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Linked Article: Sarkany et al. Br J Dermatol 2022; 186:713–720. Xeroderma pigmentosum (XP) is a genetic disease in which the system that repairs damage caused by ultraviolet (UV) radiation (which mainly comes from the sun) is faulty. Patients with XP develop eye and skin cancers from childhood and usually die in early adulthood. The main means of preventing the cancers and increasing lifespan is extreme protection against the UV found in daylight, particularly for the face, which is where the cancers mostly occur. Not enough is known about how well patients with XP protect against UV radiation. In this paper, with authors from the UK, the Netherlands and Denmark, a new method was used to estimate face exposure in 36 patients with XP over 3 weeks in the summer. The method combines measurements from a wrist‐worn UV detector with an 'activity diary' of what patients did to protect their face when outside. Some patients with XP protected themselves well whereas others did not. The difference between the face UV dose in the best and worst protecting patients was over 100‐fold. Those patients protecting themselves the least from UV exposure had exposure levels similar to healthy adults. Adults and children with XP had similar exposure to UV but achieved it differently. Adults protected less well when outside but went outside less whereas children went outside more but protected better. This variation in UV exposure is important. Poor protection in patients with XP is likely to cause cancers and premature death. As well as being useful in XP, this new method to estimate facial UV exposure may also be useful in other more common diseases, particularly patients at high risk of basal and squamous cell carcinomas, which are mostly caused by UV and mainly affect the face. Linked Article: Sarkany et al. Br J Dermatol 2022; 186:713–720. [ABSTRACT FROM AUTHOR]

Linked Article: Prens et al. Br J Dermatol 2021; 185:177–184. Hidradenitis suppurativa is a chronic skin disease in which persistent, painful, boil‐like lesions develop especially in the armpits and groin. Treatment is often difficult, and patients with severe disease are eligible for so‐called biologic therapy. The only registered biologic agent is adalimumab, a monoclonal antibody to the inflammatory mediator called tumour necrosis factor‐α (TNF‐α), although other biologic agents such as infliximab (another TNF‐α antagonist) have been used. Unfortunately, these agents may lose their effect with time, sometimes because the patient develops antibodies to the drug, or side‐effects may develop. Little is known about the long‐term results of using these treatments in patients with hidradenitis suppurativa. In this paper, the authors from Groningen and Rotterdam in the Netherlands retrospectively studied the long‐term effectiveness and tolerability of adalimumab and infliximab in patients attending either centre with hidradenitis suppurativa. They studied 104 patients who received adalimumab 40 mg weekly or 80 mg fortnightly, the recommended dose regimen. They also studied 44 patients who were treated with infliximab 5 mg/kg every 6 to 8 weeks. Of the patients treated with adalimumab, 56·3% were still taking the drug after 1 year, and 30·5% after 2 years. Similarly, 58·3% of patients started on infliximab were still receiving the drug at 1 year, and 48·6% at 2 years. Loss of effectiveness was the chief reason for stopping the drug, although some patients developed side‐effects, particularly to infliximab. Only a few patients were tested for antibodies, which were detected in roughly a half. Generally, older patients or those with a longer disease history were more likely to persist with adalimumab therapy. The authors noted that patients with hidradenitis were less likely to persist with biologic therapy than patients with other disease indications such as psoriasis, spondyloarthritis and Crohn disease. Linked Article: Prens et al. Br J Dermatol 2021; 185:177–184. [ABSTRACT FROM AUTHOR]

