficacy Trial (CARET). Atherosclerosis 1999;143:427-34. 5. Middelkamp-Hup MA, Pathak MA, Parrado C, Goukassian D, Ruis-Diaz F, Mihm MC, et al. Oral polypodium leucotomos extract decreases ultraviolet-induced damage of human skin. J Am Acad Dermatol 2004;51:910-8. 6. Villa A, Viera MH, Amini S, Huo R, Perez O, Ruiz P, et al. Decrease of ultraviolet A light-induced ‘‘common deletion’’ in healthy volunteers after oral Polypodium leucotomos extract supplement in a randomized clinical trial. J Am Acad Dermatol 2010;62:511-3.

Multiple persistent keratoacanthomas.

doxycycline, ciprofloxacin, and metronidazole. By contrast, the vasoactive properties of tacrolimus explained the insidious development of rosaceiform complication during long-term treatment in the previous report, 7 especially in patients with a history of rosacea. Our patient had no history of rosacea, however, and his rosaceiform complication showed an acute course and no recurrence. A typical flush reaction to even small amounts of alcohol has been observed in up to 7% of patients treated with tacrolimus ointment. 10 Pimecrolimus, however, does not appear to have vasoactive effects. A similar reaction pattern has not been noted with extensive pimecrolimus use in clinical trials. Finally, topical pimecrolimus 1% cream is in a cream base and seems to have less occlusive properties than tacrolimus ointment. Thus, the rosacea-like demodicidosis in our patient is probably related to the local immunosuppressive effects of topical pimecrolimus 1% cream. Pimecrolimus 1% cream is increasingly being used because of its therapeutic benefit in a number of inflammatory dermatoses and its good safety profile. Although the pathogenic role of topical calcineurin inhibitors remains to be elucidated, this rare cutaneous adverse event should be recognized by dermatologists.

Nicorandil-associated penile and anal ulceration triggered by circumcision

72-year-old man was referred to Dermatology y Urology with a 5-month history of non-healing ainful penile ulcer arising after circumcision for ecurrent non-specific balantitis associated with himosis. The patient felt that ‘it had never quite ealed properly’. Three months after the circumision, extensive ulceration developed on the shaft nd base of penis and clinically similar deep ulcertion then arose on his right buttock perianally. Relevant medical history included ischaemic eart disease, previous myocardial infarction, trial fibrillation, Type 2 diabetes mellitus and iverticular disease. Regular medications were

Current evidence on the effectiveness of systemic herbal medicine for psoriasis: A systematic review with meta-analysis.

Herbal medicines have been used to treat psoriasis for many years with anecdotal reports of efficacy which have attracted public attention. We seek to assess the effects of systemic herbal medicine in the treatment of psoriasis. Medical database PubMed/MEDLINE, AMED, CINAHL, and CENTRAL were searched. Randomised controlled trials of systemic herbal medicine used in the treatment of psoriasis included in the meta-analysis. Two reviewers independently applied eligibility criteria, assessed the quality of the trials and extracted data. Any discrepancies were discussed with additional reviewer to achieve consensus. Nine randomised controlled trials met the inclusion criteria. The trials randomised 785 participants. Three RCTs revealed that herbal medicine performed better than placebo control (RR=3.98, 1.3611.62, 95%CI, I2=68%, p=0.01), four RCTs demonstrated that the western drug competitor is superior to herbal medicine(RR=0.73, 0.53-0.97, 95%CI, I2=52%, p=0.03), two RCTs suggested that herbal medicine combined with other medication, (i.e. Auricular Acupuncture or Acitretin (a systemic retinoid), is more effective than herbal medicine alone (RR=1.92, 1.28-2.88, 95%CI, I2=0%, p=0.002). The results of one RCT indicated that herbal medicine reduced the occurrence of adverse reactions of Acitretin, when it was used in combination with herbal medicine. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Further well-designed larger scale trials are required to determine the safety and efficacy of oral herbal interventions in the treatment of psoriasis.

Cognitive behavioral therapy for acne and other chronic skin disorders

We read with interest the report by Jung and Hawang describing the knowledge and behavior of patients with acne; some patients had unorthodox beliefs about the cause and treatment of their acne and as a result had adopted unhelpful and potentially counterproductive behaviors. The authors emphasize the need for patients to establish a clear understanding of the nature and treatment of acne to allow optimum management and therefore satisfactory outcomes to occur. However, knowledge alone may not be enough to predict intention or practice of health behaviors. Research in adjustment to illness has shown that perceptions of illness are important in determining patients’ response to treatment and coping with their condition. Accordingly, patients form perceptions about their condition and its treatment, which are more elaborate than attitudes. These include perceptions about identity, cause, timeline, consequences, and cure–control over illness. The researchers in this paper label knowledge that could well be perceptions over cure–control. Therefore, the inference the authors make of their findings, i.e. that improving knowledge would result in improved behaviors, is rather weak. The authors make no mention of any emotional morbidity of these patients. Cognitive behavioral therapy, as pioneered by Beck, helps patients understand and address dysfunctional thoughts and feelings that influence behaviors. There are many potential negative feelings that a patient with acne may have, including anxiety, sadness, frustration, anger, annoyance, contempt, disgust, fear, doubt, envy, shame, despair, disappointment, reduced confidence, self-consciousness, embarrassment, hurt, and guilt. These feelings may be triggered by negative thoughts/beliefs, e.g. that they are unattractive, ugly, or unacceptable to themselves or others, self-disgust and self-hatred may occur, they may perceive themselves as inferior to others, they may think they are unlovable or unworthy, patients may see themselves as imperfect, unclean, and in extreme cases patients may have suicidal thoughts. The authors do mention some unhelpful behaviors in patients with acne. Other maladaptive coping physical mechanisms include excessive use of commercial tanning salons, repeated mirror checking or complete mirror avoidance, use of clothing, excessive make-up on body parts to cover affected areas repeatedly, excessive touching or interfering with the affected areas, compulsive picking or squeezing of spots, excessive ritualistic cleansing regimens, repeated reassurance checking, repeated Internet searches for a miracle cure and purchasing many miracle acne products, regular comparison with others or photographs in magazines, and avoidance of social events. In dermatology, cognitive behavioral therapy is helpful in eczema, psoriasis, alopecia, acne excoriee, body dysmorphic disorder, and other cutaneous hypochondriasis, including delusional infestation. It is important to note that the patients’ acne-related behavior in this study could be better understood under another comorbid disorder, e.g. BDD, which the authors did not take into account. In the UK, the medical management of acne differs from the Korean approach. Use of cosmeceuticals is not standard practice. We suggest that the overuse of cosmeceuticals or recommendation of manipulation of lesions, including extraction of comedones, in an at-risk patient with a tendency towards compulsive behavior could be harmful. Patients with acne seek medical help because of how acne makes them feel and how acne affects their daily functioning. Studies have shown that the objective physical severity of acne does not correlate with the patients’ perception of severity and impact on their life. Therefore, it is crucial to focus on the patients’ experience and perspective. Those patients who report a large detrimental effect on their quality of life are in need of a personalized Cognitive behavioral approach to supplement conventional medical therapy. Other forms of psychotherapy may be helpful in individual cases. This need appears to be unmet often. Further research in this area is desirable.