Vigfús Sigurdsson

Narrowband ultraviolet B and medium-dose ultraviolet A1 are equally effective in the treatment of moderate to severe atopic dermatitis

BACKGROUND Phototherapy may be effective in atopic dermatitis (AD). Medium-dose (MD) ultraviolet (UV) A1 was introduced for the treatment of AD. Few immunohistochemical data are available pertaining to phototherapy in AD. Regulatory T cells may play a role in clearing AD. OBJECTIVES We sought to compare the clinical and immunohistochemical effects of narrowband (NB) UVB and MD UVA1 treatment in patients with AD. METHODS Thirteen adult patients with AD were included in this randomized investigator-blinded half-sided comparison study between NB UVB and MD UVA1. Disease activity was measured using the Leicester sign score. Skin biopsy specimens were taken before and after phototherapy. Regulatory T cells were stained with the forkhead box protein P3 (FoxP3). RESULTS NB UVB and MD UVA1 both significantly decreased AD severity (P < .01) and the dermal cellular infiltrate. The percentage of FoxP3(+)CD3(+) T cells did not change after NB UVB or MD UVA1 treatment. LIMITATION MD UVA1 therapy was given 3 times per week instead of the preferred regimen of 5 times per week. This was necessary to achieve good blinding of the study. CONCLUSIONS NB UVB and MD UVA1 seem equally effective in the treatment of patients with moderate to severe AD. Neither MD UVA1 nor NB UVB had an effect on the percentage of FoxP3(+)CD3(+) T cells.

Psychosocial impact of acne vulgaris: Evaluation of the relation between a change in clinical acne severity and psychosocial state

Background: Although knowledge concerning the impact of acne vulgaris on quality of life has increased in recent years, relatively few studies have assessed the effect of a change in clinical severity on psychosocial state. Objective: Assessment of the effect of a change in clinical acne severity on psychosocial state. Methods: This was investigated by means of questionnaires and clinical assessements by acne patients and dermatologists. Fifty females with mild to moderate facial acne were seen before and after a 9-month treatment with oral contraceptives. Results: The results showed a great variability in psychosocial impairment between individuals. After 9 months, a significant reduction in clinical severity was seen overall which did not relate to the significant improvements in self-esteem, stability of self-esteem and acceptance of appearance. Conclusion: Perceived psychosocial impairment is individually based, is greater in women who subjectively overrate their acne and does not relate to clinical improvement.

Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomised controlled trial (PLUTO study)

Objective To assess the costs and cost effectiveness of phototherapy with ultraviolet B light provided at home compared with outpatient ultraviolet B phototherapy for psoriasis. Design Cost utility, cost effectiveness, and cost minimisation analyses performed alongside a pragmatic randomised clinical trial (the PLUTO study) at the end of phototherapy (mean 17.6 weeks) and at one year after the end of phototherapy (mean 68.4 weeks). Setting Secondary care, provided by a dermatologist in the Netherlands. Participants 196 adults with psoriasis who were clinically eligible for narrowband (TL-01) ultraviolet B phototherapy were recruited from the dermatology departments of 14 hospitals and were followed until the end of phototherapy. From the end of phototherapy onwards, follow-up was continued for an unselected, consecutive group of 105 patients for one year after end of phototherapy. Interventions Ultraviolet B phototherapy provided at home (intervention) and conventional outpatient ultraviolet B phototherapy (control) in a setting reflecting routine practice in the Netherlands. Both treatments used narrowband ultraviolet B lamps (TL-01). Main outcome measures Total costs to society, quality adjusted life years (QALYs) as calculated using utilities measured by the EQ-5D questionnaire, and the number of days with a relevant treatment effect (≥50% improvement of the baseline self administered psoriasis area and severity index (SAPASI)). Results Home phototherapy is at least as effective and safe as outpatient phototherapy, therefore allowing cost minimisation analyses (simply comparing costs). The average total costs by the end of phototherapy were €800 for home treatment and €752 for outpatient treatment, showing an incremental cost per patient of €48 (95% CI €−77 to €174). The average total costs by one year after the end of phototherapy were €1272 and €1148 respectively (difference €124, 95% CI €−155 to €403). Cost utility analyses revealed that patients experienced equal health benefits—that is, a gain of 0.296 versus 0.291 QALY (home v outpatient) by the end of phototherapy (difference 0.0052, −0.0244 to 0.0348) and 1.153 versus 1.126 QALY by one year after the end of phototherapy (difference 0.0267, −0.024 to 0.078). Incremental costs per QALY gained were €9276 and €4646 respectively, both amounts well below the normally accepted standard of €20 000 per QALY. Cost effectiveness analyses indicated that the mean number of days with a relevant treatment effect was 42.4 versus 55.3 by the end of phototherapy (difference −12.9, −23.4 to −2.4). By one year after the end of phototherapy the number of days with a relevant treatment effect were 216.5 and 210.4 respectively (6.1, −41.1 to 53.2), yielding an incremental cost of €20 per additional day with a relevant treatment effect. Conclusions Home ultraviolet B phototherapy for psoriasis is not more expensive than phototherapy in an outpatient setting and proved to be cost effective. As both treatments are at least equally effective and patients express a preference for home treatment, the authors conclude that home phototherapy should be the primary treatment option for patients who are eligible for phototherapy with ultraviolet B light. Trial registration Current Controlled Trials ISRCTN83025173 and Clinicaltrials.gov NCT00150930

Home ultraviolet B phototherapy for psoriasis: discrepancy between literature, guidelines, general opinions and actual use. Results of a literature review, a web search, and a questionnaire among dermatologists

Background  Home ultraviolet B (UVB) phototherapy is a debated treatment. It is currently being prescribed for patients with psoriasis, although literature on the subject is scarce. Despite the apparent contradiction between clinical practice and literature, no systematic study of either has been conducted.