Summary: Basal cell carcinomas (BCCs or "rodent ulcers") are the most common type of skin cancer and generally do not spread elsewhere on the body. They are not unusual in older people, but someone who develops lots of BCCs from an early age may have the rare genetic condition Basal Cell Naevus Syndrome (BCNS or "Gorlin syndrome"). Other clues to BCNS include an unusually shaped face, cysts in the jaw, and tiny irregularities on the palms and soles called palmar pits. The diagnosis is confirmed by testing DNA extracted from a blood sample. BCNS is caused by a mistake (mutation) in a gene called PTCH1 which is usually inherited from a parent, but occasionally develops for the first time in the embryo, in which case, the patient is described as mosaic because some body cells contain the mistake and some do not. Mosaic patients can be hard to diagnose because they tend to have a milder form of the condition (sometimes the only sign is a BCC developing in childhood) and the blood test may be negative for PTCH1 mutations. This paper, from Belgium and the Netherlands, describes two such patients: a 41 year old woman with BCCs on just one side of her body and no other features of BCNS and a 36 year old woman with BCCs, jaw cysts and palmar pits. In both patients the blood test was negative but PTCH1 mutations were found in all the BCCs tested. Confirming the diagnosis enabled the doctors to counsel these patients about possible complications of BCNS and the risk of passing it on to the next generation. Linked Article: Reinders et al. Br J Dermatol 2019; 181:587–591 [ABSTRACT FROM AUTHOR]

Interleukin-17C increases the expression of psoriasis-associated genes by an I B -dependent m... P. Ommen, L. Iversen and C. Johansen I Aarhus University Hospital, Aarhus, Denmark i Interleukin (IL)-17C is attracting attention as a potential target for the treatment of psoriasis, as it has been demonstrated to have disease-driving features. Real-world data from a cohort of patients with moderate-to-severe psoriasis in Newfoundland and Labrador from 2001-2017 (Gulliver and Gulliver), which included 459 patients with 913 biologics or phosphodiesterase-4 inhibitor exposures observed that 40% of patients remained on their first biologic, with 57% of these patients achieving and maintaining PASI-100, indicating no relapse or progression to a more severe plaque psoriasis or progression to a more severe psoriasis phenotype. P09 Defining value for patients with psoriasis: development of a patient-driven outcome set for c... N. Hilhorst, SP 1,2 sp E. Deprez, SP 1,2 sp N. Van Geel, SP 1,2 sp D. Balak, SP 2 sp I. Hoorens SP 1,2 sp and J. Lambert SP 1,2 sp I SP 1 sp Dermatology Research Unit and SP 2 sp Department of Dermatology, Ghent University Hospital, Ghent, Belgium i To date, there is no outcome set, a consensus-driven minimum set of outcomes, available for psoriasis from a patients' perspective. A total of 198 paediatric patients and 1989 adult patients with psoriasis, with exposure to secukinumab, and 41 paediatric patients and 323 adult patients with psoriasis, with exposure to etanercept, were analysed. There was a trend towards a longer drug survival in biologics-naïve patients (log-rank test I P i = 0-046) Sixteen patients (47-1%) discontinued guselkumab owing to ineffectiveness, 12 patients (35-3%) owing to side-effects and one patient (2-9%) owing to a combination of both reasons. [Extracted from the article]

Summary: Atopic dermatitis (AD, atopic eczema) is a very common skin condition affecting 10‐20% of children. It affects children of all skin colours and seems to occur more often in Asian children and children with dark skin types. However, most research is performed on children with light skin types. This study, performed in Amsterdam, the Netherlands, aimed to investigate differences between AD in children with dark and light skin types. To study this, the investigators took tape strips from 53 AD children aged 0‐12 years and 50 healthy children as control (comparison). Tape stripping is a painless procedure which is ideal to perform in children, in which a small round sticker is attached to the skin. When removing this special sticker, a thin layer of skin cells remains attached to the sticker, allowing the investigators to study several aspects of skin inflammation and skin barrier. The authors found that AD skin from children with light and dark skin have similar levels and types of skin inflammation. However, they found differences in skin barrier markers between these two groups. In light skinned children, markers of good skin barrier were lower in AD skin when compared to healthy children's skin, while in dark AD skin these skin barrier markers were not significantly different from healthy dark skin. This study showed that dark‐skinned and light‐skinned AD children are similar when it concerns skin inflammation, but in light skinned AD children the skin barrier dysfunction may play an additional role in the development of AD. This suggests that AD in light and dark skin has different mechanisms of development. Linked Article: Hulshof et al. Br J Dermatol 2019; 180:621–630 [ABSTRACT FROM AUTHOR]

