PLAIN LANGUAGE SUMMARIES Classification of segmental vitiligo on the trunk N. van Geel, S. Bosma, B. Boone and R. Speeckaert This summary relates to DOI: 10.1111/bjd.12652 British Journal of Dermatology, 170, 322 327, February 2014 BJD British Journal of Dermatology In vitiligo, areas of skin lose their normal pigment (colour) and become white, due to an absence of pigment cells called melanocytes. It is an autoimmune condition, in which the body s immune system (which normally fights off disease) rejects some of its own, healthy cells melanocytes in the case of vitiligo. In segmental vitiligo the patches only occur on one part of the body, such as the leg, face or trunk. In this study, researchers from Belgium examined images of 106 segmental vitiligo lesions (patches) occurring on the trunks of 104 patients, to see where they occur ( distribution ) and to identify any patterns. Segmental vitiligo was more frequently found on the ventral side of the trunk (lower part, near the abdomen 859%) compared to the lateral part (the sides 528%) and the back (368%). Based on common patterns, lesions were categorised into six subtypes: type 1, 2 and 3 involved the upper part of the trunk, type 4 and 5 the middle part and type 6 the lower part. 679% of all segmental vitiligo lesions could fit into these subtypes. The most frequent type of lesion was subtype 3 (226%), which showed a V- shaped pattern on the upper trunk, followed by subtype 5 (179%), a band-like pattern on the lateral side, and subtype 6 (132%), a rectangular shape on the lower abdomen. Categorising segmental vitiligo on the trunk may help doctors to predict where the disease is most likely to spread to on a patient and allow for early treatment of the area of risk. It may also help doctors to diagnose whether a patient has segmental vitiligo or nonsegmental vitiligo (vitiligo which appears not just on one body part) in its initial stage, in addition to helping differentiate it from other types of pigment disorders. The impact of skin damage due to cutaneous lupus on quality of life S.M. Verma, J. Okawa, K.J. Propert and V.P. Werth This summary relates to DOI: 10.1111/bjd.12653 British Journal of Dermatology, 170, 315 321, February 2014 Lupus is a serious, long-term autoimmune disease (meaning the body s immune system, which is meant to defend against disease, attacks the body s own, healthy cells). Systemic lupus erythematosus (SLE) is the most common type of lupus and can potentially affect the whole body, including skin, joints and organs. Cutaneous lupus erythematosus (CLE) is a form that affects the skin alone. There are several types of CLE with different symptoms. It is already known that CLE can cause poorer quality of life in patients. This US-based study of 141 patients looked more specifically at the impact on quality of life of disease damage (mainly scarring and discolouration of the skin) caused by the disease. The study also examined how disease damage affects people of different ethnicities, namely Caucasian, African American and Asian. The researchers found that, contrary to their expectations, the severity of disease damage was not linked to how greatly quality of life was impaired, and that it is the disease activity (how severe the symptoms are) that has a negative impact on quality of life rather than disease damage. This is of interest as it differs to other skin diseases that cause pigment changes, such as vitiligo, where quality of life is greatly impacted 2014 British Association of Dermatologists British Journal of Dermatology (2014) 170, pp1 5 e1
e2 Plain Language Summaries by skin discolouration. The researchers also found differences between the racial backgrounds relating to how disease activity impacts on disease damage and when disease damage first manifests itself. Antidrug antibodies in psoriasis: a systematic review L. Hsu, B.T. Snodgrass and A.W. Armstrong This summary relates to DOI: 10.1111/bjd.12654 British Journal of Dermatology, 170, 261 273, February 2014 Psoriasis is a common skin disease in which the body produces too much of a protein called tumour necrosis factor alpha (TNF-alpha) which in turn causes inflammation. Adalimumab, etanercept, infliximab and ustekinumab are four powerful biological drugs (or biologics so named because they mimic normal human molecules) used to treat psoriasis due to their ability to reduce the activity of TNF-alpha. However, the body s immune system, which normally fights off infection, can produce antidrug antibodies (or ADAs) that see biologics as harmful invaders and try to deactivate them. The US-based researchers looked at 25 studies, involving 7969 patients, to explore three issues: how prevalent ADAs are in patients receiving biologics, whether they influence how effective the drug is, and whether taking the psoriasis treatment drug methotrexate in unison with a biologic can help prevent ADAs forming. 