L. Le Cleach

Report from the kick-off meeting of the Cochrane Skin Group Core Outcome Set Initiative (CSG-COUSIN).

A major obstacle of evidence‐based clinical decision making is the use of nonstandardized, partly untested outcome measurement instruments. Core Outcome Sets (COSs) are currently developed in different medical fields to standardize and improve the selection of outcomes and outcome measurement instruments in clinical trials, in order to pool results of trials or to allow indirect comparison between interventions. A COS is an agreed minimum set of outcomes that should be measured and reported in all clinical trials of a specific disease or trial population. The international, multidisciplinary Cochrane Skin Group Core Outcome Set Initiative (CSG‐COUSIN) aims to develop and implement COSs in dermatology, thus making trial evidence comparable and, herewith, more useful for clinical decision making. The inaugural meeting of CSG‐COUSIN was held on 17–18 March 2015 in Dresden, Germany, as the exclusive theme of the Annual Cochrane Skin Group Meeting. In total, 29 individuals representing a broad mix of different stakeholder groups, professions, skills and perspectives attended. This report provides a description of existing COS initiatives in dermatology, highlights current methodological challenges in COS development, and presents the concept, aims and structure of CSG‐COUSIN.

Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg. A commentary

Erysipelas, also called superficial cellulitis in the American literature, is an acute superficial dermal–hypodermal infection that usually affects the leg and is commonly caused by streptococci. It may be severe, especially in the elderly with comorbidities, but, unlike necrotizing infections, is generally not life-threatening. Oral or intravenous antibiotics, the therapeutic keystone, e.g. mostly penicillin or macrolides ⁄streptogramins, are prescribed for 10–20 days to outor inpatients. However, the 2010 Cochrane review concluded that the antibiotic administration mode and duration warranted more thorough evaluation, especially in the community. Management should also include the control of erysipelas risk factors, mainly cutaneous barrier disruption and leg oedema. In fact, recurrence is the main specific complication of erysipelas; it occurs in 10–50% of the patients and apparently shares similar risk factors with the incident cases. What should we do to avoid such recurrent erysipelas, which may lead to major lymphoedema (with functional and aesthetic handicaps) and, subsequently, higher risk of recurrence and possibly more severe episodes? This issue of BJD reports a randomized clinical trial comparing 6 months of penicillin V (250 mg b.i.d.) vs. placebo for patients who had been treated for cellulitis of the leg (first and recurrent episodes). The hazard ratio indicated that the antibiotic reduced the recurrence risk by 47%, with repeat episodes occurring in 12 of 60 (20%) penicillin V-group patients vs. 21 of 63 (33%) placebo recipients (absolute difference: 13Æ3%, 95% confidence interval )2Æ4 to 28Æ1). For this disease with little available data, the authors should be commended for their efforts in conducting this trial and clearly reporting its findings. However, their recruitment goals were not met and the trend favouring prophylactic antibiotics is difficult to interpret and extrapolate. Notably, hospital recruitment of patients with erysipelas seems extremely difficult in western countries, as a majority of patients are seen by office-based general practitioners and most guidelines now recommend home-administered oral or intravenous treatments for convenience and cost considerations, at least for routine cases. Indeed, we are presently encountering the same difficulties in a French erysipelas trial (http://www.clinicaltrials.gov. Randomized noninferiority study comparing short course of oral amoxicillin to one of the usual treatments of lower leg erysipelas. NCT01059123). Therefore, the authors’ design and logistics recommendations for future studies should be followed. In addition, although prophylactic antibiotics may be valuable, the effect-size reported was slight, for three main reasons. Firstly, as stipulated by the inclusion criteria, 80% of the population had not experienced a previous erysipelas episode, thereby making the probability of recurrence lower than for a recurrent erysipelas population and explaining the trial’s approximately 70% nonrecurrence rate under placebo. It would probably be better to identify patients at high risk of recurrence after a first episode rather than expose more than two-thirds of the naive population to unnecessary antibiotics for 6 months. The presence of severe oedema or lymphoedema could be a criterion, as incident erysipelas may be associated with subclinical lymphoedema. The results of the ongoing PATCH I trial on patients with at least two recurrences should be informative. Secondly, several prophylactic antibiotic regimens are available worldwide, e.g. oral phenoxymethylpenicillin, oral amoxicillin and intramuscular benzathine penicillin, and their efficacies, costs and compliance rates might not be similar. Thirdly, optimal risk-factor control is essential to increase the benefit of any antibiotic strategy for recurrent erysipelas, e.g. effective elastic compression stockings and ⁄or antifungals (whether topical or oral, according to the extent and localization of dermatomycosis).

Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is the most severe type of cutaneous reactions to drugs. Involvement of the epithelium of the gastrointestinal and respiratory tracts contribute to the severity of the disease. Antibacterial sulphonamides, anticonvulsants, allopurinol, several antibiotics and some antiinflammatory agents including steroids are the drugs associated with the highest risks. Therapy of this self-limited disease relies on symptomatic management based on the same principles as for major burns.

Guidelines for the management of acne: recommendations from a French multidisciplinary group

L. Le Cleach iD , B. Lebrun-Vignes, A. Bachelot, F. Beer, P. Berger, S. Brug ere, M. Chastaing, G. Do-Pham, T. Ferry, J. Gand-Gavanou, B. Guigues, O. Join-Lambert, P. Henry, R. Khallouf, E. Lavie, A. Maruani, O. Romain, B. Sassolas, V.T. Tran, and B. Guillot for the French Acne Guidelines Working Group and Centre of Evidence of Dermatology Service de Dermatologie, Hôpital Henri-Mondor, Assistance Publique–Hôpitaux de Paris (APHP), 51, avenue du Mar echal-de-Lattre-de-Tassigny, 94010 Cr eteil, France Universit e Paris-Est Cr eteil–Val de Marne, EA7379 EpiDermE ( Epid emiologie en Dermatologie et Evaluation des Th erapeutiques), 61, avenue du G en eral-deGaulle, 94010 Cr eteil Cedex, France Centre R egional de Pharmacovigilance, Groupe Hospitalier Piti e-Salp̂etri ere–Charles-Foix, APHP, 47–83, boulevard de l’Hôpital, 75013 Paris, France Service d’Endocrinologie et M edecine de la Reproduction, Centre de R ef erence des Maladies Endocriniennes Rares de la Croissance, Groupe Hospitalier Piti eSalp̂etri ere–Charles-Foix, APHP, 47–83, boulevard de l’Hôpital, 75013 Paris, France UPMC Universit e Paris 06, 4, place Jussieu, 75005 Paris, France Accueil M edical de la SDAT, 10bis, rue du Dr-Edouard-Laguesse, 21000 Dijon, France 25, rue Saint-Jean, 14000 Caen, France Coll ege de Gyn ecologie de Bordeaux et du Sud-Ouest, 35, rue de Turenne, 33000 Bordeaux, France Unit e de Psychiatrie de Liaison, Service Hospitalo-Universitaire de Psychiatrie d’Adultes et de Psychologie M edicale secteur 1, CHU de Brest, 2, avenue Foch, 29609 Brest, France Service de Maladies Infectieuses, Hospices Civils de Lyon, 3, quai des C elestins, 69229 Lyon, France Universit e Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France 1, place Franc ois-Rude, 21000 Dijon, France 2b, avenue du Canada, 14000 Caen, France Universit e Paris Descartes, Sorbonne Paris Cit e, Paris, France Laboratoire de Microbiologie Clinique, Groupe Hospitalier Necker–Enfants-Malades, APHP, 149, rue de S evres, 75015 Paris, France 43, rue de Foncillon, 17200 Royan, France 30, boulevard Heurteloup, 37000 Tours, France Haute Autorit e de Sant e, 2, avenue du Stade-de-France, 93218 Saint-Denis, France Universit e Franc ois-Rabelais Tours, 60, rue du Plat-d’ Etain, 37000 Tours, France Service de Dermatologie, CHRU de Tours, 2, boulevard Tonnell e, 37044 Tours, France Service de R eanimation N eonatale, Hôpital Antoine-B ecl ere, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France D epartement de M edecine Interne et Pneumologie, Hôpital de la Cavale-Blanche, CHRU de Brest, 5, boulevard T.-Prigent, 29609 Brest, France D epartement de M edecine G en erale, Universit e Paris Diderot, 16 rue Huchard, 75018 Paris, France Centre de Recherche Epid emiologie Statistique, Sorbonne Paris Cit e (CRESS–Inserm U1153), 1, place du Parvis-Notre-Dame, 75004 Paris, France D epartement de Dermatologie, CHU de Montpellier, Universit e de Montpellier, 191, avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France

Revue systématique méthodologique des essais contrôlés randomisés des traitements de la pédiculose du cuir chevelu

ots clés : Douleur neuropathique ; Échelle ; Peau sensible ntroduction.— Les peaux sensibles se caractérisent par la survenue ’un érythème et/ou de sensations cutanées anormales (douleur, rurit, brûlures, picotements, fourmillements. . .) après l’exposition des facteurs physico-chimiques normalement non pathogènes eau, cosmétiques, chaud, froid, vent. . .). Le rôle du système nereux cutané est évident et on peut se demander s’il ne s’agit pas e douleurs neuropathiques a minima. atériel et méthodes.— Dans cette étude ont inclus des sujets ayant n score de stinging test supérieur ou égal à 3. Leurs sensations taient évaluées par les échelles Dermatology Life Quality Index DLQI), Sensitive Scale (échelle de sévérité de la sensibilité cutanée) t DN4 (échelle pour le diagnostic des douleurs neuropathiques). ésultats.— Soixante-dix femmes ont été incluses. Les scores oyens étaient les suivants : Stinger 4,6, DLQI 3, Sensitive Scale 8,33 et DN4 2,3. Le score DN4 était supérieur à 4/10 donc positif hez seulement 20 % des sujets. onclusion.— Lorsque le score DN4 est supérieur à 4/10, on peut etenir le diagnostic de douleur neuropathique. C’est le cas chez femme présentant une peau sensible sur 5 dans cette étude. Ces ésultats méritent d’être confirmés par d’autres moyens. Ils ne ignifient pas que les sujets concernés doivent avoir un traitement édicamenteux mais représentent plutôt un élément de sévérité et n argument supplémentaire pour une atteinte des fibres nerveuses ntra-épidermiques dans les peaux sensibles. éclaration d’intérêts.— Aucun.

Update on adverse drug reactions in the skin

Dermatologists need to be aware of recent reports of adverse drug reactions affecting the skin. Reviewed here are reports of novel agents causing skin reactions — new antiviral therapies used in HIV infection, lamotrigine, nicorandil, fluoroquinolones, hydroxyurea and granulocyte colony-stimulating factor — together with developments in patterns of drug-related skin disorders, specifically acral manifestations, bullous pemphigoid and acute generalized exanthematous pustulosis.