Summary: Background: The increasing incidence of actinic keratosis (AK) is causing a large burden on healthcare systems. The current management of patients with AK seems to vary within and between primary and secondary care; however, an in‐depth understanding of healthcare providers' management of AK is currently lacking. Objectives: To gain insight into the management of AK by exploring the underlying motives of current practices among general practitioners (GPs) and dermatologists in the Netherlands. Methods: A qualitative study was conducted consisting of semistructured individual interviews with 22 GPs and 18 dermatologists focusing on the underlying motives regarding AK management. A predefined topic list was used. All interviews were audiotaped, transcribed verbatim and inductively analysed by two researchers drawing on elements of grounded theory. Results: GPs reported conducting limited proactive clinical assessments of cutaneous photodamage due to a perceived lack of value, varying in their method of diagnosing AK. They mainly applied cryotherapy or referred to secondary care due to lack of experience, varying in their applications and providing mostly patient‐driven follow‐up care. They also reported a great need for guidelines due to a lack of knowledge of AK management. Dermatologists indicated pursuing proactive clinical assessments of cutaneous photodamage and the goal of providing guideline‐driven AK care. However, patient preferences still largely influence both treatment choices and follow‐up regimens. Furthermore, dermatologists reported the need to improve AK and skin cancer management in primary care. Conclusions: For AK care to become more standardized and uniform in Dutch primary care, the implementation of guidelines and (continuing) education are needed to address the commonly reported barriers of lack of value, experience and knowledge among GPs. For efficient use of care among dermatologists, shared decision‐making tools along with adequate (framing of) patient information may be useful. What's already known about this topic? Actinic keratosis (AK) is a high‐volume condition with a significant healthcare impact.The current management of patients with AK seems to vary within and between primary and secondary care; however, an in‐depth understanding of AK management by healthcare providers is currently lacking. What does this study add? This qualitative study provides insight into the underlying motives of current AK management.General practitioners (GPs) reported varying in diagnosing AK and in determining treatment and follow‐up schedules. Commonly reported motives were a lack of knowledge and experience and low perceived value of AK care.Dermatologists indicated that they strived to provide guideline‐driven AK care. However, patient preferences and other patient‐related factors influence treatment choices and often lead to extensive follow‐up regimens. What are the clinical implications of this work? For GPs to provide more standardized and uniform AK care, it seems useful to invest in improving GPs' knowledge of AK through continuing education and adequate implementation of the primary care guideline among GPs.Shared decision‐making tools along with adequate (framing of) patient information may be useful to facilitate dermatologists' management of patient preferences, thereby preventing extensive follow‐up. Linked Comment: de Berker and Pasch. Br J Dermatol 2019; 181:13–14. Plain language summary available online Respond to this article [ABSTRACT FROM AUTHOR]

Linked Editorial:van Zuuren et al. Br J Dermatol 2020; 182:1319–1320. Plain language summary available online [ABSTRACT FROM AUTHOR]

Linked Article:de Wijs et al. Br J Dermatol 2021; 185:555–562. [ABSTRACT FROM AUTHOR]

Summary: Aim: Jansen et al. conducted a randomized trial to compare the efficacy of four field treatments for actinic keratosis (AK). Setting and design: This was a multicentre, single‐blind, randomized trial conducted in the dermatology departments of four Netherlands hospitals. Patients were not blinded. The investigator who evaluated the trial outcome was blinded. Study exposure: This study included adult patients with at least five AKs on the face or vertex scalp. Patients were randomized to treatment with fluorouracil 5% cream, imiquimod 5% cream, methyl aminolaevulinate photodynamic therapy (MAL‐PDT) or ingenol mebutate 0·015% gel. Outcomes: The primary outcome was whether patients had ≥ 75% reduction in AK count 12 months after treatment. Results: In total 624 patients participated. The likelihood of having ≥ 75% reduction in AK count 12 months after treatment was significantly higher (twice as high or greater) for fluorouracil than for any other therapy. Approximately 75% of patients treated with fluorouracil experienced ≥ 75% reduction in AK count at 12 months. Conclusions: Jansen et al. conclude that 1 year after treatment, fluorouracil was significantly more effective at AK reduction than imiquimod, MAL‐PDT or ingenol mebutate. [ABSTRACT FROM AUTHOR]