950 (12%) of the patients tested positive for ADAs. In some of the studies involving adalimumab and infliximab this was associated with reduced levels and efficacy of the drug. ADAs caused by etanercept were not found to affect the patients treatment responses, while those caused by ustekinumab may cause reduced treatment response. However, the results are unclear. Methotrexate was associated with less ADA formation in patients receiving infliximab or adalimumab but further studies are needed. The authors found great variability in the rate of ADA detection in psoriasis patients and highlight that a number of other factors may influence ADA formation, including genetics and disease type. They conclude that ADAs acting against certain biologic agents may influence treatment efficacy. Screening for tinea unguium by dermatophyte test strip Y. Tsunemi, K. Takehara, Y. Miura, G. Nakagami, H. Sanada and M. Kawashima This summary relates to DOI: 10.1111/bjd.12660 British Journal of Dermatology, 170, 328 331, February 2014 Tinea unguium, also known as onychomycosis or, more commonly, as fungal nail infection, causes infected nails to turn white or yellowish and become thickened and crumbly. It is very common, affecting up to 13% of the general population and up to 25% of elderly people. Traditionally, testing for tinea unguium has involved taking samples of the nail and examining them under a microscope ( microscopy ), using a variety of different methods. However, it can take several weeks for the results of these tests to be available and results can vary depending of the skills of the person analyzing the samples. This study looks at a new testing method, using a dermatophyte test strip. This method involves adding small nail samples to a solution in a test tube and then using a test strip that displays a brown line if the sample is positive for the fungus. The process takes about 20 min. The researchers, from Japan, compared results from 165 nail samples, tested using both the test strip and microscopy. They found that the new method had a high level of accuracy British Journal of Dermatology (2014) 170, pp1 5 2014 British Association of Dermatologists
Plain Language Summaries e3 in detecting the infection and gave no false negative results. The authors recommend that samples that are positive from a dermatophyte test strip should then be confirmed using microscopy. Those that test negative do not require this extra step, reducing the overall number of microscopy tests required. Investigation of cutaneous photoadaptation to narrowband ultraviolet B S. Darne, L.C. Stewart, P.M. Farr and P.J. Hampton This summary relates to DOI: 10.1111/bjd.12662 British Journal of Dermatology, 170, 392 397, February 2014 Phototherapy is a treatment involving ultraviolet light (either UVA or UVB) which is used for a range of diseases, including a common skin disorder called psoriasis. In UVB treatment, patients can receive the full UVB light spectrum, called broadband UVB (BBUVB), or just a small part, called narrowband UVB (NBUVB). This is done in a hospital at regular intervals over many weeks or months. Photoadaptation is the natural process by which the skin becomes increasingly accustomed to UV light, as a result of repeated exposure to it, and therefore is able to withstand an increased UV dose. For example, tanning and skin thickening are responses to UV exposure and both allow the skin to tolerate higher levels of UV. For this reason UV doses are often increased during a patient s course of phototherapy. This study, from the UK, is one of the first to measure photoadaptation to NBUVB, as opposed to the more widely studied BBUVB. The researchers measured the minimal erythemal dose (MED) of 50 patients, before and towards the end of a 20 week course of treatment. MED is the minimum amount of UVB that it takes to cause skin redness 24 h later. As the skin becomes more accustomed to UV the MED increases (i.e. it takes a greater dose of UVB to turn the skin red). The researchers found that patients tolerate, on average, 27 times the dose of UV radiation at the end of NBUVB phototherapy than at the start. This is considerably less than reported for BBUVB. This study is the first step towards calculating accurate phototherapy dose increases for NBUVB. Efficacy and safety of systemic treatments for moderate-tosevere psoriasis: meta-analysis of randomised controlled trials J. Schmitt, S. Rosumeck, G. Thomaschewski, B. Sporbeck, E. Haufe and A. Nast This summary relates to DOI: 10.1111/bjd.12663 British Journal of Dermatology, 170, 274 303, February 2014 This study is a review of randomised controlled trials (RCTs) investigating treatments for psoriasis, including biological drugs (or biologics - so named because they mimic normal human molecules). RCTs are studies in which a number of similar patients are randomly allocated to two or more test groups, one of which will be a con- 2014 British Association of Dermatologists British Journal of Dermatology (2014) 170, pp1 5
e4 Plain Language Summaries trol group (receiving either no treatment or a placebo) while the other groups will each receive one of the specific treatments being tested. The different groups of patients are then monitored in the exact same way allowing for direct comparison between different treatments and / or between the treatment and control groups. This study examines the results from 48 different RCTs, comprising 11 178 patients involved in biologics RCTs and 1888 patients involved in RCTs for conventional treatments. The researchers, from Germany, looked at efficacy and safety of 8 different systemic drugs (affecting the whole body rather than applied to the skin s surface) and measured effectiveness as a 75% or more reduction in a patient s PASI score, which assesses the severity and extent of an individual s psoriasis. As indicators of a drug s safety in each treatment group they looked at numbers of adverse events (unwanted side effects), proportions of patients with at least one adverse event, and withdrawals from the study. The researchers found that in placebo-controlled trials biologics are more effective than all conventional treatments. Two types of biologics, called adalimumab and infliximab, were deemed more effective than a non-biologic drug called methotrexate, and a biologic called ustekinumab was found to have better results than one called etanercept. The researchers conclude, however, that reporting of adverse events is too varied to allow for definitive, direct comparisons between the drugs, and state that international agreement on how adverse events should be monitored in psoriasis trials is urgently required. Immune responses to hair dyes containing toluene-2,5- diamine J.D. Schmidt, J.D. Johansen, M.M. Nielsen, E. Zimersson, C. Svedman, M. Bruze, K. Engkilde, S.S. Poulsen, C. Geisler and C.M. Bonefeld This summary relates to DOI: 10.1111/bjd.12676 British Journal of Dermatology, 170, 352 359, February 2014 Permanent hair dyes are known to cause skin allergies in some people, and the allergen (allergy-causing substance) of most concern in dyes in called p-phenylenediamine or PPD. This study, by researchers from Denmark and Sweden, looked at the role of another dye called toluene-2,5-diamine (PTD) used in such products, as this is commonly used in dyes on the Scandinavian market. Two commercially available hair dyes containing PTD and were tested on skin and as a control compared with the response to 025%, 1% and 4% PTD, and 4% PPD. The study looked at immune responses to the dyes, meaning how the body s immune system, which normally fights off infection or unwanted cells, reacts to the chemical. These responses include skin inflammation, and how certain cells infiltrate the body s lymph nodes (part of the body s immune system). Treatment with 1% PTD was found to cause the same level of skin inflammation, measured in terms of swelling, as 4% PPD, implying that lower levels of PTD are needed to cause inflammation. They also found that the PTD-containing dyes trigger immune responses that both cause and fight inflammation, which may be why consumers can use these potent mixtures of allergens without getting a severe reaction. The authors conclude that the scale of the immune responses depends on the PTD concentration and possibly on the number of other possible allergens in the dye, as well as on the exposure regime. British Journal of Dermatology (2014) 170, pp1 5 2014 British Association of Dermatologists
Plain Language Summaries e5 Reduction of unwanted submental fat with ATX-101, an adipocytolytic injectable treatment: results from a phase III, randomized, placebo-controlled study B. Rzany, T. Griffiths, P. Walker, S. Lippert, J. McDiarmid and B. Havlickova This summary relates to DOI: 10.1111/bjd.12695 British Journal of Dermatology, 170, 445 453, February 2014 This study examined a potential therapy for reducing submental fat fat deposits underneath the chin, known more colloquially as a double chin. The treatment involves injecting submental fat with ATX-101, a laboratory-created or synthetically derived formulation of a naturally occuring bile called deoxycholic acid. The injection irreversibly disrupts fat cell membranes and causes destruction of fat cells called adipocytolysis. The cellular debris resulting from the destruction of the fat cells is then removed by special cells called macrophages which are triggered by an inflammatory response to the injection of ATX-101. The study, by researchers in the US, UK and Germany, included 363 men and women with moderate to severe submental fat. The primary goals of the trial were to demonstrate at least a one point improvement in submental fat on the 5-point Clinician-Reported Submental Fat Rating Scale and for patients to show satisfaction with their face and chin appearance on the 7-point Subject Self- Rating Scale (SSRS). The trial used two different dosages of ATX-101 (1 mg cm 2 and 2 mg cm 2 ) as well as a placebo. With the higher dosage of ATX-101, 653% of patients had a reduction in submental fat of at least one point on the Clinician-Reported Submental Fat Rating Scale compared with 230% with the placebo, and 661% of patients were happy with their face and chin appearance, vs. 287% for the placebo. In addition, calliper measurements showed a significant reduction in submental fat. Following treatment, patients also reported a reduction in the psychological impact they felt due to the appearance of their face and chin. The authors conclude that subcutaneous injections with ATX-101 yield a clinically meaningful and statistically significant reduction in unwanted submental fat, decrease the psychological impact on patients, and are well tolerated, and that this treatment is a novel, non-surgical approach to treatment of submental fat. 2014 British Association of Dermatologists British Journal of Dermatology (2014) 170, pp1 5