Kirk Barber

Managing childhood atopic dermatitis

Atopic dermatitis, a chronic inflammatory skin disorder that affects up to 20% of school-aged children, can profoundly influence quality of life. Basic therapy consists of avoidance of triggering factors and optimal skin care. Until now, corticosteroids have been the usual treatment for acute flares. Short-term safety profiles are reasonable, but long-term use of corticosteroids may involve significant adverse effects. Topical immunomodulators (tacrolimus and pimecrolimus) are beneficial and safe for adults and children and represent a major new alternative to chronic cortico-steroid use, especially in children.

Clobetasol propionate shampoo 0.05% is efficacious and safe for long-term control of moderate scalp psoriasis.

Abstract We evaluated in this study the efficacy and safety of an alternate regimen using clobetasol propionate 0.05% shampoo (CP shampoo) for long-term control of scalp psoriasis. Patients with moderate scalp psoriasis (Global Severity Score [GSS] of 3 on a 0–5 scale) first received CP shampoo once daily for 4 weeks. Patients with a GSS ≤ 2 were then randomized into the maintenance phase, receiving CP shampoo or vehicle twice weekly. When relapse (GSS > 2) occurred, patients received the 4-week daily CP shampoo treatment. Patients who had a GSS ≤ 2 afterwards reinitiated the twice-weekly maintenance according to the original randomization scheme. Among the 168 patients enrolled, 141 (83.9%) had a GSS ≤ 2 after the initial phase. The median time to first relapse was 141 days with CP shampoo, almost 4 months later than with vehicle (30.5 days;p < 0.0001). After 6 months, the percentage of patients who had no relapse was significantly higher with CP shampoo (40.3%) than with vehicle (11.6%;p < 0.001). CP shampoo was also safe during the 7-month study period, without leading to more cases of skin atrophy, telangiectasia, hypothalamic-pituitary-adrenal (HPA) axis suppression or adverse events compared to vehicle. The alternate treatment regimen with CP shampoo is efficacious and safe for long-term management of moderate scalp psoriasis.

Canadian Practical Guide for the Treatment and Management of Atopic Dermatitis

BackgroundAtopic dermatitis is a common condition, with a lifetime prevalence of approximately 10% to 20% among the Canadian population. A clear, practical, Canadian guideline for the management of these patients has been lacking.ObjectiveTo provide primary-care physicians, pediatricians and dermatologists with the first practical and comprehensive set of Canadian recommendations for the management of atopic dermatitis.MethodsA group of Canadian dermatologists convened to review the current issues of diagnosis, treatment and international guidelines and adapt them to the Canadian context. The reviewers used the latest clinical trial data on atopic dermatitis, complemented by clinical experience, to develop the consensus recommendations found in this review.ResultsIn the present report, following a brief review of the epidemiology of and clinical diagnosis criteria for atopic dermatitis, the recommendations for treatment and management are detailed. These recommendations, which are intended to provide clinicians with a useful and valuable tool to help manage their patients with atopic dermatitis, are divided into the following sections: epidemiology, diagnosis, general measures/skin care, acute management of atopic dermatitis, long-term management/disease control, adjunct therapies, and considerations for switching between anti-inflammatory therapies/handling treatment failure.General measures discussed include hydration with bathing and the use of moisturizers. Management strategies discussed include topical corticosteroids, topical calcineurin inhibitors, antihistamines and anti-infectives.A management algorithm is also presented.

Non-melanoma Skin Cancer in Canada Chapter 5 Management of Squamous Cell Carcinoma

Background Squamous cell carcinoma (SCC) is the second-most common form of non-melanoma skin cancer (NMSC). Objective To provide guidance to Canadian health care practitioners regarding management of SCCs. Methods Literature searches and development of graded recommendations were carried out as discussed in the accompanying introduction (chapter 1 of the NMSC guidelines). Results SCCs are sometimes confined to the epidermis, but they can also invade nearby tissues and, in some cases, metastasize to neighbouring lymph nodes or other organs. This chapter discusses the natural history, staging, prognosis, and management of SCC—a tumour type that is less common but typically more aggressive than BCC. For this reason, margin control is strongly preferred in treating SCCs. Conclusions Although approaches such as cryosurgery and radiation therapy may be considered for some patients, surgical excision—sometimes coupled with radiation—remains the cornerstone of SCC management. Patients with high-risk SCC may also be considered for referral to an appropriate multidisciplinary clinic.

Non-melanoma Skin Cancer in Canada Chapter 3: Management of Actinic Keratoses:

Background Actinic keratosis (AK) and cheilitis (AC) are lesions that develop on photodamaged skin and may progress to form invasive squamous cell carcinomas (SCCs). Objective To provide guidance to Canadian health care practitioners regarding management of AKs and ACs. Methods Literature searches and development of graded recommendations were carried out as discussed in the accompanying introduction (chapter 1 of the NMSC guidelines). Results Treatment of AKs allows for secondary prevention of skin cancer in sun-damaged skin. Because it is impossible to predict whether a given AK will regress, persist, or progress, AKs should ideally be treated. This chapter discusses options for the management of AKs and ACs. Conclusions Treatment options include surgical removal, topical treatment, and photodynamic therapy. Combined modalities may be used in case of inadequate response. AKs are particularly common following the longterm immunosuppression in organ transplant patients, who should be monitored frequently to identify emerging lesions that require surgery.

ISA247: quality of life results from a phase II, randomized, placebo-controlled study.

Background: Psoriasis is a chronic skin condition that can negatively affect a patients quality of life (QoL), often hindering social functioning. ISA247, a novel psoriatic agent, has shown clinical efficacy in moderate to severe psoriasis sufferers, but its effect on QoL is currently not reported. Objective: The objective of this study was to assess the effect of ISA247 on the QoL in patients with stable, plaque-type psoriasis. Methods: A phase II, randomized, double-blind, placebo-controlled, parallel-group, multicenter study assessed the effects of ISA247 doses of 0.5 mg/kg/d (n = 77) or 1.5 mg/kg/d (n = 83) compared with placebo (n = 41) for 12 weeks. QoL was assessed using the Dermatology Life Quality Index (DLQI) and Psoriasis Disability Index (PDI) scales. Results: ISA247 treatment (pooled groups) significantly improved QoL scores as assessed by both the DLQI and the PDI compared with those receiving placebo (p < .05). Treatment with the higher dose of 1.5 mg/kg/d demonstrated a significantly greater response to many of the QoL scales compared with the 0.5 mg/kg/d group (p < .05). Conclusions: ISA247 appears to improve the QoL while also providing effective treatment for chronic, moderate to severe, plaque-type psoriasis.

2016 Addendum to the Canadian Guidelines for the Management of Plaque Psoriasis 2009

Disclaimer: As in the original guidelines, physicians should use their best clinical judgment when determining whether and how to apply treatment recommendations in the individualized care of patients. This document is not intended to replace the guidance found in the relevant Canadian product monographs or other official information available for the therapeutics discussed. Every reasonable effort has been made to ensure the accuracy of this document. Any errors made here will be corrected in the next edition of the guidelines. Drug names: As in the original guidelines document, generic names have been used throughout this document. Any new trade name or generic name used in the addendum has been has listed in Appendix I at the end of this document. Directions for readers: This addendum should be used in conjunction with the original 2009 Canadian Guidelines for the Management of Plaque Psoriasis as a tool to guide physicians in clinical decision making. All changes to the content of the 2009 guidelines are presented by chapter, which correspond to the chapters in the original document. All new information is cross-referenced by page number and section/subsection to the original guidelines where the addendum applies. A table listing only new recommendations or modifications to existing recommendations follows each chapter. Legend XXXX X = If only additional references are added to existing text in the original guidelines, these are indicated in bold. All original text from the 2009 Guidelines is underlined. All new recommendations or modifications to existing recommendations are indicated in bold.

Review of Treatment for Onychomycosis: Consideration for Special Populations

This article provides a brief discussion of onychomycosis treatment in special populations such as children, the elderly, and patients with diabetes, human immunodeficiency virus (HIV), or Down syndrome. These subjects are generally not included in clinical trials, and few data on antifungal therapy are available in the literature. Issues with onychomycosis infection and treatment affecting each group are discussed, and where treatment reports exist, efficacy and safety data are presented. The discussion is restricted to agents approved for use in onychomycosis in Canada: oral terbinafine, oral itraconazole, and ciclopirox 8% nail lacquer. Although sparse, the literature demonstrates that onychomycosis therapies can be used safely and effectively in these special populations, although it is likely that the appropriateness of such treatment would have to be assessed on a case-by-case basis. Typically, oral medications are used reluctantly in these groups as the potential for adverse liver or kidney effects and medication interactions may be significant. Ciclopirox nail lacquer has recently become available for use and may offer an alternative to oral therapy in the future for mild to moderate cases of onychomycosis; however, the efficacy in these patients has not typically been reported. It remains to be seen what impact this medication will have for special populations. More knowledge of treatment in special populations must be accumulated in the literature before more formal treatment guidelines may be formulated.

Structured Expert Consensus on Actinic Keratosis: Treatment Algorithm Focusing on Daylight PDT

Background: A practical and up-to-date consensus among experts is paramount to further improve patient care in actinic keratosis (AK). Objectives: To develop a structured consensus statement on the diagnosis, classification, and practical management of AK based on up-to-date information. Methods: A systematic review of AK clinical guidelines was conducted. This informed the preparation of a 3-round Delphi procedure followed by a consensus meeting, which combined the opinions of 16 clinical experts from 13 countries, to construct a structured consensus statement and a treatment algorithm positioning daylight photodynamic therapy (dl-PDT) among other AK treatment options. Results: The systematic review found deficiencies in current guidelines with respect to new AK treatments such as ingenol mebutate and dl-PDT. The Delphi panel established consensus statements across definition, diagnosis, classification, and management of AK. While the diagnosis of AK essentially rests on the nature of lesions, treatment decisions are based on several clinical and nonclinical patient factors and diverse environmental attributes. Participants agreed on ranked treatment preferences for the management of AK and on classifying AK in 3 clinical situations: isolated AK lesions requiring lesion-directed treatment, multiple lesions within a small field, and multiple lesions within a large field, both requiring specific treatment approaches. Different AK treatment options were discussed for each clinical situation. Conclusions: The results provide practical recommendations for the treatment of AK, which are readily transferable to clinical practice, and incorporate the physician’s clinical judgement. The structured consensus statement positioned dl-PDT as a valuable option for patients with multiple AKs in small or large fields.

Treating Psoriasis and Psoriatic Arthritis: Position Paper on Applying the Treat-to-target Concept to Canadian Daily Practice

Objective. To develop preliminary treat-to-target (T2T) recommendations for psoriasis and psoriatic arthritis (PsA) for Canadian daily practice. Methods. A task force composed of expert Canadian dermatologists and rheumatologists performed a needs assessment among Canadian clinicians treating these diseases as well as an extensive literature search on the outcome measures used in clinical trials and practice. Results. Based on results from the needs assessment and literature search, the task force established 5 overarching principles and developed 8 preliminary T2T recommendations. Conclusion. The proposed recommendations should improve management of psoriasis and PsA in Canadian daily practice. However, these recommendations must be further validated in a real-world observational study to ensure that their use leads to better longterm outcomes.