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The Association of Bullous Pemphigoid With Cerebrovascular Disease and Dementia A Case-Control Study

OBJECTIVE To investigate the relationship between bullous pemphigoid (BP) and neurologic disease. DESIGN Case-control study. SETTING Tertiary care center for immunobullous diseases and skin tumor clinics at a university hospital in Oxford, England. PARTICIPANTS Ninety consecutive patients with BP and 141 controls. MAIN OUTCOME MEASURES Age-adjusted prevalence of neurologic disease in patients and controls. Time interval between the diagnosis of neurologic disease and BP and type of associated neurologic disease. RESULTS At least 1 neurologic diagnosis was present in 42 patients (46%) compared with 16 controls (11%). Patients had significantly increased odds for neurologic diseases regardless of age and sex (crude odds ratio [OR], 6.8; 95% confidence interval [CI], 3.5-13.3; adjusted OR, 6.2; 95% CI, 3.1-12.4). Four major neurologic diagnoses were observed (cerebrovascular disease, dementia, Parkinson disease, and epilepsy), with statistical significance for cerebrovascular disease and dementia (crude OR for cerebrovascular disease, 6.3; 95% CI, 2.8-14.2; adjusted OR, 6.0; 95% CI, 2.6-13.6; crude OR for dementia, 10.7; 95% CI, 2.3-49.0; adjusted OR, 7.9; 95% CI, 1.7-37.3). When accurate data on time of onset of neurologic disease were present (36 of 42 patients [85%]), BP followed neurologic disease in most patients (26 of 36 patients [72%]), with a median interval of 5.5 years. CONCLUSION Bullous pemphigoid is significantly associated with cerebrovascular disease and dementia.

Pemphigoid gestationis: early onset and blister formation are associated with adverse pregnancy outcomes

Background  It is unclear whether clinical features of pemphigoid gestationis (PG), such as timing of onset and severity, may affect pregnancy outcomes or whether the adverse outcomes in pregnancies complicated by PG are related to or worsened by systemic corticosteroid treatment.

Systematic review and meta-analysis of randomized controlled trials on topical interventions for genital lichen sclerosus

BACKGROUND Lichen sclerosus (LS) is a chronic inflammatory dermatosis that occurs mainly in the anogenital area and causes itching and soreness. Progressive destructive scarring may result in burying of the clitoris in females and phimosis in males. Affected people have an increased risk of genital cancers. OBJECTIVE We sought to assess the effects of topical interventions for genital LS. METHODS We undertook a systematic review and meta-analysis using the methodology of the Cochrane Collaboration. RESULTS We included 7 randomized controlled trials with a total of 249 participants covering 6 treatments. Clobetasol propionate 0.05% was better than placebo in treating genital LS (participant-rated improvement/remission of symptoms: risk ratio 2.85 [95% confidence interval {CI} 1.45-5.61]; investigator-rated global degree of improvement: standardized mean difference [SMD] 5.74 [95% CI 4.26-7.23]) as was mometasone furoate 0.05% (change in clinical grade of phimosis: SMD -1.04 [95% CI -1.77 to -0.31]). We found no evidence supporting the efficacy of topical androgens and progesterone. There were no differences between pimecrolimus and clobetasol propionate in relieving symptoms through change in pruritus (SMD -0.33 [95% CI -0.99 to 0.33]) and burning/pain (SMD 0.03 [95% CI -0.62 to 0.69]). However, pimecrolimus was less effective than clobetasol propionate in improving gross appearance (investigator-rated global degree of improvement: SMD -1.64 [95% CI -2.40 to -0.87]). LIMITATIONS Most of the included studies were small. CONCLUSIONS The current limited evidence supports the efficacy of clobetasol propionate, mometasone furoate, and pimecrolimus in treating genital LS. Further randomized controlled trials are needed.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

Safety of Topical Corticosteroids in Pregnancy: A Population-Based Cohort Study

Topical corticosteroids may be indicated in pregnant women with skin conditions, but their safety in pregnancy is unclear. We used the UK General Practice Research Database to conduct a population-based cohort study to investigate whether maternal exposure to topical corticosteroids results in adverse pregnancy outcomes. We identified 35,503 pregnant women prescribed topical corticosteroids during the period from 85 days before last menstrual period (LMP) to delivery or fetal death and 48,630 unexposed women. We found no associations of maternal exposure to topical corticosteroids with orofacial cleft (and its two subtypes, i.e., cleft lip ± palate (CLP) and cleft palate alone (CP)), preterm delivery, and fetal death (including miscarriage and stillbirth). The findings were similar when excluding exposure before LMP. In contrast, maternal exposure to potent/very potent topical corticosteroids shortly before and during pregnancy was significantly associated with fetal growth restriction (adjusted relative risk 2.08; 95% confidence interval 1.40-3.10; number needed to harm, 168), which was confirmed by a significant dose-response relationship (P=0.025) and the sensitivity analysis excluding exposure before LMP. The increased risk for fetal growth restriction should be considered when prescribing potent/very potent topical corticosteroids to pregnant women, and appropriate obstetric care should be provided.

The Associations Between Bullous Pemphigoid and Drug Use: A UK Case-Control Study

OBJECTIVE To explore associations between bullous pemphigoid (BP) and previous drug use in the United Kingdom. DESIGN A case-control study comparing the drug history of consecutive patients with BP and control subjects. SETTING Tertiary care center for immunobullous diseases and skin tumor clinics at Oxford University Hospitals. PATIENTS OR OTHER PARTICIPANTS Eighty-six consecutive BP patients and 134 consecutive controls from the same region and similar in age and sex who presented with other dermatological diagnoses. MAIN OUTCOME MEASURES Crude and adjusted odds ratios and 95% confidence interval of BP in relation to each drug. RESULTS Loop diuretics were used significantly more frequently by the BP patients (crude odds ratio, 2.4 [95% CI, 1.2-5.0; P= .02]; adjusted odds ratio, 3.8 [1.5-9.7; P= .006]). No significant differences were found between groups for use of other diuretics, aspirin, antidepressants, antiepileptics, antihypertensives, or central nervous system agents (eg, antipsychotics). Patients with BP used calcium or vitamin D supplements, antibiotics, antihistamines, and prednisolone significantly more often on multivariate analysis. CONCLUSIONS The findings of our study demonstrate increased use of loop diuretics in patients with BP before the development of BP. The mechanism behind such an association clearly warrants further investigation.

Evidence‐based (S3) guideline on topical corticosteroids in pregnancy

Women with skin conditions may need topical corticosteroids during pregnancy. However, little is known about the effects of topical corticosteroids on the fetus. A guideline subcommittee of the European Dermatology Forum was organized to develop an evidence‐based guideline on the use of topical corticosteroids in pregnancy (http://www.euroderm.org/edf/images/stories/guidelines/EDF‐Guideline‐on‐Steroids‐in‐Pregnancy.pdf). The evidence from a Cochrane Review suggested that the major possible adverse effects on the fetus of topical corticosteroids were orofacial clefts when used preconceptionally and in the first trimester of pregnancy, and fetal growth restriction when very potent topical corticosteroids were used during pregnancy. To obtain robust evidence, a large population‐based cohort study (on 84 133 pregnant women from the U.K. General Practice Research Database) was performed, which found a significant association of fetal growth restriction with maternal exposure to potent/very potent topical corticosteroids, but not with mild/moderate topical corticosteroids. No associations of maternal exposure to topical corticosteroids of any potency with orofacial cleft, preterm delivery and fetal death were found. Moreover, another recent Danish cohort study did not support a causal association between topical corticosteroid and orofacial cleft. The current best evidence suggests that mild/moderate topical corticosteroids are preferred to potent/very potent ones in pregnancy, because of the associated risk of fetal growth restriction with the latter.

Systematic review of the safety of topical corticosteroids in pregnancy

BACKGROUND Pregnant women may have skin conditions that require topical corticosteroids. However, little is known about their safety in pregnancy. OBJECTIVE We sought to evaluate the available evidence concerning the safety of topical corticosteroids in pregnancy. METHODS We systematically searched 17 databases and trial registers, and contacted pharmaceutical companies. Randomized controlled trials and cohort studies of topical corticosteroids in pregnant women, and case-control studies comparing maternal exposure to topical corticosteroids between patients and control subjects were included. The Newcastle-Ottawa Scale was used for quality assessment of included studies. RESULTS Seven studies, including two cohort and five case-control studies, were included. Most studies did not find significant associations of topical corticosteroids with congenital abnormality, preterm delivery stillbirth, and mode of delivery. One study found a significant association between first-trimester use of topical corticosteroids and orofacial cleft, and another study found a significant association between very potent topical corticosteroids and low birthweight. LIMITATIONS The available data were limited and mainly on orofacial cleft. The quality of evidence was generally low. CONCLUSIONS Currently limited and inconclusive data are unable to detect an association between topical corticosteroids and congenital abnormality, preterm delivery, or stillbirth. The current evidence shows no statistically significant difference between pregnant women who use and those who do not use topical corticosteroids. However, there does appear to be an association of very potent topical corticosteroids with low birthweight. Further cohort studies with comprehensive outcome measures, consideration of corticosteroid potency, dosage and indications, and a large sample size are needed.

Risk of incident chronic kidney disease and end-stage renal disease in patients with psoriasis: A nationwide population-based cohort study

BACKGROUND Psoriasis is a chronic inflammatory dermatosis that has been associated with various cardiovascular and metabolic comorbidities, including myocardial infarction, stroke, and diabetes mellitus. Recently, there are studies reporting the association of psoriasis with renal diseases. OBJECTIVE To evaluate the risk of incident chronic kidney disease (CKD) and end-stage renal disease (ESRD) in people with psoriasis. METHODS We used the Taiwans National Health Insurance Research Database to conduct a nationwide population-based cohort study to assess the risk of incident CKD and ESRD in people with psoriasis and to further evaluate the respective risk estimates in those with mild and severe psoriasis based on treatment patterns. RESULTS A total of 4633 psoriatic patients and 922,534 nonpsoriatic controls were included. Severe psoriasis, but not mild psoriasis, was an independent risk factor of incident CKD and ESRD (adjusted hazard ratio being 1.90 (95% confidence interval 1.33-2.70) and 2.97 (95% confidence interval 1.72-5.11), respectively) after adjustment for potential confounders including age, gender, comorbidities, and used of nonsteroidal anti-inflammatory drugs (NSAIDs). Severe psoriasis remained an independent risk factor of incident CKD and ESRD after various sensitivity analyses after adjusting for the presence of osteoarthritis and/or rheumatoid arthritis, use of methotrexate and/or cyclosporine, and chronic use of NSAIDs for at least 2 months. Psoriatic arthritis was an effect modifier for CKD and ESRD. CONCLUSIONS The associations of severe psoriasis with CKD and ESRD should be recognized. Assessment of renal function and avoidance of long-term use of nephrotoxic drugs shall be implemented in the integrative care for patients with severe psoriasis.

The causative pathogens of onychomycosis in southern Taiwan

Selecting an appropriate antimycotic targeting the pathogens are among the most important factors for successfully treating onychomycosis. The aim of this study was to investigate the pathogens of onychomycosis in southern Taiwan and analyse the association between various factors and the distribution of pathogens. A total of 375 patients with onychomycosis were enrolled. Histopathological examination and fungus culture of nail specimens were performed. The pathogens were dermatophytes in 227 patients (60.5%), Candida in 118 (31.5%) and moulds in 30 (8%). Compared to patients with toenail involvement, the odds ratio (OR) for those with fingernail involvement to have non‐dermatophytic onychomycosis (NDO), i.e. onychomycosis caused by Candida and moulds, was 5.04 [95% confidence interval (CI): 2.21–11.15], and the OR for those with fingernail and toenail involvement to have NDO was 2.66 (95% CI: 1.61–4.34). The F/M OR to have NDO was 2.36 (95% CI: 1.51–3.61), and 9.80 for diabetics (95% CI: 1.01–106.85). The OR for patients with paronychia to have NDO was 10.33 (95% CI: 5.61–18.88) compared to those without paronychia. Compared to patients with a non‐wet occupation, the OR for those with a wet occupation to have NDO was 4.76 (95% CI: 2.01–11.16). The distribution of pathogens significantly varies with the involved sites, patients’ gender and occupation, and presence of diabetes mellitus or paronychia. In contrast to temperate western countries, NDO is more prevalent in the tropics and subtropics including southern Taiwan.