Expression of VCAM‐1, ICAM‐1, E‐selectin, and P‐selectin on endothelium in situ in patients with erythroderma, mycosis fungoides and atopic dermatitis

Background: Erythroderma may result from different causes. At present it is unclear whether the patho‐mechanisms that lead to these different types of erythroderma are identical or different. Adhesion molecules and their ligands play a major role in endothelial‐leukocyte interactions, which affect the binding, transmigration and infiltration of lymphocytes and mononuclear cells during inflammation, injury, or immunological stimulation. The aim of this study was to investigate the adhesion molecule expression on endothelial cells in erythroderma in situ.

Idiopathic erythroderma : A follow-up study of 28 patients

BACKGROUND Erythroderma may result from different causes, but a proportion remains undetermined (idiopathic erythroderma). Patients with idiopathic erythroderma have often been regarded to have a pre-Sézary syndrome because some of these patients have developed a cutaneous T-cell lymphoma during follow-up. OBJECTIVE The aim of this study was to investigate if this was true for our group and also if it is possible to identify further which patients are at high risk of developing cutaneous T-cell lymphoma. METHODS We analyzed clinical and follow-up data and reviewed the skin histopathology of all patients who were diagnosed with idiopathic erythroderma in our clinic between 1977 and 1994. RESULTS Twenty-eight patients, 16 males and 12 females, were diagnosed with idiopathic erythroderma. This is 27% of the patients who were diagnosed with erythroderma in our clinic, during this period. During the median follow-up of 33 months, 35% of the patients went into complete remission and 52% showed partial remission. Three patients (13%), all females, had persistent chronic erythroderma. Two of the latter group progressed to cutaneous T-cell lymphoma, i.e. 1 to Sézary syndrome and 1 to mycosis fungoides. CONCLUSION Based on our results we conclude that only patients with persistent chronic idiopathic erythroderma, which is a minority, have an increased risk of developing cutaneous T-cell lymphoma and therefore need a close and long-term follow-up.

Selecting an Oral Contraceptive Agent for the Treatment of Acne in Women

In women, acne can be successfully treated with oral contraceptives. This article focuses on the results of clinical studies on the treatment of acne with oral contraceptives. From the literature, 12 such studies could be traced over the last 10 years. Most of the studies were multicenter, randomized, and double blind. Five studies were placebo controlled. All of these studies were analyzed and compared with each other. Statistically, all placebo-controlled studies showed a better result with the active treatment, than with the placebo. However, the placebo groups also showed an improvement in the acne lesions. In seven studies, two oral contraceptives were compared for their effect on acne vulgaris. All oral contraceptives studied showed a beneficial effect on the severity of acne.It can be concluded, based on these studies, that all oral contraceptives have a more or less beneficial effect on mild to moderate acne in women. Comparing the various clinical trials, ethinylestradiol/drospirenone is as good as ethinylestradiol/cyproterone, which is slightly better than ethinylestradiol/desogestrel and ethinylestradiol/gestodene. Ethinylestradiol/chlormadinone is slightly better than ethinylestradiol/levonorgestrel, which is as effective as ethinylestradiol/norethindrone, which is far better than the placebo. Ethinylestradiol/norgestimate is better than placebo.

Interleukin 4 and interferon-γ expression of the dermal infiltrate in patients with erythroderma and mycosis fungoides. An immuno-histochemical study

Background: Erythroderma, or generalized erythema of the skin, may result from different causes. At present it is unclear whether the underlying patho‐mechanisms that lead to erythroderma are identical or different depending on the original disease. The aim of this study was to investigate the dermal cytokine profile in different types of erythroderma and mycosis fungoides.

Photosensitivity testing in children

BACKGROUND Phototesting is an important diagnostic tool to objectify light-related symptoms. Data on phototesting procedures in children are scarce. OBJECTIVE The aim of this study was to evaluate phototest results in photosensitivity disorders in children. METHODS The phototest procedures are described. All children phototested in our department between 1995 and 2007 were included in this retrospective study. Children given the diagnosis of polymorphic light eruption (PLE) were selected for follow-up. RESULTS A total of 92 children (39 boys and 53 girls, age range 4-16 years) were successfully phototested. A photosensitivity disorder was confirmed in 56 children (61%, 24 boys and 32 girls). PLE was diagnosed in 39%, photosensitivity associated with atopic dermatitis in 23%, and erythropoietic protoporphyria in 23%. Other diagnoses were less common. Ten children with PLE were followed up for at least 5 years. Seven reported their photosensitivity had not changed over time, in two cases it had diminished, and in one patient the photosensitivity had disappeared. LIMITATIONS Retrospective study design is a limitation. CONCLUSION Phototesting in children is feasible when performed in a case- and child-dependent manner. PLE was the most prevalent diagnosis in our series followed by photosensitivity in atopic dermatitis.

The polymorphous light eruption-severity assessment score does not reliably predict the results of phototesting

Background  Polymorphous light eruption (PLE) is a very common photodermatosis in which patient history is highly specific. Phototesting is used to confirm the diagnosis and to determine the action spectrum and the severity of this disease. In daily practice and in research studies, it would be convenient to assess disease severity by patient